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Europeans Share Their Healthcare Experience, Part 2: Great Britain

To bring some diverse experience into the discussion on health care reform here in the USA, I’ve asked my friends in Europe to share how health care works in their lives. In this second of four entries, here are comments from my British friends:

From Martin in Wales:

The National Health Service (NHS) in Wales is essentially the same as the English NHS founded over 60 years ago. Today, the main difference between the services in England and Wales is that in Wales (as in Scotland) we pay nothing for medications. Our Welsh Assembly decided that no matter the cost of the drugs, the duration of the illness, or the wealth of the patient, no charge is made for prescription drugs.

This fulfils of the one of founding principles of the NHS — like justice, health care is “blind.” You are treated no matter who you are or what your financial means are. None would pretend that the NHS is perfect: New and expensive drugs are used to combat diseases in an increasingly aging population, which puts financial strains on our system. However, knowing that the NHS will try always to treat you to the best of its ability is something valued highly by most Welsh people.

Treatment under the NHS is free, but the cost is huge. We pay for it in our taxes. In the US, people pay insurance companies for their health care, whereas in Britain, we pay the government. You may think this makes the two systems the same, that it’s only a matter of who you pay. I don’t think so. Don’t forget that the NHS is “blind” and its blindness is its true virtue. Insurance companies insure the individual for a profit, while the NHS delivers care, free to all.

From Tom in England:

The United Kingdom National Health Service (NHS) was 60 years old last year and continues to provide “free” health care from cradle to grave. The NHS is state-funded. It is paid for by employers and employees making a contribution direct from earnings. Care and treatment is free to citizens. Drugs are about $10 per prescription. The NHS system enables completely free access and care for people who can’t pay taxes: the poor, unemployed, and elderly.

When things go wrong with the NHS, it’s given massive prominence by a media looking to sell newspapers and pump up TV ratings. However, for the majority of the English — those not made fools by hysterical media coverage — it is quite popular. We like the NHS because it takes away the worry about what would happen if your health fails, if there’s an accident, or if you just need help as you get older. It’s not perfect. No health care system is. But there are millions of people who would testify that they’d be dead without it.

The creation of our free service came after World War II, when there was a desire to spread health care to all citizens. The demographics have changed since then, however. A population that lives longer requires more costly care. Every society needs to deal honestly with this reality. Life-saving treatments have been developed that cost more. And so, in 2009, the NHS is one of the biggest topics of political debate — it’s called by some a “sacred cow.” The bottom line is that none of the major political parties will try to remove it — and certainly not when they are facing a general election in 2010. I think most of us would call our NHS a 60-year-old success story, regardless of today’s financial challenges.

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Europeans Share Their Health Care Experience, Part 1: Scandinavia

To bring some diverse experience into the discussion on health care reform here in the USA, I’ve asked my friends in Europe to share how health care works in their lives. In this four-part series, we’ll start with the most highly taxed and socialistic part of Europe: Scandinavia.

From Hakan in Sweden:

In Sweden, we have free choice in health care. It means that patients can choose a hospital anywhere in the country.

In 2005, the cost of the health and medical care sector amounted to 8.4 percent of GDP (in the US, it was over 15 percent). This amount includes the cost of pharmaceutical products, dental care, eyeglasses, and patient fees paid by households.

We employ a “high-cost protection scheme” that means that no patient ever needs to pay more than a total of 900 SEK (about $125) over a 12-month period. For pharmaceutical costs, no patient has to pay more than SEK 1,800 (about $250) over a 12-month period for prescription drugs. This way, no citizen will be put into poverty because of health problems.

The fee for visiting a doctor or hospital varies from 100-300 SEK (about $14-32), but once you have paid 900 SEK in a 12-month period, the rest of the care is totally free — no matter what kind of treatment you need. Private-care providers are also “clients” of the government. A patient can choose a private doctor or hospital, pay the small fee, and the government pays the difference.

The health and medical services have an obligation to strengthen the situation of the patient, for example, by providing individually tailored information, freedom to choose between treatment options, and the right to a second opinion in cases of life-threatening or other particularly serious diseases or injuries.

Having lived here all my life and raised my family here in Stockholm, I honestly do not see anything bad with our health care system.

From Richard in Demark:

I have lived and worked in Denmark for 24 years and have had numerous encounters with the health care system. In all cases I was satisfied or impressed with the quality of service and the low cost (apart from the tax system — more about that later).

The health care system in Denmark is free to all who live here. Even visiting tourists will be treated free of charge in case of an emergency. A non-Danish friend of mine who sprained her ankle during a recent visit was X-rayed, bandaged, treated by a doctor, and even given a pair of crutches to use — and was not charged anything. She was only asked to return the crutches when she left Denmark.

