Comparing health care systems

Of course it\’s not just people not being patched up and sent on their way efficiently. It\’s an entire culture of bureaucracy. I\’ve no doubt bits of the NHS are world-class. But the shop-window walk-in & A&E is grotesquely inefficient, and that\’s all I\’ve seen first hand. And I can compare it against the similar systems in France, Germany, Canada and Norway, all of whom manage to achieve Triage without demanding everyone who isn\’t dying always waits 4 hours.

46 thoughts on “Comparing health care systems”

  1. Odd, I’ve never waited anything like four hours, not even at St Thomas’s on a Saturday night. They must be careful to discriminate against the NHS-haters.

  2. This is a question that’s fascinated me since I sat with a guy, who’d run his hand over a circular saw, dripping blood on the floor of A&E for 2 1/2 hours. How do these places maintain a constant waiting time?
    You see, it just shouldn’t be possible. Think of it like a bowl with an outlet in the bottom & water gushing into it.. If the outlet is greater than the inlet the bowl would always be mostly empty. If smaller, the bowl fills & overflows. To maintain a constant level, which A&E does despite varying levels of inflow, you’d have to be constantly fiddling with the outflow rate.
    Why would they do this? If you sit there long enough it becomes obvious. A fair number of people simply give up & leave. Effectively, they’ve self diagnosed whatever brought them in no longer needs treatment or the inconvenience outweighs the benefit. And I’m sure that some simply feel so bloody dreadful that suffering at home is better than an endless wait on a hard bench.
    I’ve never heard this confirmed, but I can’t think of another explanation.

  3. Am I the only person I intrigued/impressed by the number of countries in which he has had to visit A & E?

    Though even the seemingly cautious Paul B seems to have more extensive personal experience than me – I never had him down as getting into scraps on a Saturday night…

  4. @PaulB: I’ve dislocated my shoulder three times, once in the US, twice in the UK. Morriston hospital in Swansea had me wait 3 hours to have it put back in, despite there being a total of three people in A&E. Frimley Park had me wait 6 hours, but it was a very busy night to be nice. On the other hand, I was unable to walk since I had an ankle operation a week earlier and had been on crutches, so a demand to leave immediately at 0200 wasn’t very welcome from my point of view. Eloy hospital in AZ had me knocked out within 15 mins of entry and discharged within the hour. No contest!

    The NHS relies a lot on people giving up and going private. Most physiotherapy treatment is delayed 6 weeks after the GP consultation for just this reason 🙁

  5. Paul B, I suspected as much – my personal trips to A &E have declined with age – one as adult c 20 yrs ago (bike – broken arm – Barts – about 2 hrs from memory).

    Which makes me even more curious as to the original poster – he’s a stockbroker (albeit a cycling one), I think without children. Does every skiing trip end up in casualty? Not really relevant, but his blog temporarily isn’t accepting comments, so I can’t ask him.

  6. Bloke in Spain>

    Think of it as working like a water tower, but in reverse. With a water tower, water is pumped up to the top at a continuous rate, a little faster than it is used on average, thus avoiding the need for a pump which can provide the pressure needed to meet peak demand.

    With Casualty departments, there is an average number of patients that’s pretty consistent, and they make sure that there are enough medical resources available to meet the average. At busy times the waiting room fills-up, and at less busy times it empties-out.

    There simply isn’t a consistent waiting time in casualty, any more than there is for the water in a water tower. That’s the simplest way to ensure maximum usage of the resources available. Ultimately, it doesn’t matter if you wait for a couple of hours in Casualty with a broken finger or some such.

    Anecdotally, in my experience if you go to a UK Casualty department outside peak times, you’ll be seen relatively quickly. I’ve also waited a long time in France to be seen for something serious which would have got straight to the front of the queue in the UK.

  7. I’ve actually had the thing of being left in the ambulance, in the hospital car park, because allowing me in might mess up their figures.

