As a future doctor interested in health policy, Alexis Doyle (’17), a double-major in Biological Sciences and International Peace Studies, received a Break Travel and Research Grant for Sophomores and Juniors to learn about the health care systems of both England and Spain over the course of seven days through speaking with health care professionals and health policy consultants. Given what she has learned through coursework about our healthcare system in the United States, she believes that we have much to learn from both the triumphs and shortcomings of our European neighbors whose approach to healthcare has been much different than our own. Alexis recently wrote to us about her experience:
Many of the most pressing policy-related questions of our generation surround healthcare systems. In the United States, just last week marked the sixth anniversary of the passage of the Patient Protection and Affordable Care Act (ACA), which has sparked debate about the trajectory of the healthcare system of the United States. For the first time in the history of the United States, the ACA enacted many subsides for people to buy health insurance with the goal of expanding medical coverage to the uninsured and improving patient outcomes. On the other hand, in Europe, many countries have been operating with a universal system of care for many years in which people largely do not pay for their medical care at the time of service. Instead, medical services are levied as a portion of their taxes, and access to basic standards of medical care is seen as a right for all people. This socialized system of care has been operating in Spain for 30 years through the Instituto Nacional de la Salud and in England for 68 years through the National Health Service (NHS).[i] A large portion of the speculation in the United States regarding our potential shift towards a system of care more similar to that of England and Spain is economic in nature. However, it is also extremely important to address the other aspects of health care beyond just the cost of healthcare services that affect the experience of patients and that can in fact have huge implications for the cost of a given healthcare system as a whole. My research sought to investigate one particular aspect of healthcare—its ability to respond to the needs of its patients, to be “patient-centered”—as a basis for conducting qualitative interviews that sought to gain insight into the positive and/or negative consequences of the health systems of England and Spain. Prior to conducting my research, I noted that some scholars argue that the restructuring of a health care system to a more socialized model will lead to a less patient-centered system in which doctors can afford even less time to spend with their patients and in which health care professionals will no longer be able to devote time and energy to cultivate compassionate, community-based, and patient-centered care.[ii] Because the U.S. has never operated with universal health coverage in the past, I sought to gain insight in the interviews that I conducted with both healthcare professionals and healthcare consultants in England and Spain surrounding the effect of the nature of the universal healthcare systems of these countries on their ability to be patient-centered in their approach.
As noted earlier, many approaches to healthcare policy research have been economic in nature and have centered on the fiscal and budgetary consequences of various types of healthcare systems. My research sought to provide a different perspective to the debate that is often not as widely heard—that of doctors and other healthcare professionals. Because this group of people is working within the healthcare system, I conducted qualitative interviews with multiple doctors and health policy consultants in Madrid, Spain and London, England in order to shed light on their perspective of their respective healthcare systems. Although the interviews centered on questions that assessed the degree to which the systems were patient-centered, every interview tended to also focus on the merits and pitfalls of the health systems in general. This information was also extremely insightful in constructing a larger understanding of the health system. In addition, my research was intentionally done in two countries with universal models of care in order to have a basis for comparison within Europe from which to analyze the data from the interviews in each country.
