Tuesday, 5 August 2014

Australia- Clarity of Vision

Arrived in Australia on 5th May after flying roughly 19,000 Kms.
So this is my experience literally so far and so faaaar!

As part of visa requirements for coming to work in Australia I had to obtain medical insurance for myself and family. As UK citizens we are entitled to reciprocal care with Medicare but its easier to do that after arrival.

So, amongst the first things I did on landing in Australia was to visit the local Medicare office to get my reciprocal card. I quickly realised how streamlined and unambiguous the system is as opposed to the UK where the same system of reciprocal care exists. In Australia I cannot access healthcare without my medicare card (can do via the BUPA cover I got for my 457 visa, have free emergency treatment or pay personally). Moreover, my entitlements are stored on my Medicare card which I need to access any service and they are not down to the whims of a GP. Also, I can access care without having to see a GP for everything.
I needed a new pair of glasses so I went to see an optician. Turned out an eye test and consultation were actually covered by medicare so I got this for free and then only paid for my prescription glasses- at no point was a referral to a GP or a referral from a GP requested.

Take a typical scenario: relatives from UK visit family in Australia and someone falls sick. They go to see a GP. The GP will charge them if they don't have a Medicare card and then they will have to claim it back under the reciprocal care agreements. At no point will the GP be pressurised to see or treat the patient for free. Moreover, not only is the GP paid, medicare will claim the money back from the NHS in UK (that is what reciprocal care is all about).
Now, reverse the scenario: Australian visits family in UK and falls sick. Family member will ring and demand an emergency appointment with their own GP. Said GP will have to see the patient as a Temporary Resident. The guidance is to only provide emergency treatment but family will demand everything including prescriptions for routine items. Either the GP refuses and only provides emergency treatment in which case his own patient (the UK family member) is upset and may complain or he does a FP10 script (a NHS subsidised script as opposed to a private one). If he does an FP10, the UK taxpayer foots the bill! (In Australia regardless of who wrote the script, the prescription benefits are stored on the Medicare card and you pay accordingly to the chemist).

In either case, no reciprocal care has occurred. There is no way the GP can record or the NHS claim from Medicare Australia for the visit to the GP (Note that  the reverse occurs). If the patient goes to A&E(even for non emergency scenario), gets a prescription or has an investigation, no reciprocal claim is being made as the GP has done the referral. In fact the BMA guidance states explicitly that it is not the GPs job to highlight on the referral or test form that the patient is under reciprocal care or even not entitled to NHS treatment (if they are from a country with no reciprocal arrangements) and that such checks must be done by the Hospital Trust. The BBC ran a programme on NHS fraud and highlighted that these checks don't  occur in almost any Trust in UK and as a result millions on pounds are lost every year. Details here on a similar report

It also highlighted that other EU countries are very good at claiming their costs back- Brits go to Europe and fall sick and NHS has to pay. EU citizens come to UK, get treatment and the  NHS can't be bothered to claim!
Add to this the huge number of patients from countries with no reciprocal arrangements. Now, as a taxpayer are you happy that your Govt is wasting your money on people who have no entitlement to care whilst simultaneously cutting down services available to you? (As if to highlight the issue recently this post from an American Dr visiting the UK was published. Have a look here)

Finally, another typical situation which I come across here daily and can't help thinking how wrong we've got it in UK. I work in Wollongong, which is a big University town with lots of overseas students and in UK I worked in Coventry which has a big and expanding University and lots of overseas students.
In Australia, overseas students have to have medical insurance and treatment is not covered by Medicare.
If the Uni expands and more students arrive there is no problem. Surgeries will hire more Drs and Medicare budgets are not squeezed. If the referrals are higher -say to psychologists or sexual health etc no one points fingers at the GPs or tries to performance manage them. The GP is free to practice in a safe and sound clinical environment as opposed to a monetary one.
Equally if practice numbers are low for Dementia, CVD, strokes etc as would be expected for a younger population that comes with a University Practice, Medicare doesn't come chasing the GP. In Coventry the University practices got a visit from NHS England for this very reason (low prevalence of certain diseases). And their funding was being threatened as 100s of patients were being removed from their lists (Payment to GPs is capitation based and Temporary Residents earn the practice a lot less than permanent patients. Are foreign students permanent or temporary?) This is the type of crazy admin work GPs in UK have to deal with on a daily basis.

