Given the recent push from the progressive arm of the Democratic party for Medicare for all, it is useful to look at nations that already have that model.  Dr Hussain Gandhi is a General Practitioner (GP) in Nottingham, England.  We discuss the UK health system and the pros and cons of universal state-funded healthcare for populations and individuals.    Aside from his practice, he is the representative to the Royal College of General Practitioners (RCGP) council, treasurer of GP Survival, local LMC representative and owner of eGPlearning – which aims to support clinicians with technology-enhanced primary care and learning. Use the following link to find your platform of choice – linktr.ee/drgandalf52 and find out more about health tech, med tech, social media use as a clinician and more, or better yet subscribe to his weekly updates at bit.ly/eGPleariningYouTube He also co-hosts the eGPlearning Podblast – the UK’s leading primary care focused health tech podcast on various platforms here: linktr.ee/egplearning.

 

EPISODE TRANSCRIPT

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Welcome to the physicians guide to doctoring A Practical Guide for practicing physicians where Dr. Bradley Block interviews experts in and out of medicine to find out everything we should have learned while we were memorizing Krebs cycle. The ideas expressed on this podcast are those of the interviewer and interviewee and do not represent those of their respective employers.
On today’s episode, we speak with Dr. Hussain Gandhi, a general practitioner and Nottingham, UK. He’s the host of the EGP learning podcast, where they discuss healthcare technology and its applications for GPS. He’s on the show today discuss the National Health System, England socialized healthcare system. There’s a push among progressive Democrats for Medicare for all a more socialized system for the US. So we discussed the strengths and weaknesses of the socialized English system from his perspective as a GP and the differences and even some similarity between his systems and ours.
Welcome back to the physicians guide to doctoring. On today’s episode, we’ve had Dr. Hussain Gandhi who’s joining us from England. He’s a general practitioner there now also hosts his own podcast. So Dr. Gandhi, thank you so much for being with us today. I think we did do an doing great doing great recording today from my mother in law’s closet in Zurich, Switzerland.
Wow. So truly international podcast with you in Switzerland in the UK.
Indeed, indeed. So first, let’s just talk a little bit about your podcast.
Yeah, so I co host what’s called the EGP learning pod blast. And so it’s a podcast that me and my colleagues set up about just over a year ago, partly because we’re both a bit tech geeks and stuff and we also GPS. So I guess for the benefit of your audience, as a general practitioner, or a GP, is probably the equivalent of a family physician that you guys would have in America, but based in our slightly different country, The structure of healthcare systems. So we do majority of the patient contacts in the UK when it comes to health services. And, you know, I’ve got a huge interest in tech, huge entities and health and provision of health and stuff. So we started up this pocket, that’s just talking about all the various different forms of health technology, and how you can use it either as clinician or as a patient and the impact that it can have. So we’ve covered various different things like simple stuff, like apps that people may use, all the way up to things like genomics, artificial intelligence, video consultations, all this kind of stuff. So yeah, it’s a topic we love to talk we enjoy. And we’ve had some really interesting stuff come out in the past few months. And we’ve got some really cool things coming in the next few months as well. So yeah,
and I think my audience is mostly, if not all in the United States, but it sounds like this is not a UK centric podcast. While it’s you know, it’s based there. I think all health tech is international. So it seems like it would be useful for Anyone?
Definitely, I mean, a lot of the stuff we may cover does relate to the kind of the structure of the NHS and the provision of health care in the UK, but particularly things like the apps themselves and the various different types of tech that we review and cover. Yeah, that’s applicable internationally and stuff. So, and one of my favorite one that we covered quite recently as part of that was something called headspace. So it’s an app that people may have heard of in America as well. And it’s designed to try and help you with mindfulness and meditation and a new mental health really, and it’s definitely applicable anywhere, whether your base really.
Yeah, my wife and I actually just downloaded that app and we started, we started meditating together before bed to help us just, you know, after you put the kids to bed and all unwind helps us get those rambling thoughts out of our head and get to sleep a little faster.
Yeah, I mean, like I said, there’s lots of different reasons for using applications and stuff. And headspace is one of my favorites at the moment. Partly in because of The way the healthcare system is at the moment, it’s one of the options I have to recommend to my patients because I may not have full access to the kind of resources at the same time. So if you’re trying to look for the positives and in terms of what you can get hold of really.
