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“Have anything to declare?” asked the Border Guard, “healthcare”, I thought

March 23, 2010

Healthcare is intensely personal, and so the pros and cons are best left to each of us for our own calculus, but one aspect I feel is lacking are some comparative facts with other systems. This stems from our own consulting experiences, where more often than not real root causes are not known and you can spend a lot of time and cash treating phantoms and symptoms, achieving nothing measureable and sustainable at the end of the process.

Last week I was in northern industrial England, a country well known and vilified in the US for its National Health Service (NHS) with, so we’ve heard, multi-month waits for hips, MRI’s and basic care.  To see how their healthcare system operated at a personal level, I asked several people in the UK how NHS works from their perspective and experience.  When the Border guards asked me if I had anything to declare Saturday at Newark Airport, I felt like saying “we need some facts” but figured a trip to the padded waiting room wasn’t going to be helpful.

First, an observation – walking in the streets, stores and the local supermarket, I didn’t see anyone with rickets, goiters, broken yellowed teeth or untreated compound fractures.  I saw a mostly working class, commonly overweight, seemingly healthy crowd passing me by. The question could be not does it work but how much of a hassle is it for the average person to receive necessary and preventative treatment? I also saw, printed on the front of each package, in the upper right hand corner, an easy to understand color pie chart showing calories, fat, salt and saturated fat contents, so people are being educated on their choices (which of course, is still up to the individual).

How is NHS Structured?

The country is divided into a number of regional Trusts, publically funded by a payroll tax which seems to go up by a small percent each year (from what they announced on the BBC recently). There are differences between the services and standards of care between various Trusts, so like choosing a house in the US based on the schools, the local NHS Trust is a factor in choosing where you live. I read in the morning papers of some NHS hospitals and ambulances being dirty, some having nurse shortages and all being under the watchful eyes of the local citizenry and Members of Parliament who demand changes, such as the hospital administrator who was recently sacked due to unfixed problems.

Apparently, even the lowest levels of NHS care are ‘acceptable’ and contrast this to a recent visit I made to a major NY hospital to see a relative where the lobby looked like something a Saudi royal would find familiar but the nutritionist gave the patient some brochure on healthier eating habits, rather than educate him.  No time, no money for that. Even though the lobby was donated and named, and so money looked like it was available for the ‘right’ reasons, the hospital would not even schedule this guy’s pre-admittance testing for an urgent open heart procedure until his insurance was squared away and he may have a $20,000 uncovered balance to handle.

NHS seems to focus on servicing the masses, and our hospitals often focus on selling patients $500 band-aids and feeding our edifice complex. Ever review your itemized hospital bill?  Forget consulting, I want to sell gauze pads. Siemens and GE both charge 2X in the US what they charge in Japan for the exact same imaging systems, it turns out (Japan has more images performed per capita than anywhere else in the world, this pricing no doubt helping availability).  Pharmaceutical companies spend incredible sums on producing amazing medicines and treatments, saving lives that would probably be lost only a few years ago. Since the rest of the Western world has several forms of drug price controls in place, all those billions of dollars in R&D is amortized across the US buying public, explaining why the same med is 1/3 the price in Canada.

Is there also a private insurance market in the UK?

There is private health insurance in the UK, with its own hospitals or wings built onto public hospitals. The pubic system has wards and the private system provides access to private and semi-private rooms in much nicer surroundings.  The level of care seems about the same, but the wait times are obviously very different for non-urgent care.  Doctors have both NHS and private appointments. OK, Doctors are people, and people being people, you do get a faster appointment via the private insurance. Most senior business managers and professionals have private insurance for the adults in their family. So in any given company, there’s a fair chance that the ‘rank and file’ employees are on NHS and the Senior Management Team has their own policy, not unlike our system of better healthcare for senior executives.

What are some personal experiences, on the ground, where theory meets daily reality?