    I always thought that one was a myth until it happened to me. Ambulance men said it was a regular thing.

    Not that I minded; I was on nitrous oxide and enjoying it.

  8. Dave
    Yes, that’s the way I’d expect it to work. So you’d expect to get the time where you turn up & get seen right away. Business I used to be in you see a lot of A&E. Blokes hurt themselves. I’m responsible for them. It never happens.
    There’s loads of analogous, constant flow, operations running throughout the economy. Supermarket checkout’s a good example. But they should clear occasionally. It’s the slight inefficiency paid so that the sudden high influx can be coped with. It’s the overall efficiency that’s important. Part of that are the customers’ needs. You wouldn’t use a supermarket that used its queues to buffer the throughput.
    Oh, but this is the NHS isn’t it…………

    One experience of my own. 3.00am. Badly cut hand. The only bod in A&E. Wait? Over an hour & only then because I started making a fuss.

  9. You are all assuming the function of the NHS is to provide medical treatment. Thats just an occasional byproduct of its real job, providing secure, well remunerated employment for the middle classes.

  10. You people are scrubs. I once had to wait two weeks for A&E treatment on the NHS. True story.

  11. All my NHS A&E experiences have been queue-free, but then again I don’t think I’ve ever actually rocked up to casualty and asked to be admitted (two ambulances – one broken leg aged 12 and one broken head aged 19 – and one GP turning white and saying “go to A&E at the hospital over the road now, I’m phoning them to ask them to admit you” a couple of years ago).

  12. Been rushed to A&E 5 times in recent years with conditions ranging from crushed skull (mine) to elderly relative dying of pneumonia.

    Terrible system.

    Waited for four hours on two occasions; once with blood pouring down my face being pestered by hookers (and their pimp), a tramp and a couple of very scary thugs.

    Both four hour waits were ended by a very senior consultant stomping through the unit screaming (literally) “For F***’s sake. We’re about to breach. Get these f****** out of here.” At which point I was stuck onto a trolly for several hours more.

    My elderly relative was seen promptly, but then nearly killed (repeatedly) by incompetent doctors and nurses who (mostly) couldn’t have cared less.

    One evening both people in the relatives waiting room had had a loved one directly killed by being booted out of hospital to make bed space.

  13. Re the different experiences everyone’s recounting on this thread, PaulB’s sarky comment, and every other NHS discussion I’ve ever read – starting to wonder whether, if you have your formative life experiences in the UK, the quality of your NHS experience is the main thing that actually *determines* whether you end up left-leaning or right-leaning….

  14. Not sure your left/right split is the correct way to look at it. Didn’t someone say something after; if your not a socialist in you twenties, you’ve no soul, if your not a conservative in your forties, you’ve no sense?
    I’ve never known anyone move from right to left. Anyone differ? Think what happens is people toddle along in their comfort zone till some big event shoves them out of it. Colliding with the NHS can often do that. And it’s not that they then move to the right. It’s they start realising many of the idealistic notions of the left don’t survive reality. Find more right wing ones do. But it doesn’t necessarily make them right wing. It’s an increase in pragmatism but it’s not even. Hence you can get people with very hard right attitudes on say, immigration, whilst reckoning the NHS is paradise on earth. Depends on which bit of reality they bump into.

  15. @ PaulB

    ‘Odd, I’ve never waited anything like four hours, not even at St Thomas’s on a Saturday night. They must be careful to discriminate against the NHS-haters.’

    ‘Luke: quite right, all my visits to A&E in the last decade have been with my children.’

    Perhaps all it will take is for you to have to visit for yourself, as an adult?

    Or you could wait until (as happened to my grandmother) you spend a fortnight in the inaptly-named Good Hope in Birmingham, where you contract oral thrush, suffer bedsores, are left in your own urine, are not properly fed, eventually lose the ability to speak, and eventually die of thirst.

    Yes, that might well turn you into a ‘hater’, but by then there’ll be fuck all you can do about it; at least you’ll die knowing the glorious social project rolled ever onward.