During the days that I was conducting interviews and visiting health facilities in Spain, I learned an extensive amount about the nature of their healthcare system, its pros and cons, and the opinions of doctors regarding its ability to be patient-centered in nature. I conducted several interviews at the medical school campus of the Universidad Compultense de Madrid. Perhaps the most informative of the interviews was with the director of the medical school, Dr. Jose L. Alvarez Sala Walther. As a doctor who has worked in the public system for all of his career, he conveyed to me that there are several aspects of the Spanish health system that were patient-centered in nature, and several that were not. According to Dr. Alvarez, among the aspects that made the system able to respond to the needs of its patients were the following: universality, the fact that its budget is set by the state, the quality of care offered, and the flexibility of the system to accommodate the expertise of other countries. The Spanish healthcare system is universal in that it will treat any patient on a basic level, regardless of whether or not the patient is a citizen of Spain. According to Dr. Alvarez, the public system offers a much higher standard of care for more complicated medical needs and procedures, which was confirmed by several other interviews that I did. However, where Dr. Alvarez said the healthcare system fell short regarding patient-centered care was in its ability to be conducive to the formation of strong doctor-patient relationships. Oftentimes, he said, the doctor can only afford to spend five minutes with the patient in the public system. He also noted that doctors do not have the ability to increase their salary based on their performance, which in his opinion leads to poorer levels of motivation in the workplace for doctors and results in lower standards of care. Finally, he emphasized that the shift in the Spanish medical education system that happened approximately ten years ago is indicative of the shift towards more patient-centered care within the Spanish system. Before ten years ago, there was much more of a focus on medical theory, while today as a result of the shift there is an increasing focus to become more practical in the education system through allowing more opportunity for patient contact in medical school. Other interviews that I did included an interview with several doctors in the hospital, and with a psychiatrist and a general practitioner who worked in a clinic. These medical professionals confirmed what Dr, Alvarez said, and the psychiatrist, Dr. Cristina Polo Usaola, emphasized that the greatest advantage of the Spanish health system, which she considered to be completely patient-centered, was its universal coverage for primary care that included significant subsidies for medication that applied to immigrants as well as citizens. She said that the only thing she would do to improve the system to make it more patient-centered would be to expand the education system to include health education and prevention education in order to better use the resources of the state. In addition to conducting these interviews in Madrid, I also had the chance to tour the clinics in which the health professionals that I interviewed worked, and also one of the newer hospitals, the Hospital Infanta Sofia, a public hospital with beautiful facilities and state of the art technology.
After conducting interviews in Spain, I traveled to England, where I conducted similar interviews with doctors and experts in English health policy. I visited the King’s Fund, which is unique in that it is an independent charity working to improve health care in England that has partnered with the NHS in many instances to inform health care providers and professionals about evidence-based research surrounding patient-centered care and the use of compassion in medical practice. One of my interviews at the King’s Fund that was particularly informative was with Ms. Becky Seale, a healthcare policy consultant working at the King’s Fund. She explained that the bulk of her work has centered on working to transform the doctor-patient relationship within the NHS. She acknowledged that she believes that the NHS is a system that is patient-centered in that it is universal and in that the same level of care is given to everyone regardless of the patient’s ability to pay. She also explained that the vast majority of all citizens of England are extremely proud of the NHS, which allows for further development of the healthcare system. However, she said that one of the biggest challenges for the NHS as a whole is the integration of social care into the system of care. As in the United States, there is an aging population in England, which presents difficulties in controlling costs of care given the high cost and demand for end of life care. In order to gain more insight into this topical issue in the NHS, I had the opportunity to interview Dr. David Oliver, a nationally and internationally renowned geriatrician who is involved in health care policy as well as his practice in the NHS outside of London. Dr. David Oliver gave me a large amount of information about his work and about his opinions of the NHS. Regarding whether or not the system is patient-centered, he said, as did the consultants at the King’s Fund, that there is an extremely high patient satisfaction rate of the NHS. He explained that the major improvement that could be made to improve the care of older adults was to better coordinate social care and medical care services, as to prevent the elderly from ending up in the hospitals unnecessarily. In addition, he said that in comparison to the United States, England has far fewer specialists, which causes mediocre outcomes for patients with complex conditions that live in areas without access to the specialists of high caliber they could potentially find all across the United States. Dr. Oliver also spoke about the notion of “gatekeepers” in the NHS as being an important factor surrounding the notion of patient-centered care in the healthcare system. He explained that unlike in the United States, there is not a concept of “doctor-shopping” in England. Everyone in the United Kingdom is registered with a family doctor, and in order to see a specialist, one must have a referral from a primary care doctor—a gatekeeper. This limits the choice of the patient seeking care, but aims at reducing costs in the healthcare system. In addition to visits to St. Thomas’ Hospital, and a smaller clinic operated by the NHS in London, I had the opportunity to visit the Bramley by Bow Centre, a revolutionary model of healthcare working within the NHS on a community level. Bromley by Bow is an independent charity operating on 25 sites in East London and with around 2,000 clients each week. They operate on a model of “health by stealth” in which they seek to address many of the social determinants of health that affect the majority of their patients such as education, financial health, social welfare, employment, and access to healthy food while celebrating the assets of the communities with whom they work. In order to do this, they have a Social Care and Arts Space, a Social Enterprise Incubator, Growing Spaces for food, a Daycare Center for kids, an Internet Connection Zone, a Vocational Learning Center, a Church, a Legal and Financial Advice Center, and an Employment Service Center that all surround their medical care offices. It was clear that the nature of this incredible model addresses the deeper roots of their patients’ suffering, and is truly patient-centered.
