Nursin' USA - You get what you pay for

6 June, 2010

Our resident US nurse Sara Morgan wonders how do patients recognise the value of the NHS if there is no connection between the service provided and money coming out of their pocket?

They say that you get what you pay for. We all pay for the NHS through our taxes, but it is still “free at the point of service”. So what I’ve been wondering is, how do our patients recognise the value of the NHS if the cost is abstract and there is no connection between the service provided and money coming out of their pocket?

I didn’t think too much about this idea until I started doing occasional shifts in a walk-in center. Along with the strep throats, urinary tract infections and kitchen injuries, I’ve seen some patients with truly minor or even non-existent complaints. On some shifts, I end up sending most of my patients home with nothing more than advice or a bit of education. On days like that, I can’t help but wonder if the PCT’s budget is best used paying me to explain to a patient in their thirties that his fatigue and general malaise is probably not the start of ME, but rather the combined result of his birthday celebrations over the weekend and his body’s decreasing ability to shake off a hangover.

Don’t get me wrong: one of my favourite parts of nursing is providing patient education. I like nothing better than taking the time to discuss with a patient her particular condition and what she can do to manage it. Modern medicine is mysterious to many members of the public and often it is nurses who act as the translators, empowering patients to take charge of their own health.

In the space of just a few minutes and with only a handful of well-chosen words, I can offer comfort, information and the tools that a patient needs to take charge of their own health. But does that mean that my time and the PCT’s money is well spent offering reassurance to every patient who comes through the doors with the opening line: “I’m sure this is fine, but I just wanted someone to check.”

During the election, I was intrigued by a suggestion that a nominal fee be attached to primary care visits. If such a fee, say £5, were required (only from those who can afford it, obviously) to seek primary care, would that save some of these unnecessary visits? Would patients appreciate that there is a limited supply of care if it had to be paid for out of their pocket? Would they more be willing to rely on common sense for common ailments than require a professional opinion, if such an opinion were not perceived as free?

When I lived in the US, I was always fortunate enough to have health insurance. I could visit my GP as often as I wished, but there was a small fee that I had to pay for each visit. It was never much, maybe $5 or $10, but it was clearly designed by insurance companies to keep patients from trying to see their GPs for every hangnail, insect bite or mild cough. It seemed to work, too, as most of the people in the waiting rooms usually looked very ill.

Of course, the inescapable potential downside to this fee is that no matter how low the cost to see a doctor, it will always dissuade some people from seeking care. And then what was a hangnail becomes a paronychia, requiring an I&D to treat.

We all know that in the coming years, nurses will have to do more with less, and deliver care as efficiently as possible. But how can we ensure that patients seek care as efficiently as possible?

About Sara Morgan

Sara Morgan trained and practiced as a nurse in the United States before coming to work in the UK. She has worked as both a nurse practitioner and as a lead nurse on the Productive Ward initiative.

Readers' comments (15)

Anonymous | 6-Jun-2010 9:44 am
I am wary of charges in the the people who need most care i.e the elderly and children would be exempt anyway, and as Sara says the cost of something missed, even as small as a paronychia soon adds up, particularly if it turns out to be something far bigger. Having a 30 year old man turn up worried about his fatigue sounds relatively unrepresentative when we know most men don't go to the GP.
Of course this is not a new debate at all, and charges have never been taken forward. Still must be better than having large parts of the population uninsured, unable to see a doctor or receive treatment, or relying on UK charities to set up clinics in shopping malls eh Sara?
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Anonymous | 6-Jun-2010 11:55 am
i have had points in my life where i've been to the doctor and not been able to afford prescriptions, now as a student nurse i dont really get time to visit the doctor for small things, will make time if i'm so ill i can hardly get out of bed. i dont think the nhs is that accessible anyway, so by putting fees on primary care visits, that will prevent probably the most vulnerable from seeking advice early - which is the best, and cheapest time to do so. i have always thought that giving some health lessons in school (not just sex education) would be a fanastic thing, because, lets face it, there are a significant amount of parents failing to educate their children on basic survival tactics.
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kathleen white | 6-Jun-2010 1:33 pm
Your article tells us nothing that we don't already know Sara.
I worked in the good old US of A too, & my abiding memory is of parents who did not have enough money to buy much needed medication for their children. I for one do not wish to see that happening here.

