Monday, 28 June 2010

Trust me, I'm a doctor

This recent illness of mine provides a nice opportunity to discuss health and medicine here in the UK. As everyone probably knows, the British government provides health care for all its citizens and residents and, from what I understand, for pretty much anyone who wanders in off the street needing some medical assistance. This is terrific, since, with the exception of a brief period between my 25th birthday and the start of my doctoral degree, when I became the "beneficiary" of the student insurance offered by the College of William and Mary, I was about to find myself without insurance in the US for the first time in my life. Thus, it is handy to arrive in a country where I do not have to worry about finding an insurance provider and choosing a plan that is both affordable and comprehensive.

It is also handy to arrive in a country where both medical coverage and treatment are reliable. The only reliable thing about my W&M insurance was that my prescriptions were free as long as I had them filled at the College's pharmacy. However, the company was quite stingy about paying for any medical treatment requiring a specialist outside the campus medical center (which was pretty much any medical treatment beyond, say, application of a band-aid or injection of a vaccine); on many occasions, I had to re-submit claims and provide supplementary documentation in order to prove that I was entitled to certain types of coverage or reimbursements. With my insurance company, as with many (or most) other insurance company in the US, I felt relatively secure that I would eventually receive financial assistance with medical bills, but I also felt assured that the company would make it as difficult as humanly possible for me to get that assistance. It seems unfair that anyone should have to live with this constant worry of losing large sums of money because he/she happens to be infected with a virus or trip and break an arm, etc.

This kind of fear must be particularly troubling to people with severe, debilitating, and/or chronic illness. I had some experience with this after I began having back problems a few years ago, and because of my lifelong battle with migraines. Recurring problems like this often require multiple trips to the doctor, sometimes in close succession, and often necessitate very expensive procedures (CAT scans and MRIs are unbelievably costly; even a simple X-ray can cost multiple hundreds of dollars). One thing I really admire about places that have nationalized health service is that they eliminate the fear associated with wondering however on earth you—or your family—will pay for medical care if you should require it. From my perspective in the US, the UK system seemed quite a bit more civilized, and I was intrigued to experience it first-hand, especially after it was mentioned so frequently during the health care debates of the recent US elections.

Despite the fact that a British hospital/doctor will treat foreigners in cases of emergency, the proper course of action is to procure a national insurance number, which is kind of like the British version of a social security number. Anyone who works or lives in the UK is entitled to a national insurance number, from what I can tell, and because I do both, that was the first step in my process to go to a doctor here. I neglected to do this for quite a long time because I was worried that it was going to be confusing and difficult, and I was still tired from having to fill out all the visa paperwork 5 months ago. When I finally did stir myself into action, it turned out to be ridiculously easy. I called the National Insurance hotline and gave them my address. They sent me a form where I filled in my basic information (name, address, phone number). Although I am technically self-employed and therefore could have been asked to fill out an extra couple pages, I also hold a spousal visa, and so the lady from the hotline center had marked through these pages, cutting down the amount of work I needed to do. I supplied a copy of my passport/visa, and a piece of mail to show that I really do live at my address, and that was it. It was simpler and less time-consuming than getting a new driver's license when I moved back to OH from VA, and.

Often, you are required to go in for an "Evidence of Identity" interview after submitting your national insurance paperwork, so I was expecting to have to make an appointment at the local branch office in Truro. I assumed that this would require a couple weeks of waiting for an open slot, plus the 30 minute train ride in either direction, plus a half hour of waiting for the interview and then another hour or so for the interview itself...but, about a week after I sent off my application, I received my national insurance number in the mail, no questions asked. Can you imagine that happening in the US?

The next step was to find a general practitioner (GP). In some ways, the UK system is similar to the system at W&M--you go to a GP and tell them what's wrong with you, and if they can't fix it, they send you to a specialist. This can require longer waiting periods than we are used to in the US, but the worst that will happen is that you will be inconvenienced, as opposed to endangered. For instance, I have a friend who recently had a hernia operation, and she had to wait a couple months after her diagnosis before she underwent the procedure. However, if she'd had a more immediate problem, such as appendicitis, she'd have been treated immediately. The only problem with GPs is that they can be overwhelmed with patients, and therefore not all GPs are willing to take on new patients at any given time. I am having this issue with a dentist right now--I'd like to go where my husband goes, but since they are chocked full of patients, I have to wait a couple of weeks until the college kids go home before the office will book me in (I'm just as happy to wait--I hate going to the dentist).

Much to my surprise, getting in to see a GP was as easy as getting the insurance number. All I had to do was go in and fill out some forms, and then I could make my first appointment:

(The Falmouth Health Centre--very unimposing.)

After my previous experiences with official documents and other important transitions between the US and UK, I assumed I would need a variety of paperwork in order to facilitate this process. I packed my passport/visa, my driver’s license, my wedding certificate, and the official letter containing my national insurance number. Imagine my surprise when all I needed to produce was my photo ID, which is something they request of all patients. My foreign accent didn’t cause anyone to take pause, and nobody asked for any evidence that I was a resident.