The findings from the interviews I conducted in both Spain and England contribute to a very important conversation on healthcare policy that exists in both Europe and in the United States today. In Europe, particularly throughout the NHS, there has been much debate surrounding the pay of junior doctors. Junior doctors went on strike for the first time in many years during the very week that I was in England in order to demand higher pay for their large amount of working hours. The doctors that I spoke to attributed these protests to an underfunding of the NHS as a whole, but there is certainly debate in England that attributes these protests to a faulty healthcare system that fails to meet the needs of its patients. In the United States, the ACA was the first successful attempt at passing legislation to reform healthcare in the United States. When asked about the system of care in the United States, every doctor with whom I spoke in both England and Spain cited the ACA as being a positive piece of legislation for the health system of the United States. Prior to the ACA, patients could be denied health insurance based on previous conditions, which the majority of doctors I interviewed found extremely unjust. This perspective of the Spanish and English doctors also fit into a larger debate that no longer exists in the vast majority of Europe, but that continues to exist in the United States today—whether or not access to a basic standard of healthcare is a right. Central to both the Spanish and English healthcare systems is the fact that everyone has access to the same healthcare within the public system regardless of their ability to pay. This is far from the case in the United States in which there does not exist a public option for healthcare and many private establishments often deny people based on the nature of their insurance—for example, those who have Medicaid coverage. For the doctors that I interviewed, the question of “patient-centered care” was not possible if the right to a basic standard of healthcare for all did not exist. Given our political debate surrounding healthcare in the United States, and whether or not it is a right, this perspective and the experience of health professionals working within other systems of care is important to consider in our own debate.
This trip was not only extremely useful for the information that it produced regarding the opinions of both Spanish and English health professionals regarding their respective healthcare systems, but it also was transformational for my own learning as a future doctor interested in health policy. Being able to speak to doctors from various specialties was quite energizing for me as a student who has not yet started medical school, and it was fascinating to hear from doctors who had such a unique perspective about the health system of the United States. In addition, spending time at the Bramley by Bow Centre in East London was particularly inspiring and informative. My own goals as a future doctor are to improve the health of the marginalized and of those without sufficient access to healthcare living in the United States. Due to the nature of our treatment-based healthcare system, working for the health of the marginalized can be extremely challenging due to the complexity of the health problems that are faced by those living in poverty. I have learned about many theoretical aspects of a health system that would be ideal to incorporate into our own healthcare system in order to truly address the health needs of the poor. Some of these characteristics include addressing the social determinants of health, extending insurance coverage for the poor, working with an accompaniment-based model, and utilizing a model of asset-based community development. What was absolutely incredible about the Bramley by Bow Center is that it has been operating as a health and community center with each of these characteristics and more—and has been doing so for 30 years! I was so excited to be able to meet many of the administrators of the clinic and learn of their revolutionary model that is just now being rigorously evaluated by institutes of health research. It is my dream that such an integrated and wholesome model of health will someday be common in marginalized communities in the United States, and I want to do what I can while I am still in school in order to continue learning about alternative models of care that place empowerment of patients at the center of their practice. Being able to see the Bramley by Bow Centre in action made me realize that this dream isn’t really a “dream” at all, but that it indeed is quite possible.
[i] "List of Countries with Universal Healthcare." True Cost Analyzing Our Economy Government Policy and Society through the Lens of Costbenefit. N.p., 09 Aug. 2009. Web. 21 Jan. 2016.
[ii] Anderson, Amy. "The Impact of the Affordable Care Act on the Health Care Workforce." The Heritage Foundation. N.p., n.d. Web. 21 Jan. 2016.