Hemali and I had trained at the same VTS in East London and I was pleasantly surprised to receive a message from her last year about the possibility of working abroad. Through that dialogue of debunking common myths about appraisals and revalidation, I learned that she was planning to go to Canada. So now, enough time has lapsed and she’s almost three months into being a fully fledged Canadian GP so guess who gets a Facebook message asking for an interview?! I’m not sure if the tone of Hemali’s dry sense of humour is evident in written format but at least I can edit out my cackling! Aside from the fact that I wouldn’t survive one of their winters, I can definitely see the attraction of the country known for its maple syrup, poutine, and hockey. There is something about Canada which has a certain allure – but that might just be a projection of my feelings towards its president, Justin Trudeau…
“My practice is in full flow now. I’m doing a little bit of walk-in clinic and GP work as well. The walk-in clinic is like an out-of-hours clinic but during the day time. With the family physician work, it’s a case of building up the practice at the moment. So basically a neon sign out the front of the building saying ‘accepting’ and then seeing who walks through the door.”
If you followed the US elections in 2016, you might have remembered a candidate called Bernie Sanders – a Democrat and a United States Senator from Vermont – before he conceded to back Clinton. The reason why I bring him up here is because he is a strong advocate of universal health coverage and would often cite the Canadian healthcare system as an aspiration for US citizens. He’s famously known to have said, “If you are serious about real healthcare reform, the only way to go is single-payer.” So I was interested to know how the Canadian system differs from the UK, another single-payer system where access to healthcare is based on need, not ability to pay.
“The Canadian system is funded through the taxes and it feels well-funded and they get everything they want at the point of contact GP-wise [although physio, orthotics and some other services are only covered on certain work insurance plans discussed below]. We can request CTs and MRIs, anything you want really. As to why they can fund it so well, I’m not sure.”
This is interesting because their healthcare only costs 0.4% more than the UK as a percentage of their GDP (7.1% less than the US – OECD figures). Is it because only 70.3% of this is covered by the government (79.3% in the UK, 49.1% in the US)? I don’t know. From what I understand, Canadians pay for all their drug prescriptions privately (most opt for a “prescriptions insurance”) rather than the subsidised system that we have (or whatever you can call it). Although the argument, in the UK, is that those who need the most prescribed medications would be those exempt from charges in other health systems anyway (e.g. the elderly, children and those on benefits) so therefore wouldn’t be much of an income-generator. The Canadians don’t have their dentistry and optometry covered either, much like the UK.
“If you have no drug cover [insurance] you pay for the cost of the medicine. So a course of antibiotics might be $50 which might be a lot for some people. And not just that but some brands are covered -like lansoprazole is covered by omeprazole isn’t. So you end up needing to ask what is covered and what drug plan they have before you can prescribe.”
“Interestingly, they have to pay for their ambulances so they don’t get called as much. They [the patients] get sent a bill after they’ve called them. Another thing they have to pay for, instead of MED3s, they have to get a letter-headed note – and they all pay $20 or so per note. But there’s also no self-certifying so every single patient who has had a day off has to come in for this letter. So that’s another transaction.There’s lots of government type forms for issues like disability, usually a two-to-three page form, and you get paid something like $60 which is about £40 or so. I find it slightly overkill and arduous for something that should be so simple like putting adjusting duties onto a MED3 in the UK.The concept of having to bill at the end of a consultation is also strange because I just don’t want to think about the money aspect of it.”
Although we are accustomed to completing private medicals and insurance forms, I wonder how I would react to being paid for every piece of paperwork required. Would I look at in disgust using social justice as my platform or would I be planning my next personal financial goal? And I guess that comes from which angle we are arriving from. Many of my friends who have emigrated to Australia state that they often underbilled on first arriving but once it becomes the norm, it is easier to bill for the actual work done. I can still see that Hemali is still adjusting.
During this interview, I can see many similarities to Australia including the way that GPs are employed. I guess the easiest way to describe it is that GP’s are self-employed and collect their own individual patient lists and “rent” a room in a practice.
“The place where I am, the practice owner is a businessman and he owns the building and then he hires two doctors and two nurses . Everything that the doctors bills, he takes a cut out of. Generally it’s 25-30% cut goes to him – for the building and he’ll have to pay wages to nurses and admin and the running of the building and the maintenance. Whatever is left over is for him.”
