The NHS Up Close: Emergency Care and Lessons from Across the Pond With Robert Pinate

In this episode of Unstable Vitals, Dr. Adam Brown and Dr. Lara Zibners are joined by a very special guest, Lara's husband, Robert Pinate, a nurse consultant with over 30 years in UK emergency medicine.

Rob helps emergency departments rethink outdated workflows and improve patient flow. The conversation dives into how the NHS actually works from its funding model and workforce of to the freedom clinicians feel when billing isn't part of the equation. Rob breaks down the rapid assessment and treatment model he champions, the culture shock of implementing America's Epic EHR in a system that doesn't bill, and what it's like walking into struggling hospitals that feel like they've regressed.

The trio explores the sobering parallels between the NHS's decline after years of austerity and the growing cracks in the U.S. system, from Medicare cuts to frontline burnout. But it's not all doom. Rob shares where he's seeing improvement and makes the case that sometimes all it takes is pulling the right people off the floor, handing them a blank sheet of paper, and asking: how can we do this better?

Transcript

SPEAKER_00 0:00

Unstable vitals is the pumpkin that takes the pulse of American healthcare, and the prognosis is critical. Dr. Adam Brown and Dr. Laura Zibner, physicians turned entrepreneurs and business leaders, expose why the system is unraveling before the rise.

SPEAKER_02 0:17

And welcome back to yet another episode, Season 2, Unstable Vitals, because healthcare is unstable, and so is she. So are we. This is a joint project. Hi, Adam. How are you?

SPEAKER_03 0:32

I'm doing well. How about you? I'm a bit tired, to be honest. I've done a lot of travel, but I mean that's comparing it to you, which is not a lot of travel.

SPEAKER_02 0:42

Please cry cry me a river.

SPEAKER_03 0:44

Right. Well, that's why I can't really be like, oh, I was out in San Francisco, and then I was in North Carolina, and then I'm going back to London, and I can't, and you're just like, yeah, I've already done that trip like 14 times over in the same amount of times.

SPEAKER_02 0:55

So I walked it.

SPEAKER_03 0:57

Right. Exactly. So in high hills. So, you know, you're like the friend there, Ginger Rogers. You can do everything he can do except backwards and in high hills. So this is where there's no competition here.

SPEAKER_02 1:08

That's right. Anyway, it's nice to see you. I'm in California today, on my way back to London tonight. So there you go. I woke up this morning and said, I can't do this anymore. I'm so tired of being tired.

SPEAKER_03 1:22

Yes, yes, I get it. So, um, but you know, this is not about you, Laura. This is about me.

SPEAKER_02 1:30

Actually, I'm about to make it all about me.

SPEAKER_03 1:32

Okay, go ahead.

SPEAKER_02 1:33

So, guess who we have on the show today? I know. I know you know. Does everyone else know?

SPEAKER_03 1:40

No, but I'm excited about it.

SPEAKER_02 1:55

This is somebody who is not only an extraordinarily accomplished healthcare professional, but he has to put up with you. He is a freak in the sheets. And I mean the excessive. I would like you to meet the man with the eye for detail, the most obsessive, compulsive, detail-oriented person I've ever met. But thank God, because I fly way up here in the sky. It is my hot husband, Robert Pinate. Yay, Robbie Bobby!

SPEAKER_03 2:32

Welcome, Robbie Bobby. So excited to have you on. Have you already? I want to say something. Have you already petitioned the Pope for like a sainthood to have to deal with Laura? My husband died.

SPEAKER_01 2:48

Yeah, I bet I believe my beatification is in the post, so uh I'm just waiting for it. So yeah, it should be through soon. Good, good welcome. Thank you so much. Thank you for finally. No, I'm joking. You've you guys have covered so much um in terms of the breadth and the depth of healthcare, and as you said, the the unstable vitals is a perfect name, isn't it? Particularly with the way the world is going at the moment. Um, and I've I've just always wanted to shed a bit of light on what is it like the other side of the pond. And having being a nurse and still a nurse after 31 years of of working in and around emergency uh medicine, I hope I can shed some light. Well, bring some insights.

SPEAKER_02 3:37

And I wanna I wanna start there because just listen to that voice. I mean, right? Yum. But uh I did marry a nurse, and I think we should start asking Rob why he went to nursing school, and it's not because he wanted to give back to humanity. Tell him the real reason, love.

SPEAKER_01 3:55

Well, I so I wasn't asking.

SPEAKER_02 3:58

How many women were in your class and how many men?