  16. @ John B ‘starting to wonder whether, if you have your formative life experiences in the UK, the quality of your NHS experience is the main thing that actually *determines* whether you end up left-leaning or right-leaning….’

    I think possibly you look for more issues if you are predisposed against – my grandmother’s horrific death (if you treated a dog in that way you would be jailed) merely (to me) proved everything I expected to find in a system run by bureaucrats, employing (at the lower level) idiots and the product of the mindset that sees the individual as something to be sacrificed on the altar of the great good.

    That said, you’d have to be a mindless cunt not to see that the NHS is a mess, irrespective of whether you’d had that experience.

    Part of it, though, is the eternally juvenile left wing desire to escape reality – even the realities of pain and death. Right wingers (using the phrase very widely) expect to suffer; left wingers think suffering can be alleviated if only enough ‘resources’ are used. This is true at the individual level, but not at the group.

  17. BIS @ 16
    “I’ve never known anyone move from right to left.”

    Depends a little what issues you pick on – I’m guessing that not many OAPs are against pension increases. And I suspect quite a lot are in favour of universal non means tested benefits for the elderly.

    I agree I can’t think of many who called themselves Conservatives when young but Labour when old.

  18. Alex Randall
    “Right wingers (using the phrase very widely) expect to suffer.” Or do they expect others to suffer?

  19. @Luke:
    ‘Or do they expect others to suffer?’

    Yes. They expect others to suffer, as well as they themselves, because that is what happens, in life.

    They prefer some amelioration, but they don’t expect it to be endless, for themselves or others.

  20. To be fair to A&E, give up and go home may be the best solution. Bed rest is an ancient remedy.
    Faced with an increasing number of parents with an only child and parental paranoia the (literal; not cleaned up by the cleaner) shit in the waiting room means toddlers are put in overheated waiting wards when all they’ve got is a fever. Then the risk of misdiagnosis (meningitis) involves a two day stay until all the tests are done.
    Better triage, quicker diagnosis is the answer. Unfortunately, A&E is et up to cope with the bleeding obvious.

  21. As Dave says earlier, A&E is a classical pseudo random arrivals/fixed resource problems.
    And since we can’t choose when we have accidents, and supply-side flexibility is very hard, we’re stuck with the outcome.
    Based on about 20 experiences in the US, UK, and Yurp (I’m a keen but rather unlucky runner) I’ve found a quite good survival guide, (except when actually bleeding to death) is to make myself useful. Let kids, women, gunshot victims go first, mend broken equipment (common in A&Es), try to limit treatment needed to minimum.
    Such excessive geniality annoys the shit out of the harassed A&E types and speeds things up excellently.

  22. Paul, do you believe in fairies at the bottom of the garden, as well?
    Is there any one here who’s experienced “Eight minutes from arriving in the department to being assessed”? This is presumably being assessed by a qualified medical person, not a f***ing form filler.
    You want a real number? Princess Royal, Haywards Heath, largely deserted waiting room, 6 people – 20 minutes. Took 5 minutes for triage.Wait from triage to treatment 2.30hrs. From their TV screen. Hung around for 20 minutes & then cancelled. Number of punters came up trumps? Zilch.

    This is me f***ing around 3 weeks ago, after exchanges with lost_nurse. Had to go to the hospital anyway & was interested, so reported a phony problem. This isn’t urban centre, midnight. This is stockbroker belt. 4,00pm.midweek.
    (And in the middle of rural Sussex, a mile from town- parking charges. Including for badge holders. Why, FFS?)
    Can I interest you in buying a bridge?

  23. BIS @ 21 “This isn’t urban midnight , this is stockbroker belt.”. Could that be the cause of the problem? Being in the back of beyond not a proper town? There are problems with living in rural backwaters. No broadband, lack of exposure to non-Anglo Saxons and poor healthcare. Come join us in a proper town.

