Speak Out Rheum: How the U.K. and U.S. Healthcare Models Stack Up

The National Health Service (NHS) in the United Kingdom is sometimes demonized in sections of the American media, particularly in the run up to presidential elections. The threat of rationing, long waiting times, and “death committees” permeate the debate, with those opposed to socialized medicine doing the shroud waving, and trying to frighten the electorate and derail any movement of American healthcare toward an NHS-style system. I recently had the honor of visiting a leading academic and clinical center in the U.S. It was a pleasure to compare U.K. with U.S. rheumatology. I have chosen not to name the center, as some of my comments may be read as critical, which they are certainly not meant to be. They are simply the reflections of an outsider looking in, from the perspective of a different healthcare system. The U.K. NHS is undergoing yet another round of enormous change, with the emphasis of the government being on increasing value in healthcare (with “value” defined as outcomes divided by resources spent). In transforming the NHS, there is much that can be learned from other healthcare systems, both in terms of what should be emulated and what might be avoided!

The U.K. and U.S. have major differences in healthcare provision. It might surprise my American colleagues to hear that after having had long conversations with esteemed U.S. colleagues, I would rather work in the U.K. NHS than in the American healthcare system. Perhaps this is familiarity, but I do think that a national socialized medical system has significant advantages over the often-fragmented and unequally distributed U.S. system. Let me try to describe U.K. rheumatology for my American colleagues, and see if I can justify my preference.

1. New patients do not have direct access to me. I am currently not allowed to advertise my services, although my contact details and patterns of work are made available to general practitioners (GPs—our primary care physicians). The majority of my referrals come from GPs. They can judge how urgent the referral appointment needs to be. This results in a high proportion of my referrals being relevant to my clinical knowledge and skills. However, this system occasionally leads to delays in referrals, and some GPs are better than others at judging whether a referral needs to be made and how speedily, though with ongoing education of, and interaction with, GPs, we seek to minimize this delay. For urgent referrals, we provide an on-call service so that patients can be seen the same day. For early inflammatory arthritis patients, we have a booking system that gets patients into clinic within two weeks of referral. Other patients do not have to wait more than six weeks for an appointment, which is a lot longer than many U.S. patients—providing, of course, they have the insurance or funding to access a rheumatologist at all.