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'British Cardiovascular Society Blogging Cardiology'

Here it is….THE healthcare debate: The UK perspective

To join the debate, this blog should be read in conjunction with that of fellow ACC blogger Wes Fisher, who I thank for inventing such choice names!

For the purposes of the exercise, we’ll take two patients, Mr. Thurgood Powell, a highly successful 57 year-old businessman making $250,000 (£166,128) per year with his company PoshPosh Entertainment, and Mortimer T. Schnerd, a pleasant 43 year old man who is unemployed but working part-time in the local K-mart, earning $17,400 (£11,562) per year. Both men will experience heart attacks, both men will present to Emergency Rooms in both countries,  and require 4-day ICD or HDU stay, require surgery, the implantation of an automatic defibrillator and follow-up for the first year after the heart attack. We are going to put both patients through the US and UK healthcare systems to compare what happens in a generalised manner…..The US perspective is on Wes’ site

This is the UK perspective. NHS versus private healthcare:

 

The UK Case of Mr. Thurgood Powell (a native Englishman) who has private health insurance

The red phone in HDU rings and the ambulance crew advise the nurse that they have a 57 year old man with a 45 minute history of chest pain and ECG changes of an anterior ST segment elevation. ECG performed and interpreted on scene by paramedic crew. ETA 50 minutes. Loading dose of aspirin 300mg and clopidogrel 600mg given by crew on scene.
The nurse contacts the hospital switchboard to activate the PPCI team to attend the cath lab. The SpR (registrar) and SHO (senior house officer) attend the front door to await arrival of the ambulance and transfer the patient directly to the cath lab.

Patient arrives. Looks poorly, but no contraindication to proceeding directly to cath lab. Angio performed and shows culprit 95% LAD stenosis. Other significant 3-vessel disease is noted. Ventriculogram not performed. His BP drops, intraaortic balloon pump placed. Due to his age and lack of comorbidities and as LAD lesion, it is decided to place a drug-eluting stent in LAD artery. Aside from some VT during case and one episode of ventricular fibrillation during his procedure requiring a DC shock, the patient tolerates the remarkably well. Patient is transferred to the high dependency unit,  HDU- a 4 bedded dedicated unit.

In an emergency situation Mr Powell is treated as an NHS patient so all appropriate care will be provided and there is no need to worry him about money. In the UK most insurance companies operate a 6 week rule. If treatment can be offered by the NHS within 6 weeks then patients are usually not covered by their insurance. Elective treatment not available for > 6 weeks on NHS is usually covered by medical insurance.

Patient is started on bisoprolol 2.5mg daily, Ramipril, Aspirin, Clopidogrel, and atorvastatin, although the local PCT has advised that simvastatin should be prescribed due to costs (as they will pay for the ongoing treatment in the community after discharge) – but the doctor uses his/her discretion.

Patient develops signs of congestive heart failure on day two, requires ongoing balloon pump support. Some atrial fibrillation occurs, requiring titration of medications to control. Echocardiogram performed to assess LV function. Balloon pump eventually is weaned on day 3.

He leaves HDU on day 4 for a bed on the NHS ward. He could pay £80/day for a private room if he wishes. As no infection control issues he may be in a 4- bedded single sex bay, or a side room, if available. He may have a TV in the side room but there is unlikely to be one in the 4-bedded bay. However, a sitting room on the ward will have a TV for all to view if well enough. His food is ordered form a menu sheet collected by the housekeeper.

He spends two more days on the ward and then is discharged to be followed-up in an outpatient clinic at his local hospital, hopefully in one month. Clinics are very busy but the local DGH should prioritise his appointment.  He may request to see a private cardiologist earlier if covered by medical insurance if he wishes to self fund. He will also be referred to the rehabilitation team at his local hospital who should be in contact within a week to commence his rehab programme. He will have had Phase 1 whilst on the ward. This is provided by the NHS.