The quality of Danish health care — which is not run on a profit motive — is very good, though there is a waiting time for some non-life-threatening operations like a hip replacement. But everyone will eventually get the operation they need. Hospitals are free, doctor visits are free, and medicine is highly subsidized so that those who need a lot of medicine get it at a greatly reduced charge. Dentistry is subsidized.

This is paid for through our tax system, which — at 52 percent — is perhaps the highest in the world. None of the 10 political parties in Denmark has ever wanted to change that, because they know that they would not get any votes. The vast majority of Danes are agreeable to pay these high taxes; they know that they get about 50 percent of the money back each year in a vast array of benefits. Seven out of 10 Danes are willing to pay even more taxes, if necessary, to maintain the health care system we expect.

Danes have the mature and realistic understanding that you cannot give everyone a quality health care system, good schools, and the elements that help to make for a good quality of life, without paying for it. Freedom does not mean not paying taxes. For us, freedom is paying taxes. By taking care of each other, and the weaker elements in our society, we all have a better quality of life with very low crime rates, few prisons, and a sense of security that it is not “me against the world.” That is part of what it means to be Danish.

From Hanne and Trond in Norway:

In Norway, everyone has, in principle, equal rights to health care. Norwegian hospitals are “free” for patients (being financed with taxes) and everyone is entitled to treatment, irrespective of income and insurance. However, many things are not always working well here.

When hospitalized, no one asks for insurance coverage. You can stay for as long as it takes without having to worry about costs. At the hospital, every part of the treatment is free, indefinitely. At home, people with chronic illnesses get medicine and necessary medical equipment almost for free, save for a limited, annual base payment.

But some parts of the system don’t function well. Depending on the illness, you could wait a long time for necessary hospital treatment (typically non-emergency surgery). For instance, you have to go through your family doctor in order to be referred to a specialist. When the family doctors have way too many patients and limited opening hours (and limited telephone hours!), this is often an obstacle. Of course, any emergency treatment is exempt from “queuing.”

As for the cost, the hospitals operate with a combined budget of approximately NOK 75 billion ($13 billion). Our health care is not free — we pay for it in our taxes: Our corporations pay a flat tax rate of 28 percent on their profits. Wage income is taxed under a progressive structure, from almost zero (very low, part-time wages) to a maximum marginal tax rate of 54 percent. The average “industrial worker” has a tax rate of 30 to 35 percent.

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Travel Writer as Curator

I’ve been in San Francisco for a couple of days — giving talks, enjoying a bit of the Bay Area, and meeting with travel publishers and travel editors. Today was filled with philosophy about the role of a travel writer and tour guide. I’m not sure exactly what we were talking about, but it stirred my thoughts nicely.

I spent breakfast talking with Spud Hilton (travel editor of the San Francisco Chronicle). One of only about a dozen journalists in the USA still earning their income as a full-time travel editor, Spud gave me an update on the state of newspapers in our economy.

As we lamented the cost to society of traditional journalism morphing into blogs and amateur Internet postings, Spud compared “citizen journalism” to “citizen dentistry” or getting a “citizen plumber” — do we really want to dispense with the professionals in trying to understand our world through news reporting?

Spud also talked about the challenges of getting good articles for his travel section. He likes a travel story that gives a place a personality profile, written by a writer who shares his experiences there in a way that tells more about the place than the writer.

I lamented how I can do a month of really productive guidebook work and come up with almost nothing of any value for newspaper articles. Then I can go out for two days without my guidebook chores and stir up plenty of great anecdotal material for newspaper and magazine writing.

Spud said one reason he likes to run my articles in the Chronicle is that people in the Bay Area already feel like they know me. This is helpful because he figures they get up and running with me more quickly, and that enables me to establish myself in a place with fewer words. And fewer words is a plus when you have limited newspaper space.

Conventional thinking is that people go to the travel section of a newspaper to learn about good deals. Spud believes you can find countless deals online these days, and for a paper to offer something unique it needs to run finely crafted articles that take you there. We were talking about my new Travel as a Political Act book, and found that we were both dealing with the same notion that there are two fundamentally different ways to travel — the old “tourist versus traveler” thing — and that one is not necessarily right or wrong. My passion has been to inspire people to both have fun and have that broadening experience.

