By Lilian Kennedy (Editor)
As a US-raised Ph.D. anthropologist studying families affected by dementia in London, I am working on coming to terms with cultural differences in understanding healthcare between the UK and US. Over the last 20 months I have become increasingly aware of the nuanced ways ‘universal healthcare’ possess cultural connotations, the depths of which are not readily grasped or deciphered by this foreign American. I’ve found that above all, the mentality that comes with a system such as the NHS is just plain hard to grasp. In this post I trace my attempts to do this, and discuss two central, underlying assumptions I’ve come across that relate to both my experiences at home, the US, and the future of universal healthcare in the UK.
Before moving to the UK I received a fair bit of advice, from various people, about living and studying among the British. As the advice often went, I wasn't in for a particularly huge cultural jump. My move to the UK seemed to prompt others to tell a pseudo-story, that the UK and the US were akin to long-lost cousins, and the fact that the two countries shared a language was an oft-cited example of this cultural kindred-ness. A shared language does, of course, help tremendously, but I think that it also conceals the fact that a matching vocabulary does not equate to matching meaning. Within these meanings are housed subtle understandings about how things work and why. In recent months, increasing contact with the NHS (National Health Service) and its UK patients, have helped me to become intimately aware of my own ignorance of the British.
When I first moved to Edinburgh, Scotland, my flat mates told me to go to my local General Practitioners office to register for the NHS. I did, with a minimum of paperwork and hassle, none of which was insurance-related. I went for a check-up with the doctor a few weeks later, and did not pay upon entering or leaving. This blew my mind. Sure, I had known about and looked forward to the NHS when first moving over from the States, but despite experiencing it, I couldn’t quite believe it. I kid you not, I went twice in the next weeks, because I was sure there was some catch, some snag. Even as I walked away with a birth control prescription, prescribed in the same visit I asked for it, and filled free of charge, I had my doubts.
Since beginning my research in London, the UK citizens I have worked with speak about health care in completely different ways than my own ‘common sense’ expects. Recent years have witnessed a fair amount of discussion and debate in the United States about socialized and/or universal health care systems, as well as the passage of the ACA (Affordable Care Act.) The tones of these debates were characterized alternately by fearful cries heralding hospitals ruled by governmental inefficiency, or broad, almost utopian epitomizations of European systems of public, universal health care. My experience of being an outsider in the UK has been most challenging not only in trying to grasp the structure of how universal health care works, but moreover the depth of the mentality that goes along with a 70+ year old institution of socialized healthcare. Only since speaking to people whose lives are tied closely with NHS services because of their loved one's illness, have I begun to parse this mentality’s depth or why universal health care can feel thoroughly commonsense to a large proportion of a nation’s citizens, but seem so baffling in its logic to me.
From my perspective, the UK state and healthcare takes on two broad qualities which clash with my outsider assumptions about healthcare: firstly, that the state is mandated to provide free healthcare for all (at the point of delivery) (1), and secondly that the state has the ability to provide this care.
I’ve found that the British people, with whom I’ve been working as part of my research, speak of universal health care as a right, a British given. It is also believed to be the responsibility of the state to provide, and provide well. Often, when speaking of public healthcare services (and any requisite extended home care as part of an illness) many people discuss any lapses or failings as an infringement of what they or others are due from a system that applies to everyone. Major care they provide to a loved one is frequently framed as ‘helping out the NHS’ by taking on some of its inherent responsibilities to their ill loved one.
This mentality is not like the one I grew up learning in the States, and illustrates two contrasts. The first is that in the US, securing health care is the responsibility of the individual: either to buy health insurance for themselves and their family, or be employed and be insured via one’s employer. Secondly, access to healthcare was not a public matter, but a private consumer affair and there was no expected common denominator among one’s peers. Healthcare had to be carefully chosen or foregone completely (before the ACA) and options are plentiful (if incredibly complex), offering varying degrees of affordability and coverage. Before moving to the UK, and while employed by a large public institution in the US, I was offered four different options of partial employer subsidized health insurance, and it was the first time I had obtained health coverage in the year and a half since graduating university. Working freelance does not ‘come with’ medical coverage, and smaller companies do not automatically offer a medical plan. These options were offered to all incoming employees and my small work team represented three different health coverage plans, and when we used or needed these plans they played out very differently.