  24. I do have a problem. I’m under treatment in Spain. A second opinion would have been nice, but not 3 hours worth of nice.

  25. bloke in spain: “being assessed” means triage. Five minutes is less than median, you should be happy. And well done to the triage staff for putting you and your time-wasting complaint at the back of the queue where you belonged.

  26. Anecdata alert.

    Last time I was in A&E, it was with a mildly damaged teenager who, frankly, we could have patched up but we don’t keep the tetanus jabs around …

    11pm. In the door – seen immediately by a professional form filler. Explained the issue. In to waiting room. Half a dozen people there in various states of broken. 1 hour later – seen by a nurse. Teenager into a wheelchair (not exactly necessary but may have been rules. Hole was in his leg.) Waiting room starts to fill up – 2 or 3 brought by the police.

    2.5 hours later, jag and bandage. Then home.

  27. “And well done to the triage staff for putting you and your time-wasting complaint at the back of the queue where you belonged.”

    Time-wasting? Sorry Paulb but who’s time am I wasting apart from my own? I’m interested in the performance of the NHS. I’m considering moving back to the UK. If I do I’ll be paying taxes towards the NHS, whether I like it or not. So as a consumer, I’ve conducted a little personal survey into it’s performance. It’s cost the NHS 5 minutes of admin time. (Would have been less if the process was more efficient.) 5 minutes of the time of a mildly skilled professional. (That’s how I regard doctors). Total cost? If it was a commercial business, say £15. NHS- fuck knows, so I’ll ignore it. Problem inherent with the system. Against that set the thousands I might pay in tax.
    I’m doing exactly what I do when I assess a service in the commercial sector. You think I take the spiel of the salesbod as gospel? I look at what’s being offered. maybe make them jump through a hoop or two, see how they perform. It’s my money. I don’t throw it around. If they don’t like it, stuff ’em. I go somewhere else.
    What do you think I should do. Accept their fairytale self assessment?
    You seem to be under the impression the resources & performance of the NHS are somehow sacrosanct. Something to be received with craven gratitude & reverence. My attitude is the same as I’ve just had to inform one of your major banks. I don’t work for you, you work for me. You do things to my convenience not yours. You don’t like it, that’s your problem. My custom can go elsewhere.

    On a point of accuracy, the wait for triage was 20 minutes not 5. That’s out of my valuable time. The 2 1/2hr wait was what was advised on their internal TV display. As I was the last in & not bleeding all over the floor or turning blue, I would hope I was at the back of the queue. If none of the half dozen waiting were seen in the 40 minutes I was there the implication is the wait could have been considerably longer.

    SE & thank heavens for anecdata. Organisations like the NHS hate it, don’t they? Detracts from the rosy glow of their own self promotion. Enough anecdata points can reveal the need to look a lot more closely at, so called, rigorous analysis.

  28. Data from the previous administration’s Minitruth (and decades of the Teacher’s ‘experts’) told us that exams were getting much, much harder and children cleverer. Those of us out there in anecdata-land with exposure to the dumbos produced by the education establishment were told to shut up and listen to our betters.

    Look how that one turned out?

    Same thing with immigration, NHS waiting lists and treatment, crime statistics, Govt finances, the Euro, energy policy etc.

    Amazing how useful anecdata is.

  29. Anecdata? Love it. Pal & myself ran a business on anecdata for 12 years. Never once advertised. Never received a single complaint we didn’t resolve to the customer’s satisfaction. All personal recommendation.

  30. bloke in spain: the clue is in “A&E”. It doesn’t stand for “Would you like a Second Opinion on your Chronic Condition”.

    The waiting times on NHS TV screens tend not to be reliable. There’s no target that says they have to be.

  31. PaulB. You still don’t get it do you? I feel absolutely no guilt in exploring the service provided by an NHS A&E. None whatsoever. It’s what it’s there for. If it can’t stand casual examination, better it doesn’t exist. Do it another way.