SPEAKER_01 4:00

Well, we'll get to that. Um the the reason why I and I fell into nursing, it's true. Um I wasn't a great student actually when I was 16, 17, 18, because I was having far too much fun playing sports and chasing girls. Um and I was I just was not a good A grade student. I certainly wasn't anything like Lara at the same age. So I actually so in the in the UK we do A-levels, and um I did my A-levels and I did it all in humanities, and I did terribly. And then it was a bit of a wake-up call. So I was 18, unable to go to university, I didn't have the grades, and it was a bit of a wake-up call, and I was like, what on earth am I gonna do now? And my next door neighbor was a nurse, and she said, You'd make a great nurse, and I and I was just like, what? And then I just I looked in more into it with my parents and it was like, oh actually, and I also at the same time, and not because of nursing, at the same time I flipped. I shouldn't have done humanities, I love them, but I'm terrible at them, in terms of exams and whatever. I flipped and I did math, chemistry, I did English literature again, and I did what's something called general study. And I did and in one year. So as opposed to two years, one year, and I did okay. Um and it wasn't until I went to university and I did a degree in nursing back in 1992 was a rare thing, but now it's standard. Um that that's when I followed. So that's when suddenly the the switch, someone hit the switch, and um yeah, three years later I qualified as as a nurse, and I always wanted to do emergency care because there's a there's a program in the UK that's been running since the eighties called Casualty, and it's like ER, but nowhere near as good. Um and there's a guy in casualty called Cash, and he is um he's the charge nurse, the senior nurse within within the the emergency department, and I just always wanted to be him. And and that's how I fell into it. And we weren't allowed to set foot in the emergency department to year three, and finally I did my placement eight six to eight weeks, and and then I was really worried that I'd hate it. And luckily, I loved it.

SPEAKER_03 6:19

And the rest is history, you know. I I think um it's a really a couple points here. I think you know, I I don't know fully about Laura's story. I know that her her dad's a doctor, um, and mom was a nurse, correct? Your mom was a nurse too. Yep. So um I I think for me, it was very similar to you, Rob. My kind of like getting into emergency medicine. It was a combination of someone saying, Oh, did you know that you could be a doctor and you would be good at it? And I was like, Oh, okay, cool. And it was ER on television, and it was kind of like that that mix of watching those two things. But I wanted to dig into something because one of the reasons why we wanted to have you on was not just because you're Robbie Bobby and not just because of Laura. Let's kind of like move Laura out for a second. Um, but no, you you know, one of the things is that we talk about is how the United States healthcare system is unstable, but we're also hearing that there's instability in the UK healthcare system and other systems around the world. And I know that as I talk with students um and people from around the world, that there's no healthcare system that has it perfectly. And so one of the things that we wanted to have you on for was to give your perspective because you're not just a nurse. You're you're a nurse, you're a nurse executive, you understand kind of like the broader system, you understand the problems that are having in the broad kind of NHS, the national health system within the United Kingdom. And there's some overlaps and there's some similarities with what we're dealing with. So the UK or the European system is not perfect, has its issues. So tell us more about this. Is why we wanted to have you on is to kind of bring some credence that healthcare is a universal problem, the operational issues are a universal problem with different features and facts and things around it. So tell us more, like we know how you got into nursing, but you focus very heavily in the operational side of looking at uh departments. And so give us kind of some just broad overview of the UK healthcare system and then what you do within it.

SPEAKER_01 8:17

Okay. Um, so I can let me start with me, just so people can understand what I do. Uh so I'm a I'm a something called a consultant nurse, and we can get into that later, but just think of a very high-level um advanced practitioner, and I'll I can describe more about it, and Lara can tell you exactly what it means, what it look like looks like stateside. Um, but I'm a consultant nurse, that's what it's called. Um, so I came up through an advanced practice uh route, but I was also an educator, I've always been an educator, and now that's the title that I hold. And I've been a consultant nurse for 12 uh since 2012 with two different hospitals. I work at University College London Hospital, and in 2020 um I began working in addition to the day job, as it were, some of my time is is spent working for NHS England, which is the the governing body of the NHS, and specifically my role is I am something called a clinical associate. And that is because I have expertise in my field, emergency nursing and emergency care. And my job is to go around the country and support organisations to improve their emergency departments. So I've had the pleasure and the privilege of going through multiple uh hospital uh emergency departments, and I literally will walk it through with you, I will try and do a diagnostic with you, not just me on my own, I wasn't fine. This is a big group, but we all work for the NHS, so we don't charge the hospital for this service. This this is the part the whole point of the NHS, right? This is free, um and that's my job. So my expertise in particular around the nursing processes, particularly the front door, triage and streaming, as we call it. Um, but I'm also uh an expert in rapid assessment and treatment systems. Uh I've studied them to a very high level, but I also help uh organizations to develop them and implement them. So I cross over with medicine, and that's the key thing to remember about my role is I cross over with my medical colleagues. Um but also I'm an expert in advanced clinical practice and I helped to write the curriculum, the national curriculum, uh as part of the Royal College of Emergency Medicine ACP credentialing program. Amongst lots of other things that I've done, but people can look at my LinkedIn and see what I've done historically.