And that sounds like an excellent segue into what we were planning to discuss today, which is the United Kingdom’s National Health System, which actually I think I’m incorrect in calling it the UK National Health System, right. It’s it’s, it’s separate for Scotland, Wales, Northern Ireland and England, right. They’re each an independent system.
Yeah, so so they’re, they’re all called the NHS, the National Health System, but there are regional variations of it that are controlled regionally as well. So although the idea in the original setup was a UK initiative, particularly with evolution in terms of Scotland and that castle, that we’ve now got our own various different portions obviously with NHS England we’ve got NHS Scotland, NHS, Wales, and NHS Northern Ireland and stuff, and they have local control over how they determine their health service delivery compared to various different areas. NHS England is the largest of the lot with the biggest population and, and definitely does seem to do things differently because in the past year or so we’ve actually seen a change in the way that they managed, particularly the primary care aspect of their health care delivery. And with Scotland kind of creating its own kind of contract particularly for the general practice in primary care.
So tell us about the overall structure of the NHS, how does how does this work?
So the NHS is a government funded health care system originally came back around I think, was 1944. Potentially it was set up on the years and sorry, is proposed in 1944. That was a and then it was effectively the father NHS as somebody called nightbot and you’re in Bevin or nicknamed 911 Who was basically came up with this idea of having health care as a socialist kind of delivery mechanism that was accessible for all. So the idea being that no matter who you are, no matter where you were, and within the country, you would be able to access and use healthcare for free, and that money shouldn’t be a deterrent for you being healthy. And eventually went through all the various processes and things went through to become law, and it came into effect. And as a result of that, in 1948, we had the national health care system, they changed from what used to be a private health care system in the UK. And you can argue that it was very much needed at that time, because we were post World War Two, where, you know, health had changed significantly with, you know, half the population. You know, effectively not being round fighting off in the wars coming back and obviously the impact that may have had over that time, that has Been adjustments to the original Constitution and it’s no longer that everything is completely free for health care access. So shortly after as they did introduce charges for prescriptions, which is based on particular criteria, and that’s changed as time has gone on opticians access and dental access has changed as well. So now you most likely will have to pay for some part of that access. So for example, your glasses frames and your glasses lenses, you probably won’t get free anymore whereas, you know, if you went back to the original time you would have done and, and it continues to change and adapt. And one of the more recent changes that we had was something called pension health and care social act in 2012, which made radical changes to the the political structure within the NHS to take away some of the responsibility from the government and also change the the amount of private investment that could occur. Within the NHS, as well as a lot of the structural aspects of how it’s delivered, both from a provider and from a commissioning perspective as well. And that’s led us to kind of where we are now really.
So a way for more private money to enter the system. I think I read that a, for the first time a hospital was bought by a publicly traded company in England.
Yes, I think so. I think it was back in again. 2012, there was a company called circle that took over the Hinchingbrooke Hospital in terms of their running and delivery and everything. Interestingly, I think a short while after about a year or so later, they had to hand it back because they couldn’t manage it financially. And they were just not making enough I guess profit or whatever. But that was handed back in terms of the contract and stuff. And I think that’s where a lot of the potential friction comes into play when it comes to health care system in the UK, in terms of the psychotic features. between private and public health care, funding and delivery. And you know, if you ask the run of the mill person, generally a lot of people seem to have originally a lot of hesitation about private health care. And in the UK, I think that that shit that is shifting, and there’s a couple of reasons why they’re shifting. And, you know, in terms of what we’re going to see, I think we are going to see more private healthcare delivery in the UK is the next few years go on at the very least.
So as a patient, is there an option for private insurance on top of your or, or even instead of your NHS insurance, if you can even call it that?
Yes. So private healthcare still continued. It’s not that with the creation of NHS, it kind of went away. No one’s ever considered it. And so there’s a variety of smaller private hospitals dotted around the area, so even where I live, which is in Nottingham, which I think is 10th largest city in England, and we have about five private hospitals in our city area. And that’s purely because, you know, some people still want the benefit going private because it has different options. And some consultants, physicians and surgeons and stuff still do private work. And they have their own lists and stuff that’s either through companies or more often not, it’s it’s a business book more than anything else, company perks. So if you’re with a company, they’ll provide you with private health insurance, either free or a discounted rate is one of your employee benefits. And then you can access that. And the key benefit has his time, more than anything, because if you’re trying to provide a healthcare system for a population that’s free. And then effectively, the main thing you potentially might have to do is wait because you go into a waiting queue and it’s the healthcare is delivered, effectively, baby On need, not based on convenience. And that’s a key part of the NHS kind of mantra such that, you know, as with anything, you know, people are triage into the category of most need first rather than, you know, what you may have specifically. And I think because of that, obviously, people want to use private healthcare system to speed up things or to make it more convenient. So maybe that, you know, if you’re sitting on the NHS, you’ll be seeing in a couple months down the line. And you know, if you want to be seen, for example, next week, but most likely would not be possible to say for example, you know, you’ve injured your knee and you wanted to have consultant opinion about that, well, you potentially are going to have to wait to have that done. So that that’s where the key differences.