For example; a young mother finds a breast lump. If she does have £5 pounds, it might be needed to buy food for her family. By the time she does consult a health professional it might be too late. How cost effective would that be Sara?

It would be much more effective to resource our Health Visiting service to do the proactive that would be cost effective. Funding our education service so that children grow up with high self-esteem and a healthy work ethic would indeed be cost-effective. Sure Start is a good example.

I recently met a 24 year old man, on his release from prison. He was full of enthusiasim for his future. He told me that his dyslexia was diagnosed in prison where he was taught to read and write. His sentence was for repeated disorderly behaviour. Frustration, as opposed to crimminality. He should never have been in prision, but ironically, prison did what school failed to do for him. He now plans to go to college and get a job.

I know all this because I took the time to listen to him ( something that our current system does not allow enough time for in practice).

What an indicmenton our education service !!!

We currently have have young people leaving school, unable to read, write or add. Many of them will never be employed and therefore will never be able pay National Insurance.

So Sara, it is more appropriate to look beneath the surface and find the root cause of why our NHS service is being misused by some people. I would like to think that the misusers are in the minority, but unfortunately due to under-resourcing in the early years, we are rearing a significant group who will never be able to contribute to the NHS. In other words, we are failing this group.

My comment is not meant to be critical of Sara's article. I'm in agreement with some of what she says. eg, the downside of a fee, dissuading people from seeking advice at an early enough stage.

But do we really want to compete with the Americans and have patients in our waiting areas looking "very ill" ? Do American doctors make more money that way?
Following the health promotion model, by consulting before the "very ill" stage should be encouraged.

I'm a Practice Nurse and it makes my day when I see a waiting room full of healthy, happy people. An ounce of prevention is worth a ton of correction.

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Anonymous | 6-Jun-2010 2:18 pm
Problem with the above rationale is - most people who see the G.P. / Practice nurse are not at the bottom of the pile - why should they not pay if it improves the service for everyone? And Health Psychology 101 says that if you attach a financial value to the consult both the patient and practitioner invest more in it.

I think everyone should be 'billed' with a cost breakdown for the NHS services they use. So both the user and the practitioner know how much it all costs.
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Anonymous | 6-Jun-2010 2:50 pm
Hear hear, Sara.
Living on an estate where unemployment (some can't, many won't find work) is endemic, I am surrounded by those who, by official measures, can least afford healthcare, yet who can afford cigarettes and regular nights at the boozer, takeouts and taxis to the easily walking distance shops or schools, that's if they don't already run a car, cannabis and phet, and holidays twice a year.
The NHS is a wonderful but sadly unaffordable luxury. An ever deepening money pit that no amount of so-called savings can fix. Those who can afford to pay should pay, and those who can't, or who say they can't, should still pay be required to pay a nominal amount.
the world is very different now from when the NHS was instigated. We could spend our entire GNP and it still wouldn't be enough. It's time politicians and we as citizens of this country took our head out of the sand and faced up to this fact.
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Brenda Wendt | 6-Jun-2010 3:20 pm
The Brits expect their medical care to be free don't forget its a nanny state and the government looks after you.
I am a British trainned nurse working in the states but I can't say this system is much better as you have so many people who can't or won't afford health care and wait until the last minute then it costs more because they are in hospital longer. They then decide they won't pay their medical bills so the hospital has to take the brunt of it.
Now we are going to have this new reform health bill which is only going to make insurance companies raise their preimums and to cover all the extra money being put into medicare will raise our taxes.
Yes the english walk into a doctors office with coughs and colds which can be treated at home but at least a serious illness can be detacted at an early stage if the doctor is a good one and not a quack.
Which system is best who knows they both fail at some point.
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kathleen white | 6-Jun-2010 3:23 pm
What a brilliant idea from comment 6-June-2010 2:18PM. Let's bill everyone and create yet another layer of administration. Why not also create another layer to manage the new employees? The new managers could be paid mega figure salaries.