SPEAKER_03 10:39

So can I just parrot that back to make sure? So it's similar in the United States when you go to an emergency department or what you call in the UK the AE, but when you go to the emergency department, you have a condition, cough, cold, gunshot wound, whatever, you're treated by you're seen by a nurse at the front end, determines by triage, you know, your level of severity, and then kind of puts you into one area of the department or sort you into um uh levels of priority. So who's being seen first, who's being seen second, and where they may be seen. So what the role you're doing in the UK, shock, similar type of system, you know, there's a uh of how people come in the door, but you're looking at how do we make this more efficient operationally? How do we actually ensure that there's smooth workflows, the right number of resources, the right number of nurses to address the patients? That's that is that kind of what you do? Am I describing it?

SPEAKER_01 11:31

Yeah, so no, no, you are. So I still go into a lot of departments and walk through with with the leads, and they describe what they do now. This is the this is the key thing. Don't go in and tell them to change something you don't understand yourself. So you go in and you do the diagnostic, you do the talking, you do the watching, you do the now because of my because of what I am, I can literally stand next to a nurse, I can stand next to a doctor, and I know exactly what it is they're doing, and I'm trying to figure out why they're thinking that, why they're doing that. And it's normally historical, as in there's it's so ingrained that it's about getting people to think differently. That's my job. My job is to get people to think differently. So most departments go in that I go into the system hasn't changed for 30 years. So when I qualified in 1995, we had patient comes in, they book in, register, they then wait, they then triage, then they wait, then they get seen by the most junior doctor you can find in your department, then they wait because we're waiting for all of these tests that we requested, and then they wait again, and then finally a senior person comes in and says, Okay, well, actually you need some this is this is what we should do. Right? So this linear process takes hours. So what I do is I help people to come in and actually break that down. Why are you doing an a system that has been operating for decades? Why aren't you thinking differently? And that's where streaming and that's where rapid assessment and treatment comes in. And uh the very shortest form I can give you is rapid assessment and treatment fundamentally flips the model on its head. Why do we have our senior doctor at the end of the pathway? Why don't we just move them to the beginning and start making the right decisions right from the beginning? And that's the same with streaming with nurses. I make the right decision, next person, the most senior person I can find. So that that encapsulates really the process. But not all hospitals will implement that, not all hospitals will will implement it in the same way. And my job is to translate that that and bring it to a site that works for them. There you go.

SPEAKER_03 13:48

No, it's it's fascinating, it's interesting. Laura.

SPEAKER_02 13:50

And this is what I was gonna say. He's a freak in the sheets, and I mean Excel, because he is like the most detailed. You know what's interesting? So back to how you get into emergency medicine. I actually was going to do pediatric cardiology and matched in the cardiology fellowship, and then did two months in the ED back to back. And all the attendings were like, You're not one of them, you're one of us. And I think that was well spotted because most of us in emergency medicine have ADHD. And I didn't just make that up, like that is a statistic that that's where the doctors with ADHD go. But Rob has the opposite issue, he's so detail-oriented that he can see things and and take the time and pay attention and just observe. Whereas I could not do his job. I would, I would fly, you know, like a yards, we fly in and we're like batting our arms around and then we fly back out. Whereas the nurses are one, the ones who actually are sitting at the front door and having the patient come in. And I think, you know, as well, I can tell you he's in high demand because he's one of the few nurses in that group. Um, be but he does have to travel to we're really weird places with names like Chester. Okay. My can you guys hear my pinging? It's my family. Will not I put myself on focus. I've said do not disturb. I have said stop texting me. I don't know what to do. Rob is out here in California with me right now, and yesterday was the first day I let him see my sister's home. How'd that work out?

SPEAKER_03 15:19

Well, here's the thing. Okay, so let's let's do some education for Laura. There is, for those that don't know, this is called an iPhone. And an iPhone has different types of things on it. And one of the things here on the side is a silencer. It's it's it's it's silent. You have to make the same the noise.

SPEAKER_02 15:36

It's silent, and then my computer also has. If you work in a Mac, your messages come on, and even if you try to shut messages off, they're ping, ping, ping. And I've got this family that yeah.

SPEAKER_03 15:47

See, Rob, again, this is another proof point of why we should have leased.

SPEAKER_02 15:52

For a moment, because we will come back to what Robbie Bobby does. But for one minute, I met Rob. For those who don't know, I also practiced in the UK. And so I actually met Rob at work at the Royal College of Surgeons in London. And so I had my own version of going into the UK and being like, why do you do that? Even though the room looks the same and the medicine is kind of the same. Um, Rob's had the flip experience marrying into an American family of doctors. And um, yeah, I think he's made some interesting observations there.

