The Two Different Systems
So, as we know - in the American healthcare system, doctors make care decisions, insurance companies pay for part of the cost of the care, and the patient also covers part of the cost through deductibles, copays, and other bills. Patients can choose between the doctors that are within their insurance plans, or the costs are even higher. To protect themselves from law suits and keep the practice profitable, doctors are incentivized toward excessive treatment and tests to cover themselves, as long as the insurance companies will cover the costs. By comparison, the UK system is a single-payer system that is run by the government entirely. You go to the general practitioner that is in your neighborhood and couldn't choose a doctor that's closer to work, for example, but don't have to worry if they are covered by your plan or not. To keep down costs, they minimize the time each patient spends with doctors, delegating as much as possible to midwives or nurses, and minimizing tests and visits wherever they can.
Prenatal Visits
- Number and location of visits: So in the US, I think I had over a dozen appointments. They started out every month, then went to every two weeks, and then every week by the end. All were in the same place, my ObGyn practice. Here, we have many fewer appointments, and they are split between 2 locations: my GP practice and my midwife group. I will have a total of 7 appointments, 5 with the midwives and 2 with the GP. Additionally, because I'm 35, I had one consult with an ObGyn, which was a total of 5 minutes long.
- Lots of Different Doctors and Nurses: In the US, I went to a practice with about a dozen ObGyns. I knew from the beginning that delivery would be by whoever happened to be on call that day - so we played Doctor Bingo to make sure we had met everyone in the practice before my due date (not that it would've mattered). I would occasionally test them by asking a question that I had asked at the previous appointment to see if I got the same answer, and always did. Here - I have the GP practice (which is several doctors and nurses), the midwife group (which is a team of several midwives), plus the ObGyn, but none of those people will be at the hospital for delivery - that's apparently a completely different team of people. My biggest complaint is that they don't coordinate together at all and give conflicting advice. For example - the midwife told me to go get a vaccine at 16 weeks from the GP, but the GP follows different guidance and wouldn't give me the shot until 20 weeks, so I had to waste time sitting in the waiting room for an hour and then reschedule the appointment.
- Tests: At each of the appointments in the US, they conducted a bunch of tests. They took a urine sample to test for protein and sugar, they weighed me, took my blood pressure, and then they palpitated my uterus (meaning awkwardly poked me in the belly). At every appointment they either listened to the heartbeat or used the ultrasound machine to check on the fetus. Here, it's just the urine sample and blood pressure - no one has weighed me yet, poked me in the belly, or listened to the baby's heartbeat. Additionally - in the US, I was giving blood samples left and right for various tests - but we only did two here. My least favorite appointment was the glucose test, which they don't do here in the UK unless there's some reason to order it. Similarly, I had at least 4 sonograms in the US, but will only get 2 here. There isn't even a machine in either the midwife or GP's office, so I have to make a special trip to the hospital for that. So in the US, I spent at least a half hour at each appointment getting all the tests and talking through all the symptoms, whereas here an appointment is 10 minutes max.
- Medical Files: In the US, even though I had a different doctor at every appointment, the care felt continuous and consistent because they would take a minute to read my medical file before each appointment. Here - they don't have a file on me. Instead, I have to carry a booklet to each appointment, where they write their notes for the next person to read. I feel like each appointment starts from scratch - I have told our birth story like 6 times already. I was extremely irritated when the first question the ObGyn asked was, "How old are you?", followed by "Is this your first baby?", two questions that seemed basic enough that he should've known the answer already.
- Scheduling Appointments: Maybe this is a small thing, but it still bothers me. In the US, after one appointment was over, you would walk to the desk and schedule the next, at a time that worked for you. Here, they just schedule my appointments for me based on what works for them, and I get either a letter or a text message telling me when my appointment is scheduled. Technically, there is a phone number to call if you want to reschedule, but no one seems to answer the phone, so the appointment basically cannot be moved. This has resulted in an appointment on a weekend with first kiddo in tow, an appointment for a test 3 weeks after it was supposed to be given, and then several appointments when I'm out of town or just otherwise busy. Clearly, the assumption is that my schedule doesn't matter.
- Pregnancy Rules: In the US, the sort of default assumption was that you probably shouldn't do something during pregnancy - whether that was eating soft cheeses or drinking herbal tea- if there was any reason to think something might be a bad idea or if it just hadn't been tested yet, doctors would advise you not to do it. All those rules, plus the constant testing and appointments led to a rather anxious pregnancy. I remember going to a reception and realizing I couldn't eat anything that was being served. Here - it would be an huge understatement to say that they have a more relaxed approach. There aren't any rules about what I'm supposed to be eating or not, and they just recommend avoiding alcohol during the first trimester. I am avoiding alcohol myself, but have decided not to follow the soft cheese and smoked meat rules. At my first appointment, I asked the midwife what number I should call when I have a question, and she said that she guessed I could email them.