Let's get real. The majority of people know how much it costs. Billing those who don't know or don't care would be pretty pointless. I suppose we could send debt collectors after them, and if that fails they could be sent to prison !!! Would that really help the NHS budget?

People should not have to pay for the simple reason that the majority are already paying National Insurance.

I meet people who have not needed to consult any NHS department for 15 years or more. Added to that are those who have private medical insurance and do not use NHS resources. They pay twice for their care and are happy to do so. Many people hand in very generous donations for the ward fund and for the local hospice when their loved ones die.

Yes there are those who try to misuse the service,like the man who recently asked me for a prescription for flight socks that could be bought for £12, for his luxury trip and bitterly complained about having to pay for malaria prophylaxis.

Much of the misuse can be resolved without introducing pointless billing.

A small increase in National Insurance combined with an effort to have more people in employment and paying NI is a better option. I know that there is resistance to this option, but it might be the only way. Sara's article does say "you get what you pay for"

On the whole the majority are investing heavily in NHS services.

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Kristine Anastasia Mckale | 7-Jun-2010 0:17 am
There is a different philosophy towards both money and health in UK compared to USA.
Before ''holding up'' the USA health systems as superior in some way let's not forget that there is a shockingly higher death rate for newborns compared to the UK or Greece for that matter! Education of patients and clients is needed to ensure that they do not try to get healthcare for minor issues. Schools, clinics,surgeries and other agencies have a place here.
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kathleen white | 7-Jun-2010 9:11 am
I agree wih Kristine. she captures the full picture in one paragraph.
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Anonymous | 7-Jun-2010 9:47 am
I trained and worked in the USA, before marrying and moving to the UK. I never really thought about the benefits of the NHS until I had my first child. It was increddibly liberating to be able to take him to see the GP without worrying if we could afford it.
The system here is worth every penny we pay out of our taxes so that it can remain free at point of use. One doesn't realise how good something is until it's taken away!
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Steve Williams | 7-Jun-2010 9:59 am
A slightly edgy sociological comment from me here, one which many nurses seem not to have clicked into... or even thought about.

Hospitals are the new Churches. For many of the lay public 'Medicine' has replaced 'Religion.'

In years gone by people would go to their church and talk to a parish priest to vent their psychosomatic or guilt-induced symptoms and return to their everyday lives "cured" or at least having their anxiety levels deeply reduced by what amounted to a 'counseling' session.

Sadly, for a myriad of reasons, nowadays the churches are less accessible than they used to be. So the great-unwashed now turn to the only other caring institution that never shuts its doors - the Hospital.

1,000 years ago The Church taxed the people for its service whether they used it or not.

Nowadays the NHS taxes the people in much the same way.

We can't turn people away because they don't have the requisite entry-fee to talk to a nurse or doctor - it's like charging the congregationalists to attend Mass or confession.

Since we have brainwashed the masses to think that their "Health" is their number one priority (even over their religion) then we cannot really moan when they haul their tired and weary asses up to the mighty alter of A&E/E.R.

Once upon a time living a "Godly" life rather than a "Healthy" life was viewed as the ultimate goal for a person. That concept has honestly shifted over the last 50 years. How many (of us older people) remember their parents or grandparents doing a daily jog, drinking bottled water or perpetually taking theur blood-pressures? No, they didn't, they went to church every Sunday and prayed every night before bedtime.

Nowadays people (aided and abetted by the vociferous, totally intrusive and uneducated media) are obsessed by their bodies well-being rather than that of their eternal soul.