SPEAKER_03 16:25

Yeah. Well, I want to ask you to talking about the differences between you know the UK and the US, let's frame that out a little bit. I mean, we talked about like specifically what's happening in the ER, but like tell us more about the numbers, kind of England by the numbers, how many people are we talking about? What does the NHS do?

SPEAKER_01 16:42

Yeah. Um, that's that's a great question because I think it's about just framing it for people that don't know or understand the NHS, right? And England. So I'm gonna talk about some numbers which are England, and I just want to make the distinction that England is not the UK. So um, right? So I'm talking about the country of England. Why? Because NHS England is just England, so it's not Wales, it's not Scotland, and it's not Northern Ireland, okay? That would be the United Kingdom. So England.

SPEAKER_02 17:10

But what's Great Britain?

SPEAKER_01 17:11

Great Britain is Scotland, Wales, and England, not Northern Ireland.

SPEAKER_03 17:15

Ireland.

SPEAKER_01 17:16

Right? So it gets complicated. Yeah, so I'm just gonna talk about England, okay, just to frame that. Okay, population. Let's talk big numbers here. Population, 58.6 million, okay? That's 84% of the UK population. Just to give some context to that, California is 39 million. Alright, so the entirety of England is 58.6 million. The land mass is 51,000 square miles. That's about roughly the same size as Alabama. That's it. Right?

SPEAKER_02 17:45

And you were just in Alabama, so you know.

SPEAKER_01 17:47

I know. The whole of the US, the whole of the US, so including Alaska and Hawaii, three three and a half million square miles. England, 51,000. So it just gives you a sense of scale, but also you get the sense of how many people we pack into that space, right? 58.6 million. Alright, NHS, let's talk about money. In 2024-25, so we work, our fiscal year works from April to March, alright? So not like the not like the American system, which is January to December. So that's why we always talk about 24-25 or 25-26 years. $204 billion spent in the N on the NHS, and that represents 40% of government spend, which is by far the largest department. The Department of Health and Social Care is by far the largest government department. It represents about 10.9% of GDP. Interestingly, the US, in figures that I could find, is about you guys spend actually 16.7% of GDP on healthcare.

SPEAKER_03 18:45

And that's actually can be low because there's some reports that are closer up to 20. It just depends on the year, but but yes, you're right. It's kind of nuts, right?

SPEAKER_01 18:54

Just gives you a sense, right? Uh we're kind of in the middle of the table of of you know uh uh of countries, similar countries. Uh workforce, we have one and a half million people, full-time equivalent, so not heads, not head count, uh full-time equivalent working in the NHS. So it's the by far the biggest employer um of anything. And actually, if you look at global stats of employers, it's up there. It's up there with Amazon, it's up there with you know these enormous uh international companies. Let's talk about my profession uh just for a minute. Uh nurses, midwives, and nursing associates have to be registered with a nursing midwifery council. And in the UK, because they don't break down the numbers, in the UK, all right, uh 860,000 people registered to practice, of which nurses, so not midwives, not nursing associates, just nurses, 793,000. Now, not all of them work in the NHS, but we do have a private sector, but it's not it's small.

SPEAKER_02 19:56

I think can we stop there for one sec? Because I think that that's something people I did not understand. As an American, you'd hear the NHS and socialized medicine. You don't realize that the NHS is the safety net, it is the base where people get their care and where they know they'll get care. You don't have to get your care in the NHS, you can step out into the private sector. And so it's not just that you have no choice, right? Um, but but for emergency medicine, what I always tell people is um in the UK, you can't private your way out of a major trauma because all emergency care happens within the NHS.

SPEAKER_01 20:31

Yeah, I think that the key, the key here is is there a private sector? Yes. Uh predominantly for elective stuff. The the only thing I would say is the vast, vast majority of people in the UK, in England, cannot afford to go private. So it's it's a misnomer to think that they can do that, they can just choose to do that. The vast, vast, vast majority of the population simply cannot afford to do that. And also the NHS is there to provide that service first and foremost. Um, and but but how do we fund it? Well, because we we're through our taxation. Okay, so let's be clear, it's not that it suddenly just comes for free. We pay for that service, but that means that when I go and attend and require the service of the NHS, it is free at the point of delivery.