[As a GP], you’re generally being paid per patient and not for what you do [as in QOF]. So some people manipulate the system a little by seeing 80 patients per day, which in our sense would seem almost impossible. But they would get paid for those patients even if each of those patients may only be seen for a few minutes. From the doctor’s perspective it’s their salary.”
So any other aspects that seem new to you?
“After three months of living here, you get a health card and you have to present this any time you want to need healthcare. As long as it is in date they can see a doctor and, if it’s not in date, they take a payment deposit until they get another card or if they’re not able to get another card they’ll take the deposit as payment. We’ve had a couple of patients who are Canadian born and bred but have expired cards.”
Who are these cash patients? i.e. those who have to pay for their care out-of-pocket.
“I [Hemali] wold have to be a cash patient because I only got my work permit and I haven’t done my three-month stint yet. Patients like university students who have moved around; international people who come to the country but not necessary have a work permit; Long-term visitors even from other provinces of Canada.”
“I feel really uneasy about the finances here. It’s good because all of those notes and all of the forms that you do you’re being paid for. But I feel really uneasy, in my walk-in clinic, for example, and you see next to their name, ‘cash patient’ – knowing that they’ve paid $60-80 to see you on that day and they’ve come in with a cough and a cold and you’re sending them away again with nothing. You do feel a bit more guilty than you would have done if it was free.”
These are all interesting points. I already know that I would hate the transactional nature of a fee-paying patient, having spoken to Anna in New Zealand. But would UK GPs feel less bogged down if they were being renumerated for each transaction themselves? The more interviews I do, the more I realise there is no perfect health system. Most amazing health system measures have a trade-off and I’m sure there will be a divide as to whether these trade-offs are acceptable. Comparing and contrasting with other health systems can start a dialogue on what could and should be changed in the NHS.
“I know we’ve been having a debate not too long ago about doctors being border control in the NHS. From the NHS perspective, every doctor thought “no, that’s not what my role is.” But here no one would think twice about seeing someone without the health card or with some sort of payment. There wouldn’t be any ethical debate here. They just wouldn’t see them.”
Hemali is referring to the introduction of upfront fees for those who are not eligible for NHS healthcare. There is ongoing debate about using front-line NHS services to disadvantage migrants who are here illegally, whether via charging them up front or passing their records to the Home Office. We advocate neither of these actions as worry-free access to healthcare is in the best interests for the individual and the general public and is most appropriate for the UK setting.
Anyway, we’re digressing. What’s the system like in Canada?
“It’s the same gatekeeping principle .The GPs would do the referrals. You don’t get rejected from referrals because, similar to us get paid per patient, they also get paid per patient in secondary care. Patients also don’t hesitate to come and ask for second and third opinions because they are used to these referrals. It is, however, good that you don’t feel quite as restricted about getting a specialist opinion although at times you might feel that you might deskill after a few years of being here”
“Waiting times are very variable. Some places, if some people are willing to travel, can be seen within a month or so to be seen in hospital. Some things are taking up to a year in some places. One of the good things is that there are no pressures from above in Canada but in the same respect it means that there are no real rules like a two-week wait – actually there is no two week wait. Nor are there the 16-week targets”
What?! What happens when you think someone has cancer?
“You write to whichever specialty, generally the nurses know who is quicker than who and you could try and call them to get them seen sooner but there is no guarantee and some people do wait to be seen. There was a patient that I saw when I was covering for someone else – he’d been waiting for about six weeks for his first appointment and he had a large rectal mass. And I feel so bad because theres no private care here. Even if they wanted to, they can’t get a private opinion. So they often go across to the US for a costly but speedy opinion.”
Has someone told Bernie Sanders this?? But is it truly universal health coverage?
“The amount of people who desperately wanted a GP but couldn’t get one is what I find the most negative here. A lot of them would be those with mental health problems or drug addiction problems and people in need but because of the way the system works, you can reject them. So you can imagine a lot of the people who need GPs the most perhaps not for physical problems but for mental health problems may get rejected and end up going to walk in clinics every couple of months to get their repeat prescriptions.”
