Has your doctor ever written you a prescription for cooking classes? Does your doctor know your parents? Your siblings? The medical history of your uncle and grandparents? Yeah, we’re serious.
This week on The Dose, Shanoor Seervai sits down with Martin Marshall, a primary care physician from the U.K. Through the stories of his patients, Martin explores the differences between his home country and the United States when it comes to delivering primary care. Martin talks about managing a patient’s diabetes with cooking classes, how he can lean on his intimate knowledge of a patient's family history to arrive at a diagnosis, and about his experience with our health system during a stay in the U.S.
SHANOOR SEERVAI: Hello and welcome to The Dose. I’m Shanoor Seervai, and on this show, we talk about health care in developed countries where everyone has coverage, and how their health systems are different from our system in the United States.
Martin, who’s a doctor in England, is going to tell us more about health care in the United Kingdom. Martin and I were talking about one of his diabetes patients, and then he tells me he sent him to a cooking class. What’s that about? Since when do doctors prescribe cooking classes? Here’s the story.
MARTIN MARSHALL: So I'm looking after a patient in my current practice who is in his early 30s. He's married with two young children. He is obese, and he has got type 2 diabetes, which is very common in our community.
SHANOOR SEERVAI: The community Martin is referring to is in East London, and a lot of his patients are poor. To give you just some idea: around 6 percent of the national population has diabetes, but it’s nearly double in this neighborhood. And the patient is struggling with a bunch of other issues. Here’s Martin again:
MARTIN MARSHALL: He's in a small apartment with a large number of family members and friends. They don't have enough beds for all of them, so they kind of — they sleep in rotation.
He eats down at a local fried chicken shop where you can what he describes as very nice food very cheaply. And he's unemployed. So he's got lots of factors which are impacting on his diabetes control, which lie outside the traditional domain of biomedicine.
SHANOOR SEERVAI: Here’s where Martin’s role, as the primary care doctor, gets really interesting.
MARTIN MARSHALL: So I do adjust his medication, but actually the more important things I have done for him over the last five years are, first of all, work with our local council to get him rehoused, and secondly a local job center to get him a part-time job. Thirdly, to send him on a cooking course.
SHANOOR SEERVAI: You just heard from Martin Marshall. He has been a family — or primary care — doctor in England for 28 years, and he's also a professor of health care improvement at University College, London. Early on in his career, he spent a year in the United States, doing research on how health care performance data is publicly released here. Living and working in the States made him notice a bunch of differences between health care here and in his home country.
In the United Kingdom, they have a system called the National Health Service, or the NHS. This is a classic example of what is called a “single-payer” model, in which the government pays for health care with tax money, and directly employs health care providers.
The reason their system is organized this way is so that patients don’t have to deal with medical bills. That doesn’t mean the British don’t pay for health care — they do, in their taxes, but they don’t have to buy basic insurance the way Americans do. And there’s a huge emphasis on primary care in the U.K., through what they call the “general practitioner” or “GP system.” Martin’s going to tell us more about how the GP system works.
Single-Payer Health Care in the U.K.
MARTIN MARSHALL: There are round about 11,000 general practices in the U.K. They are based in localities, in communities and serve communities. On average, they will have somewhere between three and six doctors, perhaps serving a population of somewhere between 6 and 10,000 patients — something like that.
And the main design feature of general practice in the U.K. is it acts as the first point of contact for almost all contacts with the NHS. So almost everybody needs to see a GP first as their route into the NHS.
SHANOOR SEERVAI: So that's an interesting feature. It sounds like GPs play sort of a coordinator role, like this is the first-stop shop for patients. Is this why the system is sometimes called a gatekeeper system?
MARTIN MARSHALL: Yes, that's right. I think the term gatekeeper is sometimes not very helpful. It sounds as if you're keeping the gate shut against the hordes of people pushing to get into hospital. And that isn't actually the case.
SHANOOR SEERVAI: How often do you need to refer a patient to a specialist?
MARTIN MARSHALL: Usually somewhere about 10 percent of the problems that I see as a GP that are presented to me as a GP I need to refer on to specialist care. So it is, as you say, quite a different model from many of the different health providers in the U.S., which tend to be more — certainly historically tend to be more specialist-orientated.
SHANOOR SEERVAI: Right. So let's say that I was a patient and you were my GP, but for some reason I felt like I had this excruciating back pain and I really just wanted to go to a specialist. What would I — I would have to come to you, or what would I be able to do?
MARTIN MARSHALL: Yes. So the vast majority of people who have back pain would come and see their GP, and we would deal with it without having to see a back specialist.