While filling out the forms, I was a bit confused by the section requesting my NHS number, which, I thought for a heart-thumping moment, was something I needed to have procured already but hadn’t. I went to ask the receptionist about this and she looked at me like I was a total idiot; this was particularly embarrassing because she was about 18 and had a look of condescension that could wither even the most confident of individuals. I gave her my typical excuse, which is that “We don’t have this stuff where I come from.” People here seem to love it when I say that, which I do often—when figuring out seats on trains, when using credit card machines, when ordering food in restaurants. I say it even when it’s not entirely true, because a) Brits love self-deprecation, and b) Brits love feeling superior to Americans. It really does work, too—by the time I left the office, the sulky receptionist was even smiling at me. As it turns out, the NHS number is something you get after your first visit to an NHS-affiliated clinic; after all that agonizing over getting the national insurance number before going to see the doctor, I didn’t even need to use it anywhere. I think officials just like giving citizens as many numbers as possible to remember.

My most immediate medical concern was getting myself some migraine medication, and the health center was able to schedule me in for an appointment within a couple weeks. When I reported back, I was delighted to find that the check-in process was very high-tech. You walk up to a computer near the receptionist’s desk, type in your birthday and your name, and it finds you in the system. Within five minutes of checking in, I was called to the back. I don’t think I have ever spent so little time in a waiting room in my life, and it was great.

The doctor to whom I have been assigned appeared to be quite a shy person, which must be difficult in the medical profession—how do you spend your life in a career that mainly consists of talking to people, if you feel uncomfortable talking to people?

(Dr. James. According to his online staff profile, he is an avid surfer and is interested in increasing the use of technology in medicine. I would never have guessed the former, but the latter, for reasons you will soon discover, does not surprise me.)

One of the most frustrating things about having a chronic condition is that you have to discuss it with every new doctor you go to, and every doctor doubts the diagnosis of all other doctors that preceded him/her. So, for about the tenth time in my life, I had to describe my migraines—when I started getting them, how often I get them, what they are like, what triggers them, what medicines I’ve taken for them, blah, blah, blah. This is such a boring thing that I have to resist the urge to make up symptoms just for my own amusement. The doctor agreed with me that I do suffer from migraines and that my former doctors haven’t been wrong for the past 17 years, and then asked what kind of medication I normally take.

Now, this is the point at which this story becomes a bit of a tragedy, and that is because of the way the NHS works. Because the NHS covers pretty much everyone, pretty much without question, it spends a lot of money on patients. One way to make sure that it doesn’t spend more money than it has to is to put pressure on doctors to prescribe only generic and/or older drugs, which are cheaper. You can have name-brand, newer, and more expensive drugs, but the doctors need to be able to show that there is good reason for this. There actually are “prescription police” at the NHS, as Dr. James described them, who look through the paperwork to make sure that nobody is needlessly prescribing expensive drugs. I understand the logic of this, and I sympathize, but I’m also a bit put-out. This is because, of the dozen migraine prescriptions that I have tried, the one that works best for me, and without the fewest side effects, is a new-ish, name-brand drug. That means I can’t have it—at least, not until I try another one and say that it doesn’t work, and then maybe try yet another one again, and say that it doesn’t work. I even asked whether I can accept responsibility for paying the full cost of the drug myself, and I was told that isn’t an option. Sometimes I miss the fiendishly capitalistic US.

What’s really amazing is the cost of these drugs. In the US, some of my migraine prescriptions cost over $200 per box of 6 pills—that’s about $33 per pill—before insurance. Even when I was only responsible for the co-pay, I could still be charged $25 each time I had my prescription filled. Here, the entire box costs about that much. Unless you belong to certain demographic groups (e.g., veterans, students, etc., who get prescriptions filled for free), you do have to pay a small fee at the pharmacy (where the person who fills your prescription is called the “chemist,” rather than the “pharmacist”). In my case I had to pay £14.40 for a prescription that I know will not work, and, further, that I know will give me awful side effects that are even more unpleasant than the headache itself. I know this because I have already tried this medication in the US, but the NHS setup is forcing me to try it again here. Actually, what I will probably do is keep the pills in a drawer somewhere for when I’m truly desperate and out of other options, but tell the doctor that I used them all and that they didn’t work. In other words, I’ll lie until I get what I want. The really sad thing about this is that the box of drugs I normally take only costs £35, and by the time I finally get around to getting that prescription, I’ll have wasted that much money on something ineffective.

Still, imperfect as the system may be, it’s preferable to the one in the US (or, at least, the one that was in place when I left). Everyone here gets the coverage and drugs they need, and everything (at least in the clinic I visited) is digitized so that all my records will be accessible in electronic form to whomever may need them. The drug database that my doctor consulted was also electronic, which I appreciated. The last time I went to a doctor about migraines, he leafed through a pharmaceuticals book that looked as though it had been published in 1950, and I couldn’t help but wonder if there might be a few newer prescriptions that weren’t listed in its pages (in fact, the doctor did prescribe me something so out of date that the pharmacist came out and had a whispered conversation with me about my physician clearly had no idea what he was doing). The electronic list made me feel quite a bit more confident that all the options were being considered.

On my way out of the clinic, I stopped by the receptionist’s desk to double-check the timing of my next appointment, which was my “new patient physical.” I found it a little odd that they insisted on a new patient physical (as opposed to just having me transfer my records from the US), but that they didn’t care if it came after my first visit to the doctor, when you would think that some of the basic clinical information might come in handy. As I was turning away to leave, the receptionist asked whether I’d been given a sample jar when I first made the appointment. Um, no. For some reason, the new patient physical requires a urinalysis, which I thought was pretty odd—I can’t even remember the last time I had to give a urine sample, especially in the absence of any symptoms that indicated one was necessary. I guess they are just very thorough here. I’m not sure whether I should be pleased with that, or whether I should start worrying about what this new patient physical is going to entail. I guess I’ll find out next week, when I show up for my appointment!

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