Two years ago I wrote about my experience in a London emergency department with my son, Victor. That post has since been viewed > 450,000 times. There are over 800 comments with no trolls (a feat unto itself) and almost all of them express love for the NHS.

I was in England again this week. And yes, I was back in an emergency department, but this time with my cousin (who is English).

This is what happened.

My cousin loves high heels. As a former model she makes walking in the highest of heels look easy. However, cobblestone streets have challenges not found on catwalks and so she twisted her ankle very badly. Despite ice and elevation there was significant swelling and bruising and she couldn’t put any weight on her foot. I suggested we call her doctor and explain the situation. I was worried about a fracture. I hoped to arrange an x-ray. If it was broken we would arrange the needed care and if it wasn’t broken I could bandage it just as well at home.

“No,” she said. She’d have to ring for an appointment. It was Friday around 11 a.m. The chance of getting into her GP by the end of the day was apparently non-existent. She would have to wait until Monday. Even is she were lucky enough to be seen that day there was no x-ray in his office so it would be a trip to see him and then a trip to the hospital. She was shocked when I suggested she call and just ask if he could order the x-ray. Apparently, that’s not how it’s done. In person or nothing.

As a gynecologist I will admit feet are not my strong suit, but no medical degree was needed to say she needed an x-ray. She also has some health issues that could impact healing from a break or the timing of surgery (hopefully that wouldn’t be needed, but you never know), so a timely diagnosis was more important for her than it would be in the situation were reversed and it was my ankle.

“We’re going to the emergency department I said,” and off we went to Sunderland Hospital.

Getting to the actual emergency room (ER) from the parking area required a background in orienteering. There was loads of construction and we had to go down hallway after hallway with Hogwarts’ worthy twists and turns. I managed to find a wheelchair, a unwieldily apparatus that only works in reverse. On purpose. This is to stop wheelchair theft, which is apparently a serious problem at Sunderland Hospital.

My cousin was triaged immediately. Within two minutes a nurse checked her ankle, gave her codeine, and then sent her off to an urgent care clinic. She wasn’t even registered in the ER. A porter wheeled her to the urgent care clinic in another building some distance away, which required a trip outside.

“What if it rains?” I asked the porter.

“We get wet. This is the North,” he said. “Of course it rains. Almost every day.”

Apparently no one complains.

The urgent care clinic had a few people ahead of us. It took about 10 minutes to check in and then no more than 15 minutes to be seen. A lovely nurse named Leslie triaged my cousin and agreed an x-ray was in order and made the arrangements. My cousin did not need to see a doctor or a nurse practitioner to get an x-ray. I’m not sure I’ve ever seen that happen in the U.S.

The x-ray and radiology report took 10 minutes. Then a nurse practitioner (also very nice) did an appropriate history and exam. The diagnosis was a torn ligament (sprain) and possibly a small fracture of the lateral malleolus (outside ankle bone). A orthopedics consult was needed. She could have a bit of a wait and be squeezed into fracture clinic that afternoon or she could have a cast and come back to Saturday fracture clinic. The clinic didn’t start until 2 p.m. and we were done in urgent care by 1 p.m. so she opted to wait. She was seen around 2:15 pm. An orthopedic consultant did an exam and recommended a tight support bandage and gave her exercises and guidelines about how to follow-up if she wasn’t meeting milestones.

My cousin was at the hospital for four hours, but over an hour was an unavoidable wait for fracture clinic and about 30 minutes of transport back and forth between the ER, urgent care, and fracture clinic. To receive this care all my cousin had to do was provide her name and birthdate. No copayments, no preauthorizations, no concerns about the radiologist or orthopedic surgeon being out of network. The nursing triage was wonderful and actually doing nursing (I hate seeing nurses relegated to charting). The nurse practitioner clearly knew what she was talking about and had reviewed the films with the radiologist. The surgeon only did the part of my cousin’s care that needed a specialist. It was a great use of resources.

Everyone I spoke with at the hospital loved the NHS, and honestly it showed. While the hospital was a veritable maze and in need of the updating that they appeared to be doing, the equipment was all fine and the people, i.e. the things that really matter, were great. Everyone from the porter to the orthopedic consultant was hard-working, knowledgeable, and friendly. What more could you ask for? I asked a few people what they would like to see changed? The only real issue was people who show up for care that is clearly not even semi urgent never mind emergent. Might a tiny user fee change that? Did we have user fees in the U.S.? Did they work?

Non-emergent care provided in the ER is obviously not the best use of health care funds, but in reality it’s a tiny drop in the health care bucket. Extra emergency room doctors and nurses and the not needed CT scans and other testing that may be generated are nothing in comparison to things like chemotherapy, or HIV medications, or bone marrow transplants. We do have user fees in the U.S. in the form of copayments. Even low copayments can cause some people to delay necessary care. They also don’t seem to deter people who don’t need the emergency room but want to go. I’ve sat in the ER with Oliver waiting for a bed while he struggled with pneumonia and overheard many examples. A man bragging that he tells the ER staff he has chest pain so he gets seen first. He was happy to pay his $100 copayment to be seen promptly at his convenience. He had nothing even remotely urgent. I’ve listened to a mother who waited hours for a diaper rash. Not a bleeding diaper rash, just a rash. Her physician had a free 24/7 pediatrics advice nurse that went unused (we had the same pediatrician, so I knew). She could have saved $40 and most of her Saturday, never mind the exposure to Oliver’s influenza, with a phone call. If you want to change ER utilization, and yes it’s a worthy goal even though it’s not the major cost driver, it’s education and outreach that are needed not penalties.

When I think of copayments I think of a 60-year-old woman with breast cancer three years post surgery and chemotherapy now in remission. She developed a cough and a fever so received a chest x-ray to look for pneumonia. The radiologist found something not quite right, a spot that was especially concerning given her breast cancer history. She needed a CT scan to see if this is a bit of scaring or if her cancer has metastasized to her lungs. When I asked her why she hasn’t yet had the CT scan she told me she couldn’t afford her $100 copayment. It will take her two months to save the $100 so she can get the CT scan to find out if her cancer has returned. She looked at me in the eyes for just a moment and then a mixture of embarrassment and fear that my eyes might tell her what she doesn’t want to know caused her to look away. And what if her CT scan is equivocal and she needs $100 (or more) for the copayment for a lung biopsy? If that’s not a circle of Hell I don’t know what it. You want to know what’s worse? I’ve heard a variation of this story more than once.

Dear U.K., the NHS is awesome. Try to treat it a little better. Maybe teach kids in school how to use the health care system (hey, why not NHS ed alongside drivers ed or sex ed?). Have safe sex. Stop smoking. Try to lose weight if you need to (obesity causes 30% of cancers). Wear lower heels for dancing. And for crying out loud stop stealing wheelchairs. The next time anyone mentions privatization or user fees tell them in America there are people trying to save enough money for the copayment for the CT scan that will tell them if their cancer has returned or not.

Thank you NHS for taking fantastic care of my cousin, of my son two years ago, and of everyone else.

To the British government, stop trying to mess it up.