So you mentioned that there are private hospitals in the United States. There are I mean, there are a few publicly like county hospitals. But most hospitals I think are are privately owned. But you get your insurance. That hospital is then paid by your insurance company, which may be a Medicare or Medicaid, which is a publicly funded insurance or it may be paid by your private insurance. So the hospital itself is seeing both private and public patients. But you mentioned that they’re freestanding private hospitals. How does that work? Is it you need to have it and how do they end up getting paid?
And so they end up getting paid by the government directly. So one of the key differences about the UK health system and for example, many other countries like American stuff, is that I think it’s something like 80% of healthcare is paid directly by the government. And the government receives that money through taxation and you know through other sources So we have something called National Insurance is paid by every working person, and how much you pay varies based on your income and that kind of thing. And then that predominately that chunk of money goes to fund the NHS. So the current NHS bill, I think for this year is something like 120 billion, I think it is pounds. And but don’t quote me on the exact number, it has just recently changed. But that’s how much it costs to run NHS England. And as a result of that, it’s like because that that money comes from taxation, that money then goes directly to the providers, and then that’s what they have in order to fund their services. And the difference between hospital care and primary care is different. So majority of hospital care is payment by results. So they get paid for based on the work that they do, compared to primary care, which is a capitation based So effectively, so I’m a GP, I run a general practice, I get paid a certain amount per head per patient. per year, and I have to deliver all the health care that that person may need from that amount, but I get. So as an example, my practice is approximately 10,000 patients. And I receive something like 130 pounds in total. And when you include all the minor tops and that kind of stuff that we get per patient. So that’s what
the 1000 Sorry, I’m a little bit off this morning, and no 1.3 million
pounds to deliver the healthcare for 10,000 patients. And that’s regardless of how many times they come to see us what they may need, you know, all those kind of things. We have to deliver the entire health care for that population for that sum of money.
So if you happen to work in an area where patients happen to be more ill let’s say it’s a lower associate I’m an area where they tend to have more medical problems, you’re going to be working a lot harder, because you have the same number of patients, but those patients are going to have a lot more vision visits. But if you’re in a more affluent area where people tend to be less ill, then then you’re going to have fewer visits or your life is going to be a whole lot easier.
That would say, yeah, that’s definitely the case. And there is meant to be some form of modification around that. So we have something called the car Hill formula, which is basically a calculation is made based on the average age of population, the location of your population, that kind of stuff that just the amount that you get, so I, I work in it in a city Nottingham area, and so quite a deprived population, very complex health needs and stuff. And as a result of that, we get slightly more than say, for example, another area of Nottingham where it’s more suburban, you know, middle class kind of stuff. So the hundred and 38 pounds, We get per patient is slightly higher than other areas to try and counteract whether it meets those demands is one of the key challenges of the NHS. And particularly at the moment, because we are having some challenges to significantly with the NHS and particularly as winter hits, and this year we’re anticipating it’s going to be quite challenging to say the least.
But it sounds like you’re financially rewarded for taking care of a more challenging population, whereas in the United States, a lot of the sicker patients have Medicaid, which doesn’t pay as well as private insurance, where people tend to be healthier. No, you actually get paid more for taking care of healthier patients.
In principle, maybe I would say that the the, the modification factor doesn’t allow for the increased use and and need so although it’s it is an increase, it’s not a significant An increase, I would argue that allows you to deliver the difference in healthcare needs. So although I get more than say, for example, a middle class area, and they would probably get about 120 pounds per patient. So it’s not a huge increase in comparison. And the other thing is, it’s the change of the providing low income. So as I said, we still have private practice and stuff in the UK. And one of the rules within primary care is that you cannot offer a direct private care service to patients on your own list. So if I have a patient living in St. John’s where I work, and I can’t turn around to them say, Well, we’ve got private service where you can be seen this, you know, quicker, or for this particular reason, I can’t offer that directly to my own patients, I have to refund another service. But can you see patients from someone else’s
list like could you do? I mean, it sounds like you’d be extremely busy with all the patients that you need to take care of. But guess if you found a way, like evenings or something to take care of private patients, you could offer them from someone else’s list.