SPEAKER_03 21:17

I I want to go back to to something about I think that's important framing. When we talk about the NHS, some people are thinking about it's just the insurance system, and it's not. So, you know, the UK is different from Canada, for example. Canada has a public baseline insurance system and then has a mix of public hospitals and private hospitals. Um, in the UK, the vast majority, there are some private hospitals like HCA, Cleveland Clinic, Mayo, but there are the vast majority are all NHS hospitals. The insurance program is NHS. The doctors, the nurses, the technicians work for. So what's different from, say, Canada is the doctors and nurses don't necessarily work for the Canadian government. They may work for the private hospital, but everyone has an insurance card. So it'd be like here in the United States, everyone working getting Kaiser Permanente insurance, working in a Kaiser hospital, all the Kaiser doctors and nurses are all and you're all working for Kaiser, or you're in the VA system and you only work within the VA system. So that's a really important thing to understand. So it is a closed, for the most part, system. And to your point, Rob, I think as you mentioned, as I've talked with a lot of people in the UK, I mean you're you're a citizen, my husband is, um, but most people do NHS only. They're they and they don't go out and get private. Some people that are a little more well off say, I'm going to buy a private insurance, boopa, and I'm going to go then to private hospitals or pay out of pocket. But that's a fairly small percentage.

SPEAKER_01 23:01

Yeah, in the grand scheme of things, I don't know what the percentage is, but it's pretty small. And a lot of people will have that benefit through their work. So so so their job will come with private medical insurance.

SPEAKER_03 23:16

But it's supplemental, it's a supplemental thing. It's an add-on.

SPEAKER_01 23:21

The key thing about the NHS system, bearing in mind it was it was created in 1948. Um so the the uh the whole idea behind it is we we pay towards it through taxation. If you're below a certain threshold, if you earn below a certain threshold, you don't pay a penny. But that doesn't mean you don't get access to it. You get exactly the same care and exactly the same services offered to you as someone that pays and earns 200,000 a year. The person that only earns 12,000 a year below the tax threshold, they may pay a little bit of national insurance, but essentially below the income tax threshold, they they will get the same care. There's there's no differentiation. So it's not about what you earn, it's about you being in the system and requiring health care. So it's about trying to get the best for everybody. And I talk about it, and and you guys will know this in emergency medicine. What I love about what I do, what I've always loved about what we do, is I I don't care who you are. I don't care whether you're a high flyer or someone that I don't know that has the lowest job you can think of. That's just as important to me as a human being, and they will receive exactly the same treatment. They can have the same tests, they can have the same medication, they can have the same referral, they can have the same outcome. That's what I love about it. It's the ultimate level up, ultimate level up. Okay, so we never ask, do you have insurance in the UK, not in the emergency department, because it's irrelevant. We never ask what you can afford, it's irrelevant. And the bit that blows a lot of Americans' minds is when I prescribe, because again, my role means I can prescribe drugs, I can prescribe any drug that you would normally do in emergency. I can request a test, I can refer you, I can all of that. Yes, I record it, but it's not I don't think about the money. I don't think, oh, that's gonna cost this much. I don't think about charting it and oh that I must no, it's just I just do it because it's the right thing to do for the patient.

SPEAKER_03 25:25

So do you think it's a little compare and contrast? Do you think that it's better? Is it good having one central ethos of how we're taking care of patients, one body of doctors, nurses, hospitals all working together? Is that a good thing?

SPEAKER_01 25:46

I think it can I think it can be for the greater good. I think that doesn't mean there's not disparities within the NHS, right? So we know that some hospitals do far better than others. Uh, we know that hospitals generally in deprived areas will struggle more because they'll have a higher demand on them. The patient population sadly will be more unhealthy, they'll have more comorbidities, etc., etc., less access to the right health care earlier on. You know, let me give you an example. A GP practice in a very deprived area, the numbers of patients on their books per GP per doctor will be far higher than in an affluent area. Right? So we know that the we know we don't it's not perfect. We haven't cracked the disparities of health care due to socioeconomic factors. Okay, it's not perfect, but the fundamentals allow us to ensure that everybody gets care. And actually, for most people, I would say that if you're really sick, you will still get great care, irrespective of where you are.

SPEAKER_02 26:55

I I think that was one of the things that I found the most freeing when I started working in, I was an honorary consultant at St. Mary's for a number of years. In the US, I I had to know every insurance, like I would have to check a patient's chart, what insurance they had, and that affected my discharge decision making. It affected what I sent them home with, who they follow up with, who I call. Um, when you're in the UK, you don't do that. You just do what you think is right. As a result, because you know, the system can't, you can't be perfect and you can't do everything. But so we actually would have a lot of patients return to the ER on a scheduled appointment basis, which you would never do in the US, because they would go to their primary care doctor. It's a different system.

SPEAKER_03 27:38

Except for rabies vaccines. That's it.

SPEAKER_02 27:40

This is for rabies vaccines. That's right. Except for that, but we don't test for rabies in the United States anymore. So never mind. Um, yeah, but no, it was super freeing because I could remember as a fellow, I had to know everybody's insurance, and back in the day, who covered a nebulizer and who covered a an MDI inhaler, right? You had to know, oh, that insurance won't cover this, and that won't do that. You don't you don't do that in the UK, you just take care of the patients.