Spud, who landed his position in part because he’s an expert in (and a fan of) the cruise industry, also sees two kinds of travel: what he terms “discovery travel” and “leisure travel.” We agreed that these are not mutually exclusive. You can go to Mazatlán and have the leisure on the beach (with a plastic wristband giving you unlimited margaritas and a stretch of Pacific beach cleared of locals)…and then head a couple blocks inland to eat real Mexican food with locals. Then I had lunch with my publisher, and the fun conversation continued. My publisher is a futurist/visionary/travel publishing wonk — a wonderful man to collaborate with if you want your guidebooks to succeed. In analyzing the ebb and flow of various guidebook series, he was into the notion that some guidebooks are into aggregation while others are into curation (as if designed by a “curator”).

Aggregation publishers build their guidebooks by pooling all the data in a giant content bank, and then ladle out various configurations as if buying modular furniture: Would you like an L-shaped sofa? How about a guidebook to clubs and shopping in capital cities? Other guidebooks are a result of “curation” — designing, organizing, and interpreting information that works together holistically, like a body works together. Knowing what a traveler needs and what they’ve learned or experienced so far, a “curation” guidebook intuits what is helpful as the trip unfolds.

I told my publisher that I experimented this summer with letting my staff dedicate days to hotel updates, freeing up time for me to “live the books” and have the experiences in order to better shape and design this end of the information. I was thinking this might be the most valuable use of my time. He said, “Yes…curation.” (Perhaps the word is just made up…but I like it much better than aggregation.)

Then, this afternoon, I talked on the phone with my tour operations department and grappled with the challenge of guides who keep their groups very happy by aggregating the travel experiences on a tour, but aren’t curators in bringing everything together to give a big context and maximize meaning and learning by weaving together what the various local guides have shared and taught.

Whether its through newspaper articles, guidebooks, or tour experiences, we are scrambling to make the travel experience as rich and meaningful as possible.

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Paola’s Arc: Many Recommended Restaurants Have a Shelf Life

I love recommending good restaurants in my guidebooks. But they seem to have a quality arc and often don’t belong in a good guidebook forever. Typically they start tentative, become stars, get lazy and greedy, and then often fall out.

Trattoria der Pallaro, one of my favorites in Rome, seems to be heading down. I visit almost every year unannounced and wander through the place talking with diners and staff and reassessing the place. It is funky, memorable, and in my 2009 visit most people there were having a wonderful experience with a quirky hostess in a memorable neighborhood setting. But now I’m getting bad reports and need to reconsider my recommendation.

Almost every place will get occassional bad feedback…but when a pattern emerges, I need to take note, even if the place is a long establshed favorite that is still generally making people happy customers. For an insight into how we deal with this phenomenon, here’s a recent thread of correspondence between our travelers using the guidebook, my managing editor (Risa), and me:

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Hi Rick,

Here are some recent negative reader-feedback emails concerning Trattoria der Pallaro in Rome. We talk up Pallaro quite a lot in the Rome guidebook. Should we contact Paola or reconsider our recommendation?

Risa

Forwarded Message #1:

Dear Rick,

I am a solo woman traveler, elderly, who has always used your travel guides to help along my holidays.

I was in Rome in September and went for dinner to Trattoria der Pallaro run by Paola which you recommend in your Rome guidebook. Well I had a terrible experience there and hence this letter.

The meal was OK but as I do not take coffee I asked for my check before coffee was served. Paola herself came to my table and I gave her €21 as your book stated. She asked for €25…. OK, the rates may have gone up after your book was published. So I gave her a €5 note and then she asked for €20. I told her that I had already given her this amount, but she insisted that I hadn’t…I had seen her slip it into the pocket of her apron and I said so. She then started to raise her voice and spat out a volley of words in Italian, in a loud and uncouth way. She then called a waiter who spoke no more English than she did, saying she did not understand what I was saying. I refused to pay more and she kept a loud tirade so that heads started to turn in our direction…rather embarrassing too as I had no idea what she was saying. Whatever I said fell on her deaf ears and finally I had to pay an extra €20… a meal that now cost €45 and was certainly not worth it. And at the end of all this, she did not give me my bill…an offense in Italian law. If I did not have to leave early the next morning, I would have gone to the Italian Tourist Police and lodged a complaint. Too late now. A very disturbing event. And an eating place best avoided.

Regards, Katie B

Forwarded Message #2:

Dear Rick,

I returned this week from a trip to Italy and relied heavily on your Rome guidebook. I found it helpful, up-to-date and precise in many of the details.

A major disappointment on the last night in this magnificent city propels me to write with the hope for some correction in your description of the Trattoria der Pallaro. I had dinner there with four friends and felt that it was a bad experience. My friends unanimously agree with my assessment.