Your services? Yeah, so definitely potentially the challenge there is obviously like I said, I work in an area which is more deprived and doesn’t have the attraction, shall we say, to a more leafy suburban, you know, kind of putting partly is aesthetics, partly its character, that kind of stuff, you know, trying to attract people that would want to pay for their healthcare service is not as easy and, and part of that could be down to services. But actually, the biggest challenge we have right now is just dealing with the day to day workload in order to have the headspace and the capacity to offer extra services to other patients. And so, it is possible and it is done in some places. But it’s not a simple kind of process to go through.
No, you can’t You can’t decrease the hours that you’re treating your other patients in order to make time for those those private patients. This is yes. Like, like I said, You’re extraordinarily busy to begin with, and you know, having a podcast and an active Twitter account. Yeah, definitely. To the business, so, um, so what are some of the issues that you’re seeing now with with NHS because we’re in America, there’s been a push on the progressive wing of the Democratic Party for Medicare for All right, the more socialized system, and we actually have a socialized system in America. It’s the Veterans Health System. And the problem one of the problems that we see in the Veterans Health System is, is there, there’s no incentive. So you’re salaried. So it doesn’t matter how many patients you see per day. At least this is the experience that I had as a resident working at the Veterans Hospital. Is that you see some people that really see as many patients as they can. And you have some people that just they work so slowly that they they’re very inefficient. And that inefficiency leads to longer wait times for for the veterans. So we have this socialized system and and they’re, that that’s just the tip of the iceberg in terms of problems with with that system. So in theory, it seems nice. Everyone has, has a right to health care, everyone should get health care, and it should be an egalitarian system where everybody gets the same care. Great, nice in theory, but in practice, there are all sorts of problems, like you said, triage, someone’s responsible for triage, seeing all these patients and determining who has more more severe problem and should be seen first. And so, that leads to long wait times, unless, of course, you want to increase taxation, in order to increase the amount of money in the system so that you can have more people taking care of more taking care of those patients increasingly investments in technology. And nobody likes higher taxes. So, you know, you have this, everyone has a right to care. Nobody wants to pay for it. So, so what are some of the problems that you guys are seeing right now with with NHS?
So I think that’s probably one of the key aspects. So at the moment, the NHS system, like I said, is predominantly funded by government funds. And in the UK, I think we’re just above the OECD average in terms of how much we fund per head per person, per per area kind of thing. Sorry, what was that OECD? How easy is that the organisation for economics and I will the CD stands for I’m afraid. But basically, it’s the comparison of how much each country puts into its national, you know, its healthcare systems and stuff. So they analyze all the data and stuff and the UK is just above the average in comparison to some other countries and And interestingly, America is the one that spends the most on its healthcare. So money isn’t like 16,000 per head. And I think the UK something like 9000 per head. Again, the figures do change. And I think that’s based off 2014 or 2016 figures, I can’t quite remember. So fairly recent. And, and what’s interesting is that they’ve looked at various different metrics in terms of how much funding you’ve put in, and the type of funding you put in sort of split between private government or self funded. And, and then they’ve also looked at things like outcomes or like life expectancy and that kind of stuff. If you look at the data, and one of the things it shows is that the UK kind of does, okay. And in terms of, you know, the amount that it spent, spends on health care versus the life expectancy of a patient. And if you think if I remember rightly, that the most cost effective country I think was Japan with a life expectancy, something like eight to one average for the amount that they put in. And the Scandinavian countries do very well. So their healthcare system seems to be fairly effective in terms of financing and delivery. And interestingly, in American one, which is probably the most funded one, and like I said about 16,000, and has not so good life, expanding the average life expectancy with some nice 61. And so there is a stark difference in terms of, you know, how much it’s being funded and the outcomes, if you’re just looking at life expectancy as an outcome. I think that the America was equivalent to Turkey.