SPEAKER_01 28:04

Well, yeah, and let me give you a real life example. So we we introduced a digital healthcare record system into our hospital. Uh UCLH, it's called Epic, which a lot of you will recognize because it's actually come from America.

SPEAKER_02 28:17

Have you ever heard of Epic, Adam?

SPEAKER_03 28:18

Yeah, I may have just written an op-ed about it, but you know, maybe.

SPEAKER_01 28:23

That's what I thought. So we we we introduced it into our hospital. Um, this is a few years ago now, and it's completely transformed the way we work. I think it's a great system for lots and lots of reasons. But what was fascinating was we had the American team come over and help us build it for our purposes, and there was these rooms of of consultants and people like me and lead nurses, and we were developing it from a clinical standpoint, and it was hilarious because the Americans kept on talking about billing, and we were like, stop talking about billing, it's not a thing. What you mean is we need to record that we've done a catheter, you need to record that we've done some blood tests, you need to record, but that's stop talking about billing, and and and people actually started getting really annoyed with them. So they they realized they had to stop talking about billing, it's not a thing in our it we don't talk about it. Do we record it? Yes. Is it do we have a tariff that sits in the background? So if you come into the emergency apartment, um the the average cost for the NHS, which is this is gonna blow people's minds, right? If you come to an AE department, somewhere between £173 for your visit up to an upper threshold of somewhere around £563.

SPEAKER_03 29:37

So $200 to $700, somewhere around there. Yeah.

SPEAKER_01 29:40

That's it. And and that higher number is because we've actually done a lot. We've put in a chest strain, we've done a CT scan, we've done this, that, and the other. So those are the sorts of numbers, and that's economies of scale. So back to your point, Adam. Does it help? Of course it does. We're not talking about a system which is a hospital-based system, we're not even talking about a regional-based system, statewide. We're talking about a federalized system for the entire population of a country. That's economies of scale, because not everybody needs health care, but they're paying their taxes. So you use that money for those that do need health care, right?

SPEAKER_03 30:17

It's an insurance pool in some respects, you know.

SPEAKER_01 30:19

Yeah, yeah, it is. And but but because you've got that greater good ethos within the whole makeup of the NHS, it allows those economies of scale. That's the beauty of it.

SPEAKER_03 30:32

I want to go to something you said about Epic. Um, you know, in one of my roles, I I work in revenue cycle and and and coding and billing. And um, and we all know that the EHR interface with the clinicians and the work can sink uh revenue significantly. There can be lots of revenue leakage. And one of the primary reasons that EHRs in the United States have been created the way they have been is for the purpose of building. Yes, they were supposed to be a part of the High Tech Act, um, that where everyone had to be in this type of electronic platform, because the whole idea was if we're moving towards value-based care, we have to be able to extract data, we have to know utilization rates, we have to know approximate costs and charges and things so that we can back into what's working, what's not working, where are there inefficiencies, where they're not. That was kind of like the idea behind the act. But the real thing is that Epics and Cerners and Meditech, and though in your case, you mentioned Epic, they were built to optimize billing. The excess charting is to optimize billing. And so it is fascinating when you say, hey, I actually like Epic. I would love to see a side-by-side comparison between what is the data input that I would have to put in in the emergency department in the US and the nurses, and when then what's the chart output versus what happens in Epic UK? I have a strong feeling that the data, the clinical data may be ultimately similar, but the amounts of data that we're having to put in for the purpose of billing is likely dissimilar.

SPEAKER_02 32:16

When I was working in New York, I remember we had to hit so many review of systems to get to a certain billing level. And so you know how this works. You to maximize your efficiency, you create these like standard templates, right? I had my chair exam, my across the room exam, like the kids ripping the room apart, he can probably go home exam. And I would, I had to excessively do review of systems on each of them just to make sure that they could get the maximum. Because if it was turned out it was something big and we could get max billing for it, if I had only listed musculoskeletal and hadn't said, you know, his sense of smell was top notch, right? Whatever, you wouldn't get that that, but it's overcharting, right? It is meant to extract data, but you overchart, it's irrelevant what somebody with a broken toe really, like how their nose is working.

SPEAKER_03 33:08

Well, the good news is is some of that has changed to where most, at least within the emergency department, um, the actual billing is based upon the complexity of the patient and the medical decision making, but that really hasn't trickled down into much change in how much that we're documenting now. Um, but Rob, you know, I what I mean, so so that's a good thing, but the charts look this very similar. There's not a lot of change, and the doctors are still putting in a ton and a ton of information um, and nurses are doing the same. I I wanted to switch gears a bit just because of time. Um, we've talked about a lot of the positives. So a big population, almost 60 million within England, um, a standardized system. Yes, there's disparities, but you can go anywhere and get treated as a part of the NHS. They're not worried about insurance, you know, and your GDP for healthcare is quite a bit lower. And fun fact, people in England live longer than they do in the United States. So, you know, value-wise, you're you're getting a better bang for your buck for a ladder um or for your pound, um, you know, for lack of better terms. Um, but there's some negatives. You you highlighted disparities, but what are you seeing now that you you uh you're you're kind of seeing both sides of the pond in a way. What are some of the negatives that you're seeing to the NHS system?