The patient is discharged home. There is no bill to pay.  The hospital claims an emergency tariff charge from the Primary Care Trust (hold the budget and commission services locally) which will equate to the most expensive procedure during his stay ie the PCI (costs to follow-sc)


Despite his treatment, Mr. Powell continues to have ongoing exertional angina and as he has private medical insurance (which he has taken out himself) and this is an elective appointment he seeks a referral from his primary care physician (General practitioner or GP) for a private consultation with a cardiologist of his choice. He may have an excess to pay depending on his policy but Mr Powell is fully covered for outpatient and inpatient treatment in this instance.

He is admitted at a date to suit him (2 days time say) for another angiogram performed by the cardiologist. The angiogram is unchanged. The stent is fine. Mr Powell stays in a private ward which is part of the NHS hospital and covered by the NHS medical team. He has a single en-suite room, tastefully decorated and with his own TV.  Food is prepared by a chef on the ward, served on tasteful china and a tray. He has his own phone in his room.

It is decided that because of his young age, pain refractory to medical therapy and his complex anatomy not amenable to PCI, that he will be referred for a bypass. He checks he is covered by his insurance company for the procedure. He is seen by the surgeon on the ward the same day and elective surgery scheduled on a mutually convenient date (say a couple of weeks time). He has a pre-operative echocardiogram which shows LV impairment with EF at 35%. He is discharged home and the insurance company receive the bill from the hospital for the angiogram and echocardiogram. The cardiologist and surgeon (consult) submit their fees to the insurance company independently. Mr Powell will pay an excess direct to hospital or doctor (usually £500-£1000/yr).

Approximately 6 weeks after surgery (which is billed directly to the insurance company), patient notes palpitations and light headedness. He returns Accident and Emergency where his is found to be in sustained monomorphic ventricular tachycardia. He is admitted to hospital again as an NHS patient (as this is deemed emergency treatment) and another angiogram is performed to check the grafts. Vessels unchanged. An ICD is scheduled for next few days (patient had atrial fibrillation in the past, after all). Patient returns home. There is no bill to pay by the patient for emergent treatment. The hospital charges tariff price for ICD and inpatient emergency tariff for most expensive procedure…likely to be ICD- costs to follow sc). If quota of commissioned ICDs has been met at the Trust, the Trust can seek payment from the PCT by ‘payment by results’. Only after negotiation and in exceptional circumstances would the PCT not pay. They would want to see national guidance is being followed.

Patient is amazed by the state-of-the art technology installed.

Follows up will be with cardiac physiologist in ICD clinic (NHS), surgeon at 6 weeks post op (privately- surgeon bills insurance company directly) and with his cardiologist (privately- cardiologist bills insurance company directly) at a mutually agreeable time.

SUMMARY: Mr Powell has received all his emergency medical care on the NHS irrespective of whether he has private insurance or not. He elected to use his medical insurance for the elective care but he could have had this equally on the NHS. His choice. His premium may go up next year. In addition his tax bill will go up next year to 60% as he is in the high income bracket. He may reconsider his options! The only difference with elective private medical care is that he can choose his physician, he will receive treatment more quickly and at a convenient date compared to the NHS. He has a more comfortable stay in a private ensuite room in the private wing of the hospital.

 

The U.K. Case of Mortimer T. Schnerd (a native Englishman) with no medical insurance

The red phone in HDU rings and the ambulance crew advise the nurse that they have a 43 year old man with a 45 minute history of chest pain and ECG changes of an anterior ST segment elevation. ETA 50 minutes. ECG undertaken on scene by paramedic crew. Loading dose of aspirin 300mg and clopidogrel 600mg given by crew.
The nurse contacts the hospital switchboard to activate the PPCI team to attend the cath lab. The SpR (registrar) and SHO (senior house officer) attend the front door to await arrival of the ambulance and transfer the patient directly to the cath lab.