That does that number seems, seems a bit low. 61 doesn’t. But But I’m, I’m not sure. I know some of the metrics that we do use are not equitable in other countries, for instance, infant mortality, I think one of the metrics we consider any birth of viable birth or any birth past No, no, it’s I think any birth past 25 weeks we considered a viable birth. Whereas in other countries, they they use a different number. So, you know, is is it possible for anyone past 25 weeks to be available birth? Yes. And so that’s why that number is used. But, you know, sometimes you’re comparing apples and oranges. And it becomes harder to compare from one health system to another. But But your point being, there are countries that spend that are more efficient with their spending, right, they spend a certain amount of money to get a certain amount of life expectancy. And while it may mean that you’re stuck waiting for your knee replacement for maybe a couple months more, in the end, you know that that convenience of being able to get that surgery soon carries with it a high economic cost. And so you have to decide where you’re going to spend this money in order to get the best value and in America, we’re terrible at that. Right because the if you have money, you can get care quickly. And if you don’t have money, it can take very long time where you don’t may not have access to certain specialties at all in your in your region, and then that leads to poor outcomes. So yeah, there’s a there’s, there’s a balance here is what you’re getting at between the two and the Japanese have them.
And I think when when you healthcare services provided exclusively by the government, there are also restrictions that come on that. So for example, cosmetic care, and very little cosmetic is funded on the NHS. So, you know, for example, if you had something that was causing an obstruction, like a mole or something like that, it was not, for example, catching on your belt line or catching on your bra strap or something like that. And you may be able to have that removed on the NHS, but you have to show that that is the that there is a medical reason for wanting to do it, not just purely a cosmetic reason. So you know, that would not be covered. And, you know, other things would be so for example, burns patients, that kind of stuff that they would still get some form of cosmetic treatment, and, and no, in terms of how that impacts patient workload, but that’s quite significant at times and patient reasons for attending the practice as well. So as I said, I work in primary care. And we see approximately 90% of the workload that comes through the healthcare system, because to see any kind of specialists, you would need to go through your GP first before you could access them. So my understanding the American healthcare system is if I wanted to go see a guy, an ecologist, well, I guess I wouldn’t want to see a gynecologist, you know, and you know, if as a patient I want to go see a dermatologist more gender appropriate one surely. And then I can just get corporate dermatology provision says center and just you know, go see a dermatologist, as long as I’m able to pay for it or have it covered by like you said the Medicare or whatever like that.
It actually depends. It depends on your so so I think it was like in the 80s Maybe the 90s HMOs were very popular, which sounds like what the what the health maintenance organization. So you signed up for a health maintenance organization, and then you were given a certain panel of patients. So this is this is the number of patients that you need to take care of. But within that panel, I’m not sorry, not within the panel. Within that HMO, there were a number of specialists. So you could have all of your specialists within that panel. And yes, you’d need to go through the GP. And there are some insurances that also make you go through but I think most of those are the the Medicaid and the managed Medicaid, where you actually need to have a referral from your primary care physician in order to see a specialist. And then the wait time really depends on where you are, right? Like if you’re, if you’re in a city, that saturated with practitioners that take your insurance, then they’re probably not going to be a very long wait time. Whereas if you’re in a rural area where there are very few specialists, it’s going to take much longer to be able to see that that that specialist is So your region then affects your outcome, which is unfortunate consequence of our system.
And I think that that would actually describe the way that the NHS service currently runs. So I was working in in city area, and we have actually really good access to things like physiotherapy. And so patients can self refer themselves as long as they register patient within the city area to a physiotherapy service. And they once they’re seen, there will be seen until their problem has a reasonable resolution. And whereas if you go to where I live in Nottingham, which is only, you know, two miles away, we’re not talking you know, massive distance at all. And if I was to injure myself, I have to go see my GP first to get referral to the physiotherapy service. And I will only get two sessions no matter what the problem is. And so even if it’s resolved or not, that’s all I’m allowed. And then I have to go back and get another referral or I have to pay for it if I want to top up kind of thing.
Wow. Yeah, I would I would imagine that most injuries warrant significantly more visits than two visits with a physiotherapist. Or here’s a here’s a squeezy ball for you. Good luck.