As nurses and doctors, to the public, we appear like the priests and priestess of 'sacred' knowledge that they want to know snippets of.

Don't get me wrong. I hate the "wasters" too. We have all got one, or three, good stories about them. When I did my stint in Casualty I took a history from a guy who said he'd found a small 'lump' on the side of his neck. When I asked him when he first noticed this small 'lump' he said "About six moths ago!" Accident and Emergency stuff?

Yes I was flabbergasted too but - looking back at it nearly 30 years later - I see he was only part of the underlying trend to view Hospitals rather than Churches as the fount of all wisdom.

Bottom point is that we simply have to get used to it and do the best job we can - with an empathetic (even if it is false) smile on our faces. :)
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Anonymous | 7-Jun-2010 11:43 pm
I don't think that Anonymous | 6-Jun-2010 2:18 pm - was saying that patients should be charged for their NHS care, just that they should be made aware how much their care is worth as a monetary value, i.e. a breakdown of 'vitual' cost, in order that the NHS could evaluate spending and patients could appreciate the money that's spent on them. It would certainly add time-costs and paper-costs, but I think that this commentator was saying that it may be time and paper well spent if it would improve appreciation of service given and future NHS effeciency when costs were then evaluated.
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mike | 9-Jun-2010 5:59 pm
I agree with many of the comments on here.

Our NHS is perhaps one of the best things this country has ever done, and I think it is far, far superior in many ways to the American model. To compare the two isn't even feasable as they run on two completely seperate dichotomies.

However, our NHS does get abused, a lot; and it DOES get taken for granted, especially in the new era of patients rights.

I do not condone payment for the vast majority of services (fines for abuse of the system is a different matter). Care should be free at the point of delivery.

However, I do agree with many on here who say that it is about time patients are made aware of the full cost of their stay, and how lucky they are to have it. A bill at the end for all their treatment, staff costs, etc, with a note saying 'paid for by the NHS' or something simialar might stop people taking us for granted at the very least.
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Steve Williams | 10-Jun-2010 1:36 am
mike. The more I think about it the more I think that your negated billing idea is bloody brilliant!

It reminds me of that old, overly sentimental, song “No Charge” http://artists.letssingit.com/tammy-wynette-lyrics-no-charge-bs1v3c3

“For the nine months I carried you growin' inside me, no charge
For the nights I've sat up with you
Doctored you, and prayed for you, no charge
For the time and the tears
That you've cost through the years, there's no charge
And when you add it all up
The full cost of my love is no charge.

For the nights filled with dread
And all the worries ahead, no charge
For advice and the knowledge
And the cost of your college, no charge
For the toys, food and clothes and even for wipin' your nose
There's no charge, son
And when you add it all up
The full cost of my love is, no charge.”

Oh yeah, a teeny-weeny point of order to all and sundry who *actually* read this stuff...

Please be judicious and circumspect about your use of the term “America” in your replies. There are two countries that occupy “North America” - ‘Canada’ and the ‘United States of America.’

The former has a health system closely modelled on our Mother Country’s ‘National Health Service’ - the latter has a health system closely modelled on ‘Dante’s Inferno!’

Just another small point - but it really does “cut us to the quick” when UK nurses disparage “American” health-care systems... There’s South America, North America, The United States Of America or Canada - there’s no such thing as the popular euphemism of “America!”

It’s like one of my Canadian colleagues calling me “English” - because I am Welsh - it rubs me up the wrong way - I give in to their understandable naivety and tell them I am British (not Irish, Scottish or English... but Welsh) I just happened to be born in Canada!!! :)

Okay, tiny-rant over.

Definitely mike! Send them the itemised bills to show exactly where there tax/National Insurance dollars have been spent - then say “No Charge - you lucky Bar Steward - you live in the UK!”

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Anonymous | 15-Jun-2010 2:04 pm
Absolutely brilliant, Mike! What a fantastic idea!
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