How health care works around the world

Meera Senthilingam

March 18, 2017

In a doctor's waiting room in South London sit three people of varying ages and ethnicities, waiting among a sea of empty green plastic chairs. It's Tuesday afternoon in the Hetherington Group Practice, which serves more than 8,500 people from dozens of miles in every direction from its base in the bustling area of Brixton. Adorning the many notice boards on the walls are posters asking people to get flu vaccinations, to embrace more walking as part of their day to day and to speak up if they feel that they may have symptoms of bowel cancer. Another poster informs that the Accident and Emergency room at the local hospital "won't kiss it better," appealing to people not to visit their local ER when something is not urgent. Records from the National Health Service show that the numbers of people visiting an emergency room in England have risen from just over 4.5 million per quarter in 2004 to almost 6 million per quarter by the end of 2017 -- almost a 25% increase. In the corner of the waiting room sits a "patient pod" consisting of a computer, a blood pressure machine and scale, for people to measure their vitals in their own time. They can even monitor their mood by answering a series of questions about how they're feeling and what they're thinking. The practice has more than 230 patients registered with severe mental health problems, such as psychosis. "It's about managing demand," said Dr. Steve Mowle, one of the nine physicians at the practice and a spokesman for the Royal College of General Practitioners. This "pod" and the option of a phone consultation aren't the norm for all general practitioners' facilities but Mowle -- like any other GP in the United Kingdom -- has a budget to spend on his practice each year, based on a capitation, an amount paid from the government's budget per patient registered. He and his partners may use it how best they see fit to meet the multiple needs of their large patient base. Demand on the practice has increased significantly in recent years. Unusually, the rise is not in terms of patient numbers, which have in fact fallen, but by people living longer with greater numbers of increasingly complex conditions to manage. Each day, Mowle will have contact with 40 to 50 patients, he explained, with 60% of those in person and the rest through phone consultations. "My clinics are longer," Mowle said. A clinic represents a half-day of seeing patients and is meant to last three hours each. His clinics routinely last at least five hours. Steve Mowle works at the Hetherington Group Practice in London, contacting 50 patients, on average, each day. "Being a full-time GP is impossible," he said, adding that there is "more and more administration" on top of seeing patients. The demographic of his patient base is as vast as the region the practice covers, ranging from the homeless, newly arrived refugees and blue-collar workers to high-earning middle-class and lawyers and bankers whose houses are worth millions. More than 140 languages are spoken locally. Despite their differences, the patients at this clinic -- and anywhere else in the UK -- have one thing in common: Not one of them will pay or receive a bill for the care they receive here. Their health care is free and universal and has been since the formation of the country's National Health Service in 1948. The population's health care is funded through tax and compulsory national insurance contributions deducted from income, which go toward many state benefits. But as the demand for health care has increased across all levels of care -- primary, secondary and tertiary -- so has the strain on this once-coveted health system -- particularly on its finances. A changing climate for health care Health care budgets in the UK have been plateauing, with only minor increases in spending, as percentages of gross domestic product spent on it have been declining. According to the Kings Fund, an independent health care charity, the National Health Service is halfway through its most austere decade ever. Figures from the World Bank reflect this: In 2009, the UK spent 9.8% of its GDP on health care; by 2014, it fell to 9.1%, according to the World Bank. Along with this came more people, who are living longer and with multiple conditions like diabetes and heart disease that require treatments also rising in cost. Meanwhile, hospital bed numbers have fallen, numbers visiting emergency rooms have risen, and the demand for social care -- such as home care or equipment -- in the community has increased with limited services in place to provide it, again leaving more people with fewer hospital beds. "The current situation is unsustainable," said Dr. Ian Eardley, vice president of the Royal College of Surgeons in the UK and practicing surgeon at a hospital in Leeds. "There are patients who are medically fit but can't get help in the community, or support, to leave hospital." Austerity has brought extended wait times for people seeking elective or routine treatments, such as knee or hip surgery, while emergency treatments for serious issues such as cancer or heart attacks continue to be treated promptly, as they should, according to Mowle. Guidance requires anyone in the UK with signs of cancer be seen within two weeks. "(But) you can't bring patients in for elective surgeries," said Eardley, who further stressed the complexities surrounding people living longer. "People often live longer with other medical problems being controlled and managed," he said, adding that greater expectations by patients today and the tendency to discuss cases in greater detail all add time and strain to an already overwhelmed system. Another financial constraint is the increasing, but important, role of computing. "Most of these countries have seen a need for increased spending with changing technology," said Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine. Real National Health Service spending in 2015-16 increased by just 1.6%, according to the Kings Fund. "The budget has been frozen for too long," McKee said. More funding is needed, he said, to decrease the debt owed by hospitals whose budgets were not enough and to ensure a greater transition from care settings into the community.

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