Kid Visits
- Standard Well Child Visit: In the US, there was a schedule for standard healthy kid checkups, that was every few weeks, then every few months, and then once a year. At each visit, a nurse would measure his weight and height and calculate the percentile. Then, the doctor would come in to review the results and discuss any other questions that had come up. This was a great time to ask random things that we had been worried about but that weren't enough to schedule a special trip for - like: "Do you recommend a sunscreen?" or "Should we worry that he won't eat anything green?". She would often give us an answer and refer us to a book or website for more info, and all in all in at both helpful and reassuring. Then, the nurse would come back in to give him the schedule vaccines. Here, you can get the measurements taken by the midwife, but they can't answer any questions - you have to make a special appointment with the GP for that. Only the nurse at the GP office can give shots, so that's a separate appointment too. Here the measurements stop at 2 years, so after that - you need would only go to the GP if there was a cause for concern - eliminating our chance to just check in and make sure we're on the right track.
- The ASQ Test: In the US, before each appointment, they would send us a link to an extensive test, which changed for each visit based on the recommended milestones for that age, i.e., "Can your child pick up a cheerio with just his index finger and thumb?" or, "Does your child speak in sentences with three or more words?". The doctor would review the test results before each appointment and discuss anything unusual - but it was also just a chance for us to learn his strengths and weaknesses. Here, they seem to have the same test (paper only), but will only give it if there's a reason for concern. The midwife asked if I was concerned that he might be behind in anything, but what do I know?
- Vaccines: In the US, there's a schedule for vaccines that follows the schedule for well child visits, so you just get the shots while you're already at the doctor anyway. Here, the schedule for shots doesn't match the schedule for measurements - so you need to track two different schedules for the two different offices. Also, the schedule is different than the US schedule, including both some different vaccines that we don't give in the US and some different timing. For example, they don't vaccinate for chicken pox here but do vaccinate for meningitis, and have a booster a 3 years, 4 months that we don't give in the US. I tried to ask the midwife about it - but of course she referred me back to the GP - who had already referred me to them in the first place - so it feels like it falls to me to figure out if he's going to get behind on anything.
- Percentiles: As any parent of a young child knows - everything hangs on a kid's weight and height percentiles. We have so much data on growing kids that we can easily calculate how a kid's height, weight, and head circumference compare to other kids of the same age - which is their percentile. You want to know both the percentile itself, and the trend from previous measurements. Our kiddo dropped to the low percentiles at his 2 year appointment, so it's something we're extra concerned about - so I found an app that allows you to easily calculate and track your percentiles over time. Here - the midwife used an old school paper graph to chart his measurements - determined that he was somewhere between 25% and 50%, and then said - "He looks fine to me". So - I flipped out, and started my own excel file tracking his percentiles using my app and regular measurements of my own. Again - I feel like the onus falls to me.
Dentist
Similar to the prenatal and health kid appointments, the dentist also delegates any lower level work to a nurse (the hygienist), which is scheduled separately, though thankfully in the same location. So, I went for a checkup which was a 5 minute appointment with the dentist just looking for cavities. He then recommended a cleaning, which I will have to schedule separately and go back for during another appointment. In the US, of course, it's all done in one appointment.
Costs
It wouldn't be fair to compare these two different systems without talking about cost. In the US, we had very good insurance when I was pregnant, and then dropped down to minimal insurance afterwards. Thanks to Obamacare, all the prenatal visits and well child visits were free, but we would occasionally get a bill in the mail for various tests or appointments that weren't covered - and of course, a several thousand dollar bill for the delivery. Bills were always mysterious and unintelligible - it was never clear why something was covered or not, and certainly not clear during the appointment. Here - there's none of that. I haven't paid a pound out of pocket for any of this care - and won't. Our taxes are much higher of course, which is what covers this all. It's nice to know we won't be spending any miserable nights trying to compare plans and decide if a $20 copay is more or less than 15% of covered costs under a different plan.
Conclusions
As a good Democrat, I really want to like the UK system, but I don't. I'm getting the distinct impression that they don't care about my time or what's convenient for me, and things could easily fall through the cracks. I'm trying to remind myself that the system I'm comfortable with was probably overdoing it - and that it wouldn't hurt to relax a bit on things. After all, they have plenty of healthy kids and routine deliveries here too. I'm also trying to remind myself that we moved here to have some different experiences and adventures - even though this is an area where safe and boring would've been fine. All in all, I'm sure everything will be fine - we are lucky to be very healthy - so I'm just going to try to go with the flow and google the hell out of everything.
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