SPEAKER_01 34:22

Um I think I think it's the last, I'd say since about 2010. Not surprisingly, there was a change of government in 2010.

SPEAKER_03 34:32

Um, austerity.

SPEAKER_01 34:35

Right. So as with any healthcare system, I think globally, it's a political, right? And and there's always been an argument about how do you how do you distance the politicians from from uh healthcare. And I don't think anyone's cracked it, certainly we haven't. Um because it means in our system we have a general election approximately every five years. The parties can change in that sort of time frame. Well, guess what? They expect the entire NHS to pivot and just to start doing something differently rather than just saying actually no, you're doing really well, just keep going. Anyway, back to the austerity thing. That was a political decision, but it was a choice. Um we didn't have to do austerity, other countries didn't do austerity opposed to the twenty two thousand and eight crash. That's a whole different discussion. But that's the choice that was made, and we have been chronically underfunded as a healthcare system and social care system in particular, bearing in mind they are two starts different parts of the same positive. And we are now paying the price. Um, there is no question that we are paying the price. Um, all of the standards that we were achieving back in then, we are failing to achieve now. So the four-hour standard, which is a standard within emergency care. So you should come into an emergency department and leave the emergency department within four hours, not be seen within four hours, finished within four hours. We actually still manage, uh so 2024-25, we manage 73.9% of all patients, 27 million in a year coming to the emergency room would leave within four hours. Okay, just to give you the sense. But that's bad. We used to do 90 odd percent. So we're not hitting that target. We're not hitting something called the 18-week wait target, we're not hitting cancer targets. And and the list goes on and on and on and on and on. So that the NHS is in a far worse position now than it was 15, 15, 16, 17 years ago because of political choices which are inevitably made. Um well not inevitable, but political choices that were made. Now we've got a change of government, right? So Labour's got back in, uh Labour created the NHS, and now they are trying to turn the the super tanker. But like any super tanker, well that's a bit politically uh I did I I didn't realise I was talking about super tankers given what's going on in the US.

SPEAKER_02 37:02

NHS is going through the Strait of Hormuz, I guess.

SPEAKER_01 37:04

Yeah, basically. So it's it takes at least I I think it'll take 10 years to turn this ship around. But Labour may not stay in power for 10 years. So then what happens? So is the NHS in a worse position now than it was 10-15 years ago? Without question. I think what I've found personally very difficult, and I and a lot of my colleagues that have been around as long as I have would also attest to this. We had this extraordinary period in the 2000s, the first decade of the 2000s. Seeing the NHS get better and better and better. We got more efficient, we would deliver better care, we had better outcomes to deliver. And just seeing that slowly uh wither on the vine, uh I call it a death by a thousand cuts. It's never one big thing, it's just the accumulative effect of cutting here, cutting there, freezing here, jobs freezes there, just continual. And it's brought us to this position. And now we're trying to turn the ship around. But a lot of people have suffered as a result, and healthcare outcomes are have deteriorated in some respects. So that's the challenge when you've got such a big system.

SPEAKER_03 38:24

It's it's a it's a it's a warning, it's also a lesson, and also not surprising, all rolled into one, right? You know, that healthcare costs are expanding, are increasing because utilization is changing, our technologies are getting more um refined and better and our treatment options, but that also costs something. And so when that's happening, plus you have inflation, granted, you know, over the decade post um after the systems reduced quite a bit after the financial crisis, you have all of those things kind of pouring together. You can certainly see that it's a perfect storm that if you cut the legs out from someone, they're not going to be able to run. And um, and it is unfortunate. I I think we're seeing some similar things happening decade over decade with like declines in Medicare rates for doctors, um, cuts to Medicaid, which is under insuring or not insuring large portions of the population, and that has a trickle-down effect, creating more disparities in some of our most vulnerable areas. It's kind of a story that we keep seeing, and we do nothing about it.

SPEAKER_02 39:25

That's one of the similarities I've seen in the two systems is that the the actual frontline providers, and that's often the emergency department, but certainly the doctors and nurses, they if you if you make it so hard for them to do the job that they showed up to do, you lose morale and you lose, you lose workforce. And I think that that's the part that's really not understood by what I call the the Gucci's, you know, the administrators who walk around in nice clothes and make decisions without really understanding the implication of the front line. And I think we can see that that's happened. I mean, I'm certainly hearing it from my friends. I left the US 20 years ago, but I it hasn't gotten better, it's gotten a w a lot worse. Everyone I talk to. Um, and I hear the same thing at home from Rob, you know, about the and I think you've said it that you haven't seen the morale and conditions like this in a very long time.