Yeah, exactly. So there is massive difference. And I think comes down to this simple principle, there’s a certain amount of money in the pot, everybody kind of wants or needs a piece of it. And and what do you do in the pot runs out? Because that’s the current challenge we’re having to deal with the NHS at the moment. And healthcare is increasingly becoming more and more expensive, because of technology because of medications because of, you know, the the governance as well, you know, increasingly more and more people are becoming more medical, legally aware. And therefore, you know, you can argue that clinicians are over requesting at times to cover themselves. So that’s
happening in your system too.
easily. I think any healthcare system is starting to happen because it’s a natural creep, isn’t it? And part of that, I think is in guideline driven and so is more and more guidelines. Come out. You look at the complexity and the level of depth of care that we have now for simple health conditions compared to what was done 20 years ago, you know, the number of potential tests and recommendations and what kinds of you may have to do is completely different. And compared to that kind of time, and you know, and that has an impact in the workload in the process, you know, that kind of stuff. So, I now have patients who we focus a lot on prevention and prevention of ill health. And that can mean either screen programs and that consult, which are now becoming more prolific. And, you know, I’m a 40 year old medic, 40 year old patients who are taking anti blood pressure medications and statins because of cardiovascular risk scores to try and prevent them having the problem in the future. And that comes with the workload that it comes with. So you know, we would need to see them at least probably once a year, just to check that they’re okay. Check their blood pressure, check their bloods to make sure the medications aren’t causing damage to the liver. And possibly to the cholesterol again, and that kind of stuff. And that all comes with workload that all comes with cost, which is not borne directly by that person. They don’t pay for that. But they do through taxation. So it’s, you know, pay through various different costs. And that creates challenges in terms of, like I said, the provision of health care, because what do you do when the pot is so bursting, that at times you want to provide things and you can’t. So one of the more recent changes we’ve started to have is that actually, they’re now starting to restrict a lot of the potential kinds of treatments that we may be able to offer. So one of the more controversial ones that we’ve had recently is patients with celiac disease, and you have things like the flowers and the, you know, the food items available on prescription, and if you didn’t pay for your prescriptions, effects we got for free. And so therefore, and you know, there were patients that had access to that and became As changes in the way that they’re looking at things, they’ve now basically said that all those prescriptions are no longer appliable. So we can’t offer things like the, you know, the the gluten free products and stuff on prescription anymore. And if you don’t pay your prescription, then you don’t get them at all. So you now have to bear that cost yourself.
It seems though, that that would add some efficiency to the system, right that you have a central body that looks at the cost versus the benefit and is able to make those decisions while as an individual patient, you might say, Wow, this, I have this, this problem. And now it’s not being I’m not getting the assistance of the assistance of the government anymore in terms of being able to have eyes on the entire system and the way the financial cost versus the actual benefit. That would seem to be beneficial, although I’m sure they’re going to be comfortable. decisions where a lot of people don’t agree, you know, sacrifices need to be made.
Definitely. And I agree it would be useful if it was a central kind of group that made those decisions, and they make some of them. And part of the challenge as a clinician comes in the way that those decisions come down in terms of wording. And so a lot of the changes that come into play. So, more commonly used ones are a lot of the medications are available over the counter. So for example, paracetamol, which I could leave you guys call acetaminophen, and, you know, the fevers and pain for kids, antifungal creams that you can easily use to treat self limiting conditions, that kind of stuff. A lot of those are now not recommended to be prescribed for use by patients for you know, a minor illness or or self limiting condition. But interesting, the wording they’ve used is not that you can’t prescribe them, it’s that you should not prescribe them and that slide semantic aspect is actually a real challenge for particularly, you know, GPS in my situation. Because the, the overriding tenants of descriptions when it comes to the NHS system is that if the clinician is recommending that you have the treatment, you should offer it on a prescription. And therefore, if I’m seeing a patient and I say, Yeah, you’ve got a fungal infection, you should have an antifungal to treat that then I’m telling you that I’m now being told I can’t prescribe you them because you should buy it yourself. But then I’ve got another tenant that says I should prescribe it if I’m recommending it. You know, there’s nothing to stop that patient from then complaining and potentially taking you through the legal process, not issuing them a prescription that they wouldn’t have free.
Are there any repercussions for over prescribing to you?
directly, no, apart from I guess, reputational issues and stuff, and obviously, the cost of that comes into it overriding lead to the health care providers. So for example, the money that my practice gets that doesn’t include the drug costs for our patients that’s borne by the higher organizations, the CCGs and the area teams and that kind of stuff. So, MCC g stands for clinical commissioning group which there’s about 50 I believe over the country that basically they get the money to deliver the health care provision, both primary care, secondary care, opticians, dental, that kind of stuff. Sounds like
it sounds like that’s the HMO the CCM an HMO? Yeah, that’s description.