In UK, foreign students pay a much higher fee and are  therefore  entitled to free NHS treatment. Fair enough, I think.
But only if part of that higher fee is transferred to the NHS. Otherwise the taxpayer is footing the bill for the Universities and the Universities love overseas students because they charge them higher fees. So in a city like Coventry, more overseas students means less NHS budget for the local taxpaying population. Fair you think?

Any health care system will have advantages and disadvantages. All systems are prone to misuse/abuse but in Australia I think there is a clear vision- your entitlements are clearly defined and carried by you on your medicare card. No one can sidestep that. Sure, there are losers and winners but the rules are clear. Medical professionals do not have to juggle financial, ethical, moral and clinical decisions. If the Govt wants to make cuts it simply changes the benefits available via your card. For example if you have diabetes you can get 5 visits to allied health professionals in a year (podiatrist, physio, dietitian etc). If the Govt decided to save and reduce costs they would simply reduce that number to say 4/year. Or if they thought diabetes is under diagnosed/treated etc it could increase the benefits. The GP doesn't bear the wrath of the patient nor is there any ambiguity as with all NICE guidelines for example (they recommend a treatment algorithmn and then say its up to the clinician's decision and patient choice should be respected). Look at the contradictory advice regarding glucose testing strips from NICE and DVLA for example. NHS would love you to stick to NICE guidance, but if a patient has a hypo at the wheel and you have not given enough testing strips as recommended by DVLA you get sued or struck off. A ridiculous situation to practice medicine in.

In UK, the Govt leaves everything, deliberately I feel a bit muddy. You are not entitled to free care if you're not from a country with reciprocal agreements but it's up to the GP to see them as a temporary resident and if the GP feels its appropriate they can register the patient. The NHS charter says tests, referrals etc must be paid for but the BMA advises against it to GPs. When things go wrong the Regulatory bodies- GMC etc will use the higher moral ground and stick to BMA guidance. But, in order to drive costs down the Govt uses all its might to make you go against BMA advice- the erstwhile PCT and now NHSE, CQC, NHS Choices, the complaints procedure for the NHS all make it impossible for frontline staff to follow the BMA guidance. In short, its clear as mud.

This kind of muddy thinking pervades all spheres of UK Govt and policy. When Coventry built a new Super Hospital the number of parking spaces were reduced as compared to the old Hospital because more parking spaces were against the Govt's 'Green Agenda'. Now, the hospital is notoriously congested and when the Air Ambulance lands or takes off even Ambulances are queuing just outside the hospital and the local residents are fed up. The Hospital has put up several bids to ease the parking problems and all have failed. 

Take this 'Green Agenda' a bit further. UK Govt says its committed to reducing ownership of cars and would like people to use public transport and greener cars. Yet, when the depression hit, one of the premier policies of the Govt to get us out of it was the car scrappage scheme which put thousands of new cars on the road. 
Equally if you follow this logic of less people buying cars and using public transport instead being good for the country, then all British car manufacturers will go bust. British car manufacturers are either at the Luxury end of the market(JLR, Rolls Royce etc) or bespoke sports cars- Morgan, TVR, Bristol etc. All these cars are distinctly eco-unfriendly. Is the govt prepared to see them go under? When JLR hired new people in Coventry this was greeted by Ministers as a step forward and a sign on investor confidence returning in UK. Surely, they should have been lamenting the fact that more gas guzzling, CO2 spewing cars were going to be manufactured?

I feel things in Australia are much clearer. They may not be to your liking but they are clearer. Australia has a big land mass and Australians drive long distances over roads that are often uneven. Ergo, they drive big cars and houses, garages, parking spaces etc are built to accommodate this. In Wollongong, in order to promote public transport we don't have congestion charging or prohibitive parking charges. Instead, in true Aussie style we have the The Gong Shuttle- a free bus service that connects all the major spots and the University. It runs a schedule that is better than any paid for variety in Coventry and also runs on Public Holidays and weekends (see schedule here).
Australians love the outdoors and the vast majority live by the coast. So, in Wollongong the council is spending money on running free swimming pools, public baths, free beaches with life guards (see here for details) and is also spending millions on a cycling/running path running some 20 odd kms. 

What exactly does UK stand for currently? I actually struggled to come up with an answer to that. I would have thought that education and the English language itself,  and the NHS would surely be in the top 10. Yet, Councils are busy closing down public libraries, toy libraries and Schools have had a freeze on funding and the NHS is facing massive cuts.

Time to ask- what exactly does being a Brit mean? What values, institutions etc would you like to preserve? And time to get voting my friends!  

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