The first dish of lentils was bland and uninteresting, but we still hoped for better things to arrive. Even an amateur cook could produce this easiest of dishes. Next came hard-to-chew penne (pasta al dente is good, pasta quasi cruda e altra cosa) with what must have been a weak tomato coulis mixed with either a little cream or milk. In an effort to enhance the taste, a tiny quantity of grated pecorino was on the table. Despite that, I could not finish the dish. Another complete miss was the secondo piatto, a kind of non-descript meat ragout — probably made of leftovers. In addition to the food the house wine served, I think, was acidy and reminded me of the very cheap wine I would drink in my student days three decades ago: some rather unremarkable commercial brand. Service was sloppy. To top it all off, there was a small bowl of peaches in a sugary syrup. I do not remember the other offerings in this gastronomic palette, but I am quite sure they were of the same ilk.

The package was offered at somewhat above €26, but we would have been very pleased to pay a bit more if only the quality of the meal would have been slightly higher.

We hope to continue to rely on your guides and that somehow attention will be given to this complaint.

Sincerely,

Gerald R

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Risa,

While just two unhappy customers, this is disconcerting and part of a trend. On my visit this spring, while most of our readers were having a blast there, I heard similar complaints and have had similar concerns with Paola getting more aggressive and taking our recommendation for granted. Send me our guidebook listing and I’ll edit it down. We should email her about this troublesome pattern, too.

Rick

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Rick,

Here is the current listing in Rick Steves’ Rome: Trattoria der Pallaro, a well-worn eatery that has no menu, has a slogan: “Here, you’ll eat what we want to feed you.” Paola Fazi – with a towel wrapped around her head turban-style – and her family serve up a five-course meal of typically Roman food for €25, including wine, coffee, and a tasty mandarin juice finale. As many locals return day after day, each evening features a different menu (Tue-Sun 12:00-15:30 & 19:00-24:00, closed Mon, cash only, indoor/outdoor seating on quiet square, a block south of Corso Vittorio Emanuele, down Largo del Chiavari to Largo del Pallaro 15, tel. 06-6880-1488).

Risa

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Risa,

Let’s go with this edited listing warning readers about the potentially uneven experience. This is what I should have written after this year’s visit, but my judgment was clouded by happier visits in past years and wishful thinking:

Trattoria der Pallaro, an eccentric and well-worn eatery that has no menu, has a slogan: “Here, you’ll eat what we want to feed you.” Paola Fazi – with a towel wrapped around her head turban-style – and her gang dishes up a five-course meal of bland but typically Roman food for €25, including wine and coffee, and capped with a thimble of mandarin juice. While the service is odd and the food is forgettable, the experience can be fun (Tue-Sun 12:00-15:30 & 19:00-24:00, closed Mon, cash only, indoor/outdoor seating on quiet square, a block south of Corso Vittorio Emanuele, down Largo del Chiavari to Largo del Pallaro 15, tel. 06-6880-1488).

Rick

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Rick, We’ll use this for reprints and the next edition. Thanks. Sounds like Pallaro is turning into a quirky experience like the Cimbraccola in Milano (run by Stefanini, with mediocre food, pins in the map, and imaginary mama in the kitchen). This write-up better reflects the experience our readers will have. Risa

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In 2010, Is an Electronic Guidebook Packing Too Light?

There’s an exciting buzz among travelers and travel publishers about electronic books replacing paper ones. For those of us in travel publishing, this is a season of digital scrambling. And users’ heads are spinning with all the new technological options: iPhone apps, books on phones, electronic books on Kindle (the Amazon electronic book reader), small books printed on command (like our popular new Snapshots series), Urbanspoon, and Yelp.

I’ve met lots of travelers in Europe enthusiastically toting Kindles. Some are obnoxiously evangelical about them. Others are not so happy. I just received this interesting email report from someone upset about traveling with an electronic “book.”

Dear Rick, We made a huge mistake. We thought we could use the Kindle version of your Venice guidebook. Wrong! We just arrived and there is no way to use it as a guidebook while traveling. It is great reading, but not convenient to use while exploring. (That is a Kindle issue.) Is there someplace in Venice that carries your guidebook? Or, is there one of your people in Venice that we can get a copy of your book from? Please help.

– Charlie and Mary

I am pretty slow in all of this. And, while determined not to be a Luddite about the demise of paper, I recently invited one of my employees (who I thought was a bit over-enthusiastic about futuristic forms of travel information) into my office, pointed to the 30 different Rick Steves guidebooks lining my windowsill, and said, “This is what we do…paper guidebooks.”

I know the publishing world is changing very fast. I just like paper guidebooks. I’ve bumped into lots of people in Europe thrilled with their Kindles. While it is a brilliant innovation and certainly the future, at this point some find the technology still clunky for guidebooks.

I’d love to hear about your own thoughts and experiences in the Comments.