Patient arrives. Looks poorly, but no contraindication to proceeding directly to cath lab. Angio performed and culprit 95% LAD stenosis and other significant 3-vessel disease is noted. Ventriculogram not performed. His BP drops, intraaortic balloon pump placed. Due to his age and lack of comorbidities and as LAD lesion, it is decided to place a drug-eluting stent in LAD artery. Aside from some VT during case and one episode of ventricular fibrillation during his procedure requiring a DC shock, the patient tolerates remarkably well. Patient is transferred to HDU. He is in the next bed to Mr Powell.

Mr Schnerd is an NHS patient so all appropriate care will be provided and there is no need to worry him about money.

Patient is started on bisoprolol 2.5mg daily, Ramipril, Aspirin, Clopidogrel, and atorvastatin, although the local PCT has advised that simvastatin should be provided due to costs (and they will pay for the ongoing treatment in the community after discharge) – but the doctor uses his/her discretion.

Patient develops signs of congestive heart failure on day two, requires ongoing balloon pump support. Some atrial fibrillation occurs, requiring titration of medications to control. Echocardiogram performed to assess LV function. Balloon pump eventually is weaned on day 3.

He leaves HDU on day 4 for a bed on the NHS ward. As no infection control issues he may be in a 4- bedded single sex bay, or a side room, if available. He may have a TV in the side room but there is unlikely to be one in the 4-bedded bay. However, a sitting room on the ward will have a TV for all to view if well enough. His food is ordered form a menu sheet collected by the housekeeper.

He spends two more days on the ward and then is discharged to be followed-up in an outpatient clinic at his local hospital, hopefully in one month. Clinics are very busy but the local DGH should prioritise his appointment. He will also be referred to the rehabilitation team at his local hospital who should be in contact within a week to commence his rehab programme. He will have had Phase 1 whilst on the ward. This is provided by the NHS.

The patient is discharged home. There is no bill to pay.  The hospital claims an emergency tariff charge from the primary care trust which will equate to the most expensive procedure during his stay ie the PCI (costs to follow-sc)


Despite his treatment, Mr. Schnerd continues to have ongoing exertional angina and mentions this at his outpatient appointment He is placed on the waiting list for an angiogram (the target on the NHS pathway is for referral to treatment to be completed in 18 weeks- 18 week RTT time) performed by one of the cardiologists team, which is unchanged. The stent is fine.

Mr Schnerd stays on the day ward. He is in a 4 bedded single sexed bay. There is no TV (which is in the day room) or telephone (again in the day room). Food is ordered from a card. Lunch will be sandwiches. Hot meal in the evening as required.  

It is decided that because of his young age, pain refractory to medical therapy and his complex anatomy not amenable to PCI, that he will be referred for a bypass. The cardiologist writes a letter to a surgeon and he will be seen as soon as possible in the surgeons clinic (he is still on the 18 week RTT pathway). He is referred for an out-patient  pre-operative echocardiogram which shows LV impairment with EF at 35%. He is discharged home The hospital bill the PCT (Primary Care Trust who hold the budget and commission services) for a daycase angiogram tariff- a standard fee across the UK with some weighting in certain situations eg in London.

 

Approximately 6 weeks after surgery, patient notes palpitations and light headedness. He returns Accident and Emergency where his is found to be in sustained monomorphic ventricular tachycardia. He is admitted to hospital again as an NHS patient and another angiogram is performed to check the grafts. Vessels unchanged.

An ICD is scheduled for next few days (patient had atrial fibrillation in the past, after all). Patient returns home. There is no bill to pay by the patient for emergent treatment. The hospital charges tariff price to PCT for ICD and inpatient emergency tariff for most expensive procedure…likely to be ICD- costs to follow sc). If quota of commissioned ICDs has been met at the Trust, the Trust can seek payment from the PCT by ‘payment by results’. Only after negotiation and in exceptional circumstances would the PCT not pay. They would want to see national guidance is being followed.

Patient is amazed by the state-of-the art technology installed.