Privately Insured

It’s complex. I know of a successful executive who had some eye illness requiring surgery on both eyes reasonably quickly.  He used his private insurance to get to his doctor immediately, but then used the NHS for the procedure the next morning. His speedbump was getting to the eye surgeon and under the private market that delay went away.  The NHS provided ambulatory procedures the next day went smoothly and without wait, although he had a choice of private or NHS given to him by the doctor but the facilities and wait times were identical and NHS had no paperwork involved. Interestingly, his wife was on NHS while she was pregnant (like all pregnant UK women) and her children, to this day, are on NHS since they are under 18.

NHS user

Contrast the private insurance experience above to a ‘pure play’ NHS patient.  A woman I know, a single mother of a teenager, uses NHS and has doctor and dentist checkups every 6 months for her and her teenage daughter.  Asked if she had trouble getting to the doctors and dentists every 6 months, she replied that she booked 6 months in advance and sometimes called periodically to see if there was cancellation which worked for her.  Of course, I asked if she saw the same docs and dentists each time and she replied in the affirmative.    Note she mentioned dentist, as in everyone has dental care. Compare that to the US where only 44% of Americans have dental insurance.

I asked her “what happens if you or your child is sick and needs to see a doctor or has a toothache?” Her answer was” then you get an immediate appointment”. “What about prescriptions?”  “We don’t’ have drug plans per se, but they are heavily subsidized and you can go to your pharmacy and get whatever you need very affordably”. In all fairness, I read in a morning paper last week about some cancer drug not allowed under NHS rules because it’s too expensive, but I do believe we have the same thing here with our private insurers, so we’ll call that a ‘draw’.   “I have HMO coverage”, I continued, “do you have to choose a primary care physician and they give you referrals to specialists”. “No”, she replied, “you go directly to the specialist you need”.  Ok, I went on, “now what about imaging, such as waiting for an MRI?”  “If it’s not urgent, you can wait several weeks which you have to just accept”, was her reply. “And if it is urgent?”  “Then you get it right away”. Her father is chronically ill, in and out of his local NHS hospital, and her reply on what the wards are like was “not very nice, sometimes awful with no privacy at all”. “Does he get all the care he needs, even though he’s a chronic case”, I sort of gingerly asked.  “We just call ahead to say we’re bringing him in, it’s kind of like he has his own dedicated bed (she chuckled) and he gets his usual consultants (‘specialists’ to us)”, she added. This has been going on for about 20 years she added.

Can the system be abused by non-citizens?

Friday’s newspaper had a headline saying people from the former Eastern Bloc were coming to England for faster treatments or having procedures performed that are unavailable in their own countries.  They do get treated and this is a drain on national funds.  Will it be fixed?  I cannot say, but the article quoted a number of angry Members of Parliament and so I would guess it will be at some point.

Did I personally see any interesting operational efficiencies?

Here’s an interesting efficiency improvement over our system for emergency response.  In many US towns, the Police arrive first, determining if an ambulance is required and generally taking control of the scene.  In the UK, the first responder to a house call (not an auto accident) is a station wagon filled with medical supplies and 2 EMTs. They first try to see if the issue can be treated locally, and if not, they call for the ambulance.  A large number of house emergency calls are resolved without transporting the patient to the hospital, making the Emergency Room truly a room for emergencies.

Does NHS work and are there any aspects of it which we should examine and cherry pick?

NHS does seem to work in its own way but which sounded very foreign to my American free-market ears.  The idea of the fast response EMTs in a well equipped van avoiding ambulance runs seems solid and doable here. The local mall had a number of pharmacies which I walked by on my way to lunch each day, so it seems to be a mix of public/private. People seemed happy with their medical care from either the private or NHS channels since the delivery arm is typically the same and timing is the major difference for most people. While it’s obvious why the privately insured would be satisfied, my question is “are the NHS patients happy because after being in place for about 50 years is NHS is all they know?”

Is our healthcare delivery system broken?  Not broken, but definitely needing a major end to end rethink with cost takeout and a co-focus on both deliverer and receiver. Do we need more facts about already operating healthcare delivery models to do that without reinventing the wheel? Absolutely.

Rich Eichen is a Managing Principal of Return on Efficiency, LLC, who’s website is and is one of their senior turnaround leaders/CROs, Program and Interim Executives with over 25 years experience reshaping companies, Operations and key initiatives. He can be reached at

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