SHANOOR SEERVAI: Right. Well, how do your — how do your patients feel about that? Do you have incidences or times you remember when you have had a patient who has sort of come in really hoping to be able to see a specialist and you haven't been able to recommend that?
MARTIN MARSHALL: Well, it's very interesting because the vast majority of people have confidence in their family doctor and don't come in demanding to see a specialist. Sometimes they do, but usually they don't.
The vast majority of people — particularly those who have lived in the U.K. for a long time, just accept this is the way the system runs and that specialist referrals aren't required.
Sometimes specialist referrals are required. Sometimes in consultation with a patient I will say, "You know, I think I have probably done as much for you as I can. Let's consider a specialist referral. Do you agree? Where would you like to go?" And then I will arrange it for them.
Only very rarely do I find patients coming in demanding a specialist referral.
SHANOOR SEERVAI: Can you think of any examples?
MARTIN MARSHALL: Where I work in East London, we have a very multicultural and mobile population. In particular, we have quite a lot of people from Eastern Europe and some of the old Soviet states which do not — which aren't countries that historically have had a strong system of general practice. And sometimes they will come in saying that they want to see a specialist because they don't believe that a general practitioner can deal with their particular problem.
In that situation, often it's a nice professional challenge for me to persuade them that I can deal with something competently, and that they can trust me to deal with it competently. Sometimes I succeed, and sometimes I don't.
SHANOOR SEERVAI: It sounds like this is a system that's based on a lot of trust, and it's a pretty personal relationship between doctors and patients.
MARTIN MARSHALL: Yes, exactly. So that level of personalized care and continuity of care is a very important part of the service as we provide it, not least because as you say, when you get to know somebody you develop a trusting relationship. It's much easier to provide care for them when you have a personal relationship. Patients believe that you're acting in their best interest, that you're doing the best for them.
So that — the relationships are fundamental and something that we in general practice tend to call the therapeutic relationship because just the relationship itself adds value to the interaction between a patient and a doctor.
Traditionally, GPs do go into a practice and work full-time in that practice for the whole of their career. So they might well be serving a community for 40 years or so.
I remember in my first practice that I worked in before I became an academic, I looked after five generations of the same family.
SHANOOR SEERVAI: Wow!
MARTIN MARSHALL: It gives you a deeper understanding, which allows you then to bring a psychosocial dimension to what otherwise might have been a traditional medical consultation.
SHANOOR SEERVAI: So you really get a good sense of the whole family’s medical history. Tell me more about this family you looked after for five generations.
MARTIN MARSHALL: Yes it did. This was a particularly interesting family. It was a socioeconomically deprived family, not a high level of educational attainment. Each generation of girls in the family had got pregnant usually before the age of 16, which is the legal age of consent in the U.K. So they might have started a family at the age of 15, often multiple children, often with different fathers. So it was a socially chaotic family.
And understanding the nature of that family dynamic, the perpetuation of particular behaviors, allowed me to do more for that family than if I had just been a doctor popping in and seeing them for the first time.
SHANOOR SEERVAI: What do you think patients value about these personal relationships?
MARTIN MARSHALL: They value continuity of care, and there is a growing evidence base that the quality of care that you can provide when you know a patient well is much greater and the costs are less.
So if I see a patient who I know well and I say to them, "I don't think you need to have an MRI scan for your headache," or "I don't think you need to see a neurologist for your headache," they're much more likely to trust that decision than if it was somebody that I didn't know well. And that continuity is a really important part of delivering high-value care.
Health care systems that put a strong emphasis on primary care and general practice deliver better outcomes at lower cost than ones that are more specialist-orientated.
SHANOOR SEERVAI: Hmm, sounds like you really get to know your patients. But tell me about some of the downsides of your system — I’ve heard that primary care doctors in the U.K. are really overworked because people visit their GP a lot. So GPs have a lot of patients, and they don’t have enough time to see each patient.
MARTIN MARSHALL: Yeah. I mean, that is the nature of general practice. One of the structural features, which I think is bad in British general practice, is the quick consultation. So the average consultation length is still only about 10 minutes. That's why continuity of care is so important because, in fact, it isn't a 10-minute consultation. It's a series of 10-minute consultations over days or weeks or months. That's how you manage different conditions at different times.
So it can be difficult.
SHANOOR SEERVAI: What kind of medical issues do you typically see as a GP?
MARTIN MARSHALL: Sometimes we are dealing with pretty straightforward, pretty simple stuff. Other times we're dealing with really quite complex stuff, and some people call the GP, the family doctor, the expert medical generalist, as opposed to the expert medical specialist.