And so they bear the cost of the drugs. And we get monthly reports of how much in terms of our previous year comparison we’re spending, whether we’re overspending under spending that kind of stuff to give us a marker so and you know that they will make those figures and publicly evident. We’ve actually got a really interesting website created by a guy that got challenged to basically Look at prescribing, he created a website called over prescribing dotnet and looks at the individual prescribing habits of every general practice in England and compares them. So it tells you how many practices are prescribing antibiotics. And it tells you how many practices are prescribing, you know, other kind of medications. And sometimes just having that information out there in public can be quite a stark and contrasting kind of tool to make you think about your prescribing habits.
So you’d be they’re using shame as a tool to get you to prescribe
fewer things. And I’d see it more as a learning tool. But yeah, I guess you could look at it as you know, a positive and a negative. And so, you know, there are definitely medications that I think needs to be controlled a lot better. I mean, America is in the grips of an opiate crisis and the UK is falling you quite closely in fact, we’re not far behind you guys in terms of the impact that opiates are having on the general public. We are having huge issues with patients taking significant levels of opiates for, you know, potentially inappropriate reasons and, you know, being able to see where you are sometimes can be a good marker giving you an idea of what you may need to change within practice and the way that you approach things and stuff. And in that sense, I think it can be quite a powerful motivator to see where you are and how you need to change and the impact that will have both on system care but also patient care as well. Because no,
yeah, that’s that’s that would be an interesting thing for for us to do as well. I think in some regards. It could be used as a marketing tool, because you have patients that say, I definitely need an antibiotic right now. I want to give I want to go to the person that prescribes everybody antibiotics. But in the same regard, we also have this public information tool that I think many people are interested in seeing that tell us how much money you get from the drug companies and from the equipment company. So if you have someone that comes to your office and brings you a lunch once a month to tell you about their medication that goes into system, and that is then made public, and I don’t really think anybody’s looking at it, but if you had something that was prescription based, that showed how much people how much people are prescribing, I think that would be a useful tool, like you said, a metric for yourself to see where you fall and help you reflect and improve, but also system system wide. To help us manage trends and manage our prescription medication use, I’m going to be having someone on the show in a bit to talk about the importance of antibiotic stewardship, because that’s that’s just such a huge problem.
It is, I mean, that’s one of the massive things that’s being pushed at the moment in terms of you know, making sure that patients get the right treatments for the right cause and actually is making a difference. You know, I am now actually having many patients say to me, Well, I don’t need them to politics, but what they want is Then check to make sure that they’re still healthy. So the reason why that’s quite interesting is so I talked about the fact that our healthcare system is based on the capitation had, so you know, I get 130 pounds per patient. I’ve seen that patient no matter what their healthcare needs may be, and say, for example, they’re worried that they may have a cold, and they can book in see me to talk about the cold. And I would have to see them. And that could be once a year, and that could be once a week, potentially could even be once a day. And I can’t really turn around and say to them, we’re not going to see you. unless I’ve got a system in place to try and triage them out in some way, shape or form, particularly, they’re coming to me every single day. And that’s obviously how how do you balance that cost in terms of provision of service, and versus what you’ve got in the pot to pay for it kind of thing. And so I do actually have some patients that will come and see our practice on a weekly The basis is, you know, 50 odd appointments in the year, and not a lot. And I imagine spending that much time at your doctor’s office. And, and some of that is appropriate. And some of that you could argue is not appropriate. But the impact that has is that that’s a resource they’re using. And then you still need to provide resources outside of that, unless you can change their health behavior, which is where a lot of the things like antibiotic stewardship has come into play. You know, I think it’s getting people to recognize you don’t need antibiotics to solve every kind of cough or cold all that kind of thing, because the reality is you don’t. But what it has shifted people to is that they’re now asking the question, I just want to make a check to make sure I’m okay. Yeah. And that is having quite a significant impact and the way I try and describe it to particularly nowadays, we are seeing a shift in the fact that people the NHS system was always designed to tell you if you’re unwell but nowadays, people are wanting To know if they’re healthy, which is not really what the NHS is actually designed to cope with, is purely there to tell if you’re unwell and deal with you if you’re unwell. It’s not really a public health tool. And I think a lot of people try to use it as a public health tool. And that’s having a significant impact on the way in delivery the workload is having to deal with.