Admittedly, everyone has access to a doctor but perhaps not a regular doctor. But I can’t help feeling slightly uncomfortable with this. It appears that when you set up shop, you organise a “meet and greet” with prospective clients/patients. You both have to like each other to agree to go on the doctor’s waiting list. Don’t get me wrong, I hate my experiences with difficult patients (and I’ve had a couple who’ve almost made me cry) but I’m sure we can all have at least one challenging patient on our books that we still consult with because we know it’s in their best interests.
“The meet and greets are so odd. It’s like first dates but medical. It’s really odd. They fill out a little questionnaire before they come in which is a brief medical history and a social history – smoking, alcohol. Then you go in and they’re like “hey I’m looking for a new GP,” So I say “let’s learn about you. You’re generally quite well” “yes, generally I’m quite well”. “So a little bit about me – I’m a GP from England, please can I have a a second date?” And then basically it’s “if you’re happy to join, I’m happy to take you, let reception know on your way out.” Some of my new patients haven’t had a GP for 10-15 years and they haven’t been checked up during that time. There’s a few cases which I think would have been picked up earlier in England just because of the ease of access which I think we take for granted in the UK. “
Another thing I really pick up on during this interview is the power status, for want of a better phrase, of the doctors. The “meet and greet” and lack of GPs mean that patients are a little on the back foot, although one could argue that this would give patients more onus to self-care (although Hemali refutes this!).
“As much as at the moment, I have no patients and I need them but a lot of doctors have full lists and they don’t need more people. There is that initial… not desperation but… they’re in a position of inferiority – they need you. A lot of doctors would have waiting lists. Until you get on that waiting list, there is a power difference there.”
Nurses act as assistants to doctors rather than autonomous practitioners (something I see also in Japan and many other countries) and doctors have the choice to work how they would like. Also, there is no obligation to do home visits.
“For a doctor, working wise, you can choose how long your appointments are so most of us it’s 15 minutes and there’s lots of flexibility [with working hours]. Here, you can power on through [the day] and get home earlier. For example, my working week is 9-2, 9-2, 9-4 and then you have to do an out-of-hours shift which is 1-8 and that’s because I don’t really take much of a lunch break or a significant one.”
“It’s a bit like locum life in terms of that flexibility but, like locuming back at home, there’s no benefits – there’s no mat leave, no sick leave, no annual leave.”
Also, it appears that doctors can start particular streams, like minor ops, in their practice without necessarily doing a course or being signed off – more of a ‘see one, do one, teach one’ attitude of the days of yore.
“It’s great having that free reign to do as you please and as you want. And it’s a good example of how it should work, but you also have examples of people just going ahead and doing things and patients coming back and having interesting things to say about their previous GP’s.”
We do talk about whether giving GPs this autonomy over their working day would help the burnout crisis in the UK. There is evidence to show (and this is my most favourite fact in the world) that in high- stress jobs like ours, low autonomy leads to burnout but high autonomy leads to job satisfaction. So perhaps the solution to current burnout epidemic is not teaching resilience – my least favourite word in the world – but giving choice back to how we engage with work.
“As much as our patients would deny it, we [in the UK] do bend over backwards to help them. We would literally bend over backwards for forms and notes that we weren’t getting paid for, that we’re just going above and beyond. Here it’s not that way. [The other GP at the practice] doesn’t do any sessions past 4 o’clock apart from that one session from 1 till 8 but none of her patients would leave her – they would rather take time off to see her. And a lot of her patients live over half an hour drive away as she brought them with her from her last practice”
So aside from the flexibility, what else would she import back to the NHS if we could?
“The ease of tests, X-rays and ultrasounds. To see someone with a query fracture and you can send them around the corner in the same building to radiology – and they will give you a stat report there and then – and you can send them on their way. Where I am, you can also get the results of ultrasounds in a week and MRIs in two to three weeks and we still don’t have to worry about the cost.”
And what about her reflections on the NHS from over the pond?
“I just think it’s great. It’s one of the oldest systems so therefore obviously it’s going to be one of the first to show those cracks. Ethically, I love the fact, and I know this will make it sound really corny and cheesy, but we’re doing it to help these patients. We’re not doing it to bill someone at the end of the day. And I guess, anybody, regardless of your mental or physical health background can walk into the GP and register. That’s the bit that I find the hardest to accept. To me, anyway, I just find it really hard associating a patient with a dollar sign above their head. If this has done anything for me, its definitely made me appreciate our NHS more than I would have ever done before.”
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