The characteristics of an expert medical generalist is they can operate across different medical conditions. But most importantly they provide whole-person care. So they never treat a problem in medical isolation. They're look at the social determinants of it. They'll look at the social determinants of it, and they'll look at the psychological determinants of it. And it's that provision of whole-person care. It's the interest in the person, rather than the interest in the disease that defines a good family doctor.
Health Care Costs in the U.K.
SHANOOR SEERVAI: You said a little earlier that systems focusing on primary care cost less than ones that rely on specialists. So how much does the NHS actually cost?
MARTIN MARSHALL: It's a very cheap service, so if you look at the percentage of gross domestic product spent on health in different countries, in the U.K. it is around 9 percent. In Germany it's about 11 percent, in the Netherlands about 12 percent, in France about 13 percent, and in the U.S. somewhere between 16 percent and 17 percent of the —
SHANOOR SEERVAI: Right, and now it’s around 18 percent.
MARTIN MARSHALL: So as a consequence of having a gatekeeper system, general practitioners are on the front line. And as a consequence of controlling costs by having a tightly managed public service, we deliver better outcomes than you get in the U.S. for, as you say, about half of the GDP spend.
SHANOOR SEERVAI: Okay, so health care is cheaper than in the U.S. But it sounds like the government is really involved.
MARTIN MARSHALL: And that's a massive cultural difference between our two countries, where I think there is a deep suspicion of government in the United States and a compliance with government in the U.K. I won't say a love-off, but a compliance with government.
SHANOOR SEERVAI: I like that. You don't have to love, but you can comply.
MARTIN MARSHALL: Exactly. Exactly. We're very compliant, the British.
SHANOOR SEERVAI: On this point of compliance actually, my understanding is that the NHS is funded by tax revenue.
MARTIN MARSHALL: That's right.
SHANOOR SEERVAI: And so it's residents and citizens who are paying taxes. How do people feel about the taxes that they pay for health care? Do they — is there a sense that this is money being well invested, or is there a sense that people wish they had to pay less money in taxes?
MARTIN MARSHALL: People don't have an allocated percentage of their tax revenue that's then given to health. So there is a federal taxation pot, and health is one of the services that's paid for by government out of that pot. So individuals don't think that my X dollars are going towards the health service. They just think this is all going towards public services in general.
U.S. Health Care Viewed from Outside
SHANOOR SEERVAI: You came to the U.S. — almost 20 years ago? What was it about our health system that struck you as most different when you first moved to the States?
MARTIN MARSHALL: I think it was the provision of equitable care for the whole population was something that struck me. I'm used to living in a country that regards health care as a right. So coming to a country, which at the time had somewhere between 40 and 50 million people without health insurance only receiving care, if they were lucky, through public hospitals was very shocking to me at the time.
And the other element, I guess, on the negative side was the extent to which there was such confidence in the medical model, and what I would describe as such overuse of medical technologies, whether it be investigation with blood tests, scans, walking down a high street in a town an seeing multiple adverts for MRI scans, whole-body scans was just remarkable to me.
And also like the high level of specialization and the relatively small number of generalists — of expert medical generalists operating in society. So that also came as a shock to me.
SHANOOR SEERVAI: Once you got over the shock, was there anything you liked about the medical care you got here?
MARTIN MARSHALL: Fortunately I never needed acute medical care. But if you are in that lucky proportion of the population that does have health insurance and you need high-tech care, there is no better country in the world to be than the United States. And that's the paradox for you, I guess. The best of you do extremely well, but that isn't available to the vast majority of the population.
If you live in a society that is more individualistic, then maybe that's an acceptable trade-off, but if you live in a society like ours, which is more collectivist, there wouldn't be an acceptable trade-off.
SHANOOR SEERVAI: How did you feel when you left the U.S. to go back to England?
I came away feeling a remarkable affinity for Italians and Greeks, where there is a kind of collectivist ethos in Europe based on our history. And I felt — I felt less close to my American cousins as a consequence of that. It was very interesting.
SHANOOR SEERVAI: Right. Well, I was just going to end by asking if you had to choose between your health care system and ours, which one do you think you would pick?
MARTIN MARSHALL: No contest. Ours. Sorry. Ours, I mean the U.K. one because I believe strongly in equity and free access to care for everybody irrespective of your background.
So as a health system, I would choose the NHS, and I think we provide okay care for acute conditions, not as high-tech as you have in the U.S., but I think we provide okay care. So I think on both counts I would — I would rather grow old in the U.K. than in the U.S.
SHANOOR SEERVAI: All right. Well, thank you so much for your time, Martin.
MARTIN MARSHALL: Tremendous. All right, good luck. Thanks so much. Bye-bye.
SHANOOR SEERVAI: And that’s it for The Dose. See you all next week.