But that would also be the advantage of having a central system, right is that if you have this paradigm shift, then the central system is able to pivot whereas if there’s no central system, to be able to respond to something like that, then that’s not possible to have that paradigm shift. Because I think this that paradigm shift is happening in many places, right, where you’re, you’re trying to optimize your wellness, not just treat the treat the illness.
Yeah, I guess the difference is that we’ve got a separate organization is meant to be doing that. So we have a public health department across the entire country. This job is to try and deal with, you know, and keeping people healthy. And you could argue quite clearly that public health has better impact on population based healthcare than any individual doctor will ever have in their time. Apart from probably Edward Jenner thing is probably going to have a better outcome. But, you know, it’s a massive shift. And you know, I see people for social reasons, I see people because that lonely, I see people because, you know, there’s no other route for them to go to. And they end up coming to see me to try and sort out things that realistically, I would love to help them. But I don’t have the bandwidth, I don’t have the capacity and I don’t have the routes to give them the help that they need. Because all those services all those things they may need, and either don’t exist or have been chained, used to prioritize for other kind of health options, and therefore the only way for them to access it would be to pay for it themselves. But we live in an area where in an age where the NHS is seen as the main healthcare provider, and people don’t want to pay for it unless they’ve got the funds to do so. And that may not always be the case, particularly working in a in a city deprived area. And someone that is changing. And so I mentioned earlier that we’ve got, you know, new players in the market, we’ve got the proliferation I think, probably in America, you’ve got the same video consultation services for health care, and, and that’s providing a new avenue for people to access health care services in a way and a method that they would want to and there’s both positive and negative and you know, one of the providers, you pay 20 pounds a month and for that you can have as many consultations as you want through a video interface with a GP and if you back Missy privately and or you can See them through in certain areas on NHS basis as well. And you’ll get your health care delivered by that method, which obviously has some benefits in the sense that you don’t have to take time off work to go necessarily you don’t have to go sit around in a waiting area. And you know, with other people, that’s one of your challenges that you have from a mental health perspective, for example, or from infection control. Yes. If you’ve got chickenpox and things, and and you get health care that what kind of way that you want it. And then the other question is, does that also drive a different method of delivery? So are you therefore more likely to get prescribed, like you said, things like antibiotics or medications or, you know, even complaints is one of the things I’ve seen people have increased because then mental Actually, we do need to see face to face. No one don’t want to come down and you know, vexatious complaints as a challenge at times.
Well, I think that’s a great segue back into your podcast, the technology in, in primary care, so it’s Why don’t you just tell us about that podcast one more time before we wrap up?
Yep. So it’s the EGP learning pod blast. And so we’re on all various platforms like iTunes, pod bean, and that kind of stuff. So if you search for it, it will come up quite easily. And it’s mainly hosted on on our pod bean site and pod bean comm slash EGP learning. And we provide a monthly podcast where we cover a variety of different things like app reviews, healthcare, tech, reviews and deep dives. And so one of our more recent and popular episodes is one that looks at video consultations. So if you want to hear more about how that impacts healthcare delivery and stuff, that’s a good one to have a listen to. And and yeah, so every month we do that as well as an in between we interview people who’ve done and created health tech as well to see the journey and share that with our listeners.
Is there anywhere else people can find you?
Yes, as I’m on Twitter, at EGP learning but my personal one which more than happy pupils contact me on is at Dr. Gandalf. 52. And just to be clear, I’m not 52 years old, which is one of the common questions I get.
Now there were just 51 other doctor handoffs before you, I guess.
No, there weren’t. But it was just a way to just unfortunate ganged up was taken by a dead account, which really annoyed me. I’ve been complaining Twitter for many years, because it hasn’t posted for about seven years now. That it’s probably a dead account, can we please close it? So I can take it but Twitter don’t seem to want to listen, which is fair enough. They’re an international company that don’t really have to listen to me, but it’d be nice if it did.
Right. So Dr. Gandalf 50 to EGP learning, fantastic podcast. I’ve really learned a lot about the National Health System and maybe some trials that we’re going to end up with in the United States as we may end up moving towards more socialized system. So I really appreciate you taking the time to discuss this with me and our listeners and been a pleasure. Thank you.
That was Dr. Bradley Block at the physicians guide to doctoring. Find all previous episodes on iTunes, Stitcher, Google podcasts or wherever you get your podcasts and write us a review. You can also visit us on facebook@facebook.com slash physicians guide to doctoring. If you are interested in being a guest or have a question for a prior guest, send a message or post a comment.
Transcribed by https://otter.ai