    “The waiting times on NHS TV screens tend not to be reliable. There’s no target that says they have to be.”
    Then what’s the point in having it? WTF’s a ‘target’ got to do with anything? I couldn’t tell a customer that my promise to turn up Wednesday doesn’t actually mean Wednesday because our projected attendance isn’t subject to evaluation. They’d laugh at me.

    And actually, you’ve gone to the heart of my original comment. My suspicion A&E waiting times are a device to regulate use of the service. I’ll make a special point of returning to that A&E next time I’m back. Check that TV. If it’s still showing 2 1/2 hrs we’ll have good reason to suspect it is. I’ll let you know.

  32. My last visit to A&E (with teenage son, yet another sports injury) involved TWO queues – one for triage (3/4 hour), then another one to book in at reception (20 min). Over an hour of queueing even to be registered on their system. Once registered, the published waiting times then applied, which for minor injuries that evening was 1 1/2 hours. We were indeed seen in 1 1/2 hours – so they met their target – but our total waiting time was over an hour longer. The NHS has its own way of fudging figures…..

  33. There is extensive evidence (both NHS internal, Parliamentary and anecdata based) that NHS doctors/managers ‘game’ the waiting time system anyway.

    They’re only human after all.

    Every system regulators design will be gamed. That’s why voting with your feet is always best – and always hated by the left.

  34. BIS, “I’ll be paying taxes for the NHS whether I like it or not.” Just as well – you’d struggle to get private insurance for a pre-existing condition.

    Are you also going to test the police service by assaulting someone and seeing whether you get arrested? The prison service? Why not the nuclear deterrent while you’re about it?

  35. Luke. Your & PaulB’s attitudes are revealing. You both in the public sector? Because tackling the revealing of a shortfall by disputing how the shortfall was identified is pure public sector. You don’t like people sniffing round your precious NHS? Mum’s just died in its care & my father still is. I do have an interest.

    Anyone know how that survey Paul quotes was arrived at? The 8 mins average wait for medical assessment just doesn’t stack up. Do they include all the ambulance admittances? That’d be more like a pass the parcel exercise, wouldn’t it? The ambulance crew would have already done an assessment. 1 minute, 2 minutes? That’d bring the averages way down.

  36. bloke in spain, I think people are finding your experiment and subsequent outrage a bit odd, that’s all. You went to A&E with a “phony problem”, you waited 20 mins for triage, which itself took five minutes. You didn’t say what your “phony problem” was, but clearly it wasn’t something like a gunshot wound, a broken neck or a heart attack. You waited 20 mins and then left, therefore the NHS is rubbish. It doesn’t make much sense, does it?

  37. bis
    “Is there any one here who’s experienced “Eight minutes from arriving in the department to being assessed”? ”

    Yes me about six months ago, at a hospital only twenty miles from Haywards heath as it happens. OK it was a bit more than eight minutes, maybe ten, fifteen at most and I was there with suspected heart problems ( false alarm ) still not bad and the nurse who gave me an ECG and the doctor I saw immediately afterwards were very effIcient and informative. It probably didn’t do any harm though that I had my sister with me who is a nurse, I made a point of mentioning that. So that’s one positive A&E experience and I’m not all that kindly disposed towards the NHS for other reasons. It should also be noted that this hospital has a poor record on operations and MRSA.

  38. bloke in spain: No, I don’t work in the public sector. No, the purpose of A&E is not to satisfy your curiosity, it’s to provide emergency healthcare. There are more recent statistics here: you’ll see from the notes that ambulance admissions are included. You can if you wish download a spreadsheet giving considerable detail, including some data quality checks. It’s clear from the spreadsheet that the claim we started with that “everyone who isn’t dying always waits 4 hours” is nowhere near the truth.

    My remark about TV screens and targets was a joke, but never mind. My experience (mostly not in A&E) suggests that NHS staff are not punctilious about updating the information, so unless it’s automated it may well not be reliable.

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