SPEAKER_01 40:17

No, uh so when I visit certain hospitals, but bearing in mind my my job and and the job of the rest of the people at work in the in the group within the NHS England. So it's called getting it right first time.

SPEAKER_02 40:32

GERF. GERFT.

SPEAKER_01 40:34

Um so it's called Getting It Right First Time and GERFT. Yeah, so there's a there's a whole group of people. Yeah, and I never work alone. I've got the my colleagues in GERFT, there are experts in their field around all sorts of processes and data and this and that and the other. What I bring to the party is my clinical expertise. So I've been an emergency nurse, I've over 30 years. What what what is so challenging sometimes is going into a hospital and we're asked to go to the most challenged organizations in the country, walking through the emergency department and seeing doctors, nurses, porters, healthcare assistants, receptionists, all the people that make your emergency department work. I think they're just as important as we are, right? And you walk through them and you think this is what it was like in the 90s when I qualified, when the NHS was on its knees, and we've we've gone full circle, right? We've gone absolutely full circle. And and to see that level, those sorts of conditions that the people are working in again 20 years later. Yeah, it it's difficult sometimes because you just like it doesn't have to be like this. I know it doesn't have to be like this because we weren't it wasn't like this. Now we're back, now we're back to square. It feels like we're back to square one in the none of this space.

SPEAKER_03 42:01

So we have 60 seconds uh left. I I just you know, one of the things that we like to ask is is that you know, healthcare is unstable, but what what do you think, Rob, that we can help stabilize the healthcare system and make it better? What's kind of your your high-level takeaway?

SPEAKER_01 42:19

Oh well, it all right, so two answers. First one is is far too easy for me to say, which is more more funding, right? As we've already pointed out, that everyone bangs the drum in the UK about it needs to be more efficient. Well, uh actually, if you look at the numbers, we're pretty darned efficient. We are one of the most efficient healthcare systems in the world. Um, so for instance, 10.9% of GDP, right? So so we must be doing something right. Um I guess the key thing for me is and it reflects what I do, is often when we go in, when I go in, you actually do have the tools and you do have the people and you do have the thoughts to make things better. What what no one ever gets in in front line is time. Time to think, time to step back and look at what they're doing and saying, How can we do this better? And I'm so lucky that my job is to literally go in and pull the right people away from the front line. I literally put them in a room sometimes with a blank piece of paper and say, forget everything you've been doing for the last 20 years, which is a different conversation to have, how can we make this better with what we've got? This is the reality, but we can still make it better. And we've seen some real successes, and we continue to see real successes around the country, and that that I think is the green truth, is like as I say.

SPEAKER_02 43:41

Well, and I will let Adam bring it home, but I just want to add that we didn't even get to touch half the stuff that you've done in your career, and I'm super, super proud of everything he's done. We didn't talk about, you know, he he actually wrote the credentialing for emergency nurses, advanced practitioners in the UK. He's one of the only Nurse consultants not credentialed because he wrote the credentialing. So he's the chicken or the egg, depending on the day. You know, he's he founded the major nursing trauma group. Like he's done some really extraordinary things. But right now he's you know super happy and passionate and won't quit no matter how much I try to get him to live full-time with us. So we will continue to allow the NHS to have him for a while longer until I can drag him away fully. But um I was just I'm really happy that we got to have Robbie Bobby on because I'm very proud of this man.

SPEAKER_03 44:30

Oh, you should be. I'm I'm so glad that to have you on as well because you know it's uh the perspective is interesting. And when we when we're trying to solve healthcare problems, oftentimes uh you to make things more stable, we tend to look inward and we just kind of still like bare our heads down and we just keep going through the day. But sometimes you have to look externally, like what's working in other places. Just uh, Rob, as you were saying, you know, put people that are on the front line in the room, give them a blank sheet of paper and work on a solution. Um, you know, having people with different perspectives, backgrounds to say, can we do this better? I think is a really, really important way to help solve the problem. So I am very grateful for you. Thank you. As someone who lives in the US and the UK, thank you for making the NHS better. Um, because I probably have to go there at some point in time too. So um, but uh, but thank you so much for joining us. We really appreciate it.

SPEAKER_01 45:19

Thank you so much.

SPEAKER_00 45:20

Thanks, guys.

SPEAKER_03 45:21

All right, have a wonderful one. Take care.

SPEAKER_00 45:24

Thanks for tuning into Unstable Vitals. If you enjoyed this episode, make sure to follow us for more unfiltered conversations on the pulse of healthcare. Connect with us on LinkedIn or visit us on Unstablevitals.com to stay in the loop.