I learned the hard way that all insurance policies are not created equal. I incurred incredible costs for having received emergency treatment at a hospital outside my insurance plan, as well as other more expected costs for follow-up treatment and medication provided within my insurance umbrella. Often, these bills would need to be contested in some small way, and services, such as x-rays and MRI scans, were offered to me by my doctors with the caveat that costs (as determined by my insurance) would be incurred for using them. When a co-worker and I both wished to get a specific dermatological prescription, the type of doctor visits and processes we had to go through did not in any way match: my ‘cheaper’ insurance option resulted in two more dermatology visits before I had the prescription in hand than my co-worker had to undertake.
In my American experience, using health care is not only a medical event, but a financial one as well, as often bills for services must be paid by the patient in conjunction with insurance (and sometimes battled against as well). Some of these services are ‘offered’ to patients by doctors – seeming to point to cost determining medical care as much as doctors’ expertise. Importantly, my experience was in many ways only intelligible as a coherent narrative between my insurance, my doctor, and myself. There was no standard course of medical care for a medical event such as a car accident between my peers and me, because we were all coming to a medical event with different methods (insurance) to pay for this care. Perhaps the constant in experiences such as these is that insurance must be navigated just as closely as recovery must.
My experience that health coverage is not automatic has prepared me to be a thorough outsider, researching within the UK system of universal care. I come to conversations with people in the community I am researching using the almost emotional logic that healthcare is not a given, must be secured through personal action and will be costly. When I encounter people’s stories and conversations about clinical care received by their loved ones during my research in London, two things defy my American common sense: the considerable degree to which almost everyone understands the system everyone else is talking about, pointing to a more-or-less shared breadth of knowledge about the NHS, and that they come to know, very similarly, what to expect over the course of care for someone with dementia.
Though there are differences in coverage and healthcare models, and though differences arise between GP offices and hospitals, discussions about what an ill person can, and should, expect in terms of treatment remain remarkably consistent. Also, these stories are not about the financial negotiation of clinical care costs that typify the experience of many Americans. Indeed, clinical treatment and even social care (as it becomes pertinent to the situation being discussed) does not become itemized by medication prescriptions or hospital stay costs (as I would expect from working with an American insurance company.) Instead, outside costs such as adult diapers or walkers are named and, further, sometimes framed as being paid for ‘for’ the NHS by families. I’ve observed a powerful commonality run through UK experiences and expectations of the state in keeping its public healthy and treated. To me, these discussions underline a common sense which dictates that healthcare is available, and is available for you, me, Tom, Joe and anyone else in the room. Care is not just the purview of families, but the state as well.
And so, we arrive at my second point, briefly: the ‘obviousness’ of the assumption that the NHS actually has the ability to provide the assumed healthcare. While I have stated this in simplified terms, the trust and faith inherent in many of my informants’ discussions about the NHS strike me as particularly British. And, given the older population I'm working with, one that has perhaps been substantiated by a lifetime of evidence. Seemingly, it is an institution that will endure, as part of and as long as the British state does.
Perhaps a mentality similar to this might become part of how a large proportion of Americans will view access to safe and dependable (both financially and medically) healthcare in the future, as moves to more a ‘universal’ system are pursued. The US politics leading up to the Affordable Care Act, and the controversy surrounding it, however, in no way show a broadly unified attitude towards government-decreed healthcare for all American citizens.
But is this state of health care affairs in the UK necessarily so?
There has been a growing public debate, particularly leading up to the election, which suggests perhaps not. In particular, outcry against changes unfolding in past years within the NHS - resulting from changes in the most recent Health and Social Care Act of 2012 (2,3) from the previous 2006 version - are apparent. It would seem that services provided by the NHS have increasingly been made the purview of private companies, and this increase is expected to continue to combat growing NHS costs and backlog (4, 5). Reports also exist that the future will see a possible influx of American insurance companies to provide certain services under the banner of the NHS brand (6,7,8,9). And while, perhaps, this debate centers more on which services, and to what extent, things will be privatized – very different from an American system in which almost all healthcare is privatized and run by a for-profit model – I foresee a shock to the UK mentality I’ve encountered thus far. I’m not sure how encounters with a healthcare system founded on the idea that it is free (at the cost of care) for all, which prides itself on person-centered approaches (1), will make sense of and cope with a system instead comprised of services that are set up to reduce cost and time. Interestingly, a large number of GPs and physicians are also angry and fearful of these changes (10), signaling that the experience of the healthcare recipient (or perhaps, future consumer?) experience a culture clash. When current universal care practices meet for-profit models, the experiences of doctors themselves will be marked by their attempts to navigate the task of providing good care within a system that prizes fiscal variables (11). Perhaps this is why the fight is becoming increasingly tenacious (and covered up? (12)). If the NHS, a British institution, a pillar of modern society, is no longer truly held by and decided by the British – does the way that care is done in the UK stay British?