Follows up will be with cardiac physiologist in ICD clinic (NHS), surgeon at 6 weeks post op (NHS) and with his cardiologist at a mutually agreeable time.

SUMMARY: Mr Schnerd has paid nothing for all his treatment…all on the NHS.

 

So visit the USA blog by Wes Fisher to see the story from the other side of the pond and tell us what you think!!! Is the NHS so bad, can we learn from the US system? Are both systems in need of reform…a Congress bill coming up in the US, an election in the UK..your chance to have your say! Fire away!!!!

Sarah

PS please note that these are fictional characters and scenarios and statements are those of author, generalised and not exhaustive. It is recognised that other scenarios may be different but the cases are for general illustration and comparison only ie dont shoot me!!

5 ResponsesLeave one →

  1. Sarah-

    Thanks so much for your help constructing these scenarios from the UK perspective.

    From what I see, it seems that the PCT (Primary Care Trust) holds the money and makes the rules in the British system->how much they’ll pay, if they’ll pay, how many procedures they’ll pay for, etc., etc. This seems to be a fundamental difference between the UK’s system and that in the US. Rationing currently does not occur, but our new health care bill will likely visit some form of covert rationing upon our populace to save costs inthe years to come.

    I enjoyed attending the session at the recent ACC meeting between the British Cardiovascular Society and the American College of Cardiology. While we clearly have a health care cost crisis in the US, I was surprised to learn that the costs are shooting skyward in the UK as well. According to one talk there, the UK’s annual budget for heath care was about £44B in 2000 and projected to be £112B in 2010 – over 120% increase. With the high British tax rate already in place, one wonders how long these health care cost growth rates will be sustainable. Despite this, it seems there’s a remarkable lack of transparency about costs regarding ICD’s there. I would LOVE to see what an ICD costs the PCT versus what it costs our hospitals. I bet the difference would be staggering! (We’d pay more because, well, they can get it.)

    Also, I was struck that primary angioplasty was not implemented in the UK nationally until it as studied between 2005 and 2008 and determined to be cost effective. This slow adoption rate would not be tolerated in the US currently. We have a hard time saying “no.” There is a tacit perception as a professional that if you’re not implementing the latest technology or intervention as soon as it’s available, you’re a laggard. Americans don’t like being laggards.

    Well, I’ve carried on too much, but wanted to share some of my thoughts at first blush. It’s been a pleasure working with you on this and I hope we can continue the effort in other ways!

    All the best!

    -Wes

  2. Emily

     /  March 24, 2010

    “Mr. Schnerd continues to have ongoing exertional angina and mentions this at his outpatient appointment He is placed on the waiting list for an angiogram (the target on the NHS pathway is for referral to treatment to be completed in 18 weeks- 18 week RTT time) performed by one of the cardiologists team, which is unchanged. The stent is fine.”

    Eighteen weeks is a LONG time! Mr. Schnerd may have to wait up to 4.5 months for an angiogram? What if the stent hadn’t been fine?

    Not that the US system is any better; patients without insurance or the means to pay cash have to wait much longer to get appointments and, where I work, are seen by the resident rotating through clinic, rather than having the same attending physician most of the time.

    Thanks for the fascinating comparison!

  3. Sammy O. Henns, MD

     /  March 27, 2010

    What a complicated health/medical maze you all have to deal with in Britain. In any case, one can see that the main predicating or guiding factor in both system’s health-care delivery is the way the insurance companies control the way medicine is practiced by physicians.

  4. Health care provider may refer to either an individual or an institution that provides preventive, curative, promotional or rehabilitative health care services in a systematic way to individuals, families or communities

  5. Adam

     /  June 7, 2011

    Fascinating scenarios. 18 Weeks for the angiogram. Hmm… And 80 pounds per night for a private room seems low. We just paid 500 pounds per night for a private room at the John Radcliffe Hospital in Oxford. The room compared very poorly with Motel 6.

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