On the second day, I attended a government-sponsored town hall meeting about the "Big Care Debate." There are big changes afoot here in the U.K. and the government has come up with some ideas--and they are reaching out to the communities for feedback on which option is most appealing (or least appalling). In attendance were NHS staff, town council members, other providers of service, and--most importantly--users of service, including the elderly, caregivers, people with disabilities and even people with learning disabilities. You can find the background here.

Britain knows that their resources are dwindling and that before long, there will be only two working people for each retired person. That won't be enough to continue funding both the National Care Service and the National Health Service. It is very much like the Medicare dilemma currently going on in the U.S. One thing that is very clearly not an option, and has been voiced to me several times already, is that they will not tolerate denying care to anyone who needs it. This was expressed not just from those with liberal leanings, but also conservatives (Tories) as well.

Later in the week, I attended a day at one of the satellite offices that house an adult day unit and has a fully-equipped rehab gym. The RN falls coordinator is based here and there is a nurse who also provides fall assessments. I see great opportunity here to turn this into a brilliant falls clinic and lab! I will be interviewing a physio to man this facility in three weeks. I'm excited about the possibilities here!

Some other things that I didn't expect:

1. They use a different blood sugar scale here. The United States measures blood glucose in milligrams per deciliter, or mg/dL. Whereas, In Europe and the U.K., it is measured in millimoles per Liter, or mmol/L. So a normal reading here is between four and eight. The first time I heard a nurse say that someone had a blood sugar of five, I thought, "Well, even orange juice won't help that one. Better call 911." Five is ideal.

2. The emergency number here is 999 not 911.

3. Temperature is in Celsius of course. Would you know if someone with a temp of 35 was normal or not?

4. Home Care doesn't end at 6pm here. It is a 24/7 service with nurses making calls throughout the night. I will go into more detail about that later.

So as you can see, there is a big learning curve, lots of cultural competency to master with regard to the health system, and a lot of very exciting challenges ahead.

By the way, I've been driving solo all week and so far the car, the British population and myself have survived.

I'm sure my spouse, friends and family are also happy that I'll be working again.

I don't do downtime well. Don't get me wrong, I love my vacations and I do take them. It is very different though when you're not quite sure that you have a job waiting at the end of the tunnel. Excessive downtime can make me very fidgety, anxious, and not the most pleasant of company to be with.

I've heard it said among some theater friends of mine that "an actor is only an actor if he actually has a part, otherwise he is a waiter."

When we're not actively practicing, are we still a PT? Of course I've used this time to read up on the NHS, where I'll be working, to read articles on rehab and health related topics, to stay abreast of the politics of health care both in the US and the UK, and to apply for admission to a Masters in Public Health program. However, the role that has been the center of my life for nearly 20 years, PT, has been dormant. This has caused some real identity issues.

What it brought to light for me was the impact illness has on our patients. They too have been busy with their lives which give them their identity, something happens to throw a wrench into their normal routine and they come to us to assist them in making them whole again. They want themselves back; the athlete, the writer, the musician, the mom, the dentist, the provider, the person with something to offer.

Sure, we've all learned about this in PT school and understand it on an intellectual basis. But really stop and think and feel about how would you be affected if one day, suddenly, you couldn't practice PT anymore?

What would you do?

Cameron brings up some interesting points. For instance, the lack of competition has resulted in complacency in the mindset of NHS. He states bidding out contracts to private companies will force the NHS to control costs and improve quality of care. Patients will then benefit from the process, have greater choice in their own treatment and jobs will be created from the competing companies.

Isn't that the system we have in the U.S.? We have the luxury of choice in providers, insurers and hospitals. We also have the risk of not receiving care at all or of racking up debts way beyond comprehension to address medical needs. Could the UK be heading for the same conundrum the U.S. is in right now?

Cameron doesn't want to eliminate the NHS. The British are not about to be left without basic health care...yet. Could both countries be heading for a similar resolution but from opposite starting points? Privatizing care for those who can afford it but offering a basic coverage for those who cannot afford it or for those who choose not to participate, is that the solution? What impact would it have on small business (private PT practices for example) if they didn't have to shoulder the burden of health insurance for their employees?

There is a Chinese curse that says, "May you live in interesting times." As for health care, the times are fascinating.

Those products don't exist here.

I have an anaphylactic reaction to anything containing aspirin so I have to read labels very carefully. It took me three days and a few discussions with pharmacists to discover that paracetamol is what acetaminophen is called here. That was a huge relief because for a while, I didn't know if I'd be able to take any pain relievers at all! Claritin exists here, but is spelled differently. Nyquil? No such animal, nothing even similar exists here. Even the cough remedies are behind the counter at the pharmacies so one needs to know what all the active ingredients are in each preparation. There's nothing as simple as Robitussin DM, a brand that also doesn't exist here. I tried taking Actifed here to clear my sinuses and put me to sleep. I didn't read the label and assumed it was the same product as at home. Nope. It contains Sudafed as well. Sudafed is a stimulant so instead of getting a good night's sleep, I was awake for the entire night.

I think I finally have a handle on the products that I'll need for myself. However, now I understand that when I start working with patients, I'll really need to research the meds that they are on and not make any assumptions based upon my experiences back in the states. The results could be tragic. Time to find a UK PDR!

On the work front, my national insurance number has been issued! They won't give it to me over the phone though, only by the postal service. The postal service is on strike.

I guess I'm supposed to be learning a life lesson on patience.

Of course my first stop was the Internet where I searched for medical insurance in the UK. I came up with a number of choices and a few that give multiple quotes from multiple insurers. Within a day I had seven companies give me quotes. The coverage was all similar and this is what they offered: Full hospitalization coverage in either an in-network private hospital or a private wing at an NHS hospital, full outpatient coverage for diagnostics like MRI or treatment like PT, and varying degrees of specialist/consultant coverage like a cardiologist or orthopaedist.

There were no copayments and no preauthorization requirements. There was a 200 GBP deductible each year. Primary care is not covered as it is only an NHS service, however a few people do pay out of pocket for a visit to the MD. You would see the same MD, however under NHS payment, you will wait up to two weeks for an appointment, whereas with private pay you will get an appointment within two days. If something is truly urgent then one goes to an NHS walk-in center or to an Accident and Emergency (A&E), their version of an ER.

This insurance would cost me 49.49 GBP/month or the equivalent of about $80.00 USD/month. I got a letter from my previous employer regarding my COBRA benefit. If I wanted to continue coverage, which also includes prescription drugs ($20.00 copayment) and pre-authorizations for all referrals, as well as $500.00 deductible and $20.00 copayment for each MD visit, my premium would be $540.00 / month. 

The stories about long waits for service under the NHS and overcrowded hospitals are apparently true from the people I've spoken to so far. Private insurance cuts through the waits and provides for a more pleasant inpatient stay. What I wonder is why the huge cost discrepancy? Is it because there is a baseline of coverage so that private insurance in the UK just doesn't have the market that exists in the US? Does the fact that the government funds the hospitals and offsets the costs affect it to that degree? How about that the pay scales are lower and malpractice incidents are very much lower? There also isn't the huge influence of the medical equipment manufacturers and pharmaceutical companies in the UK as in the US (it is here, just not as big a force as the US).

With the current health care debates going on back home, it is fascinating to see first hand how another system works or fails to work. There is one very important thing that a local pointed out to me the other day, "Not a single British citizen has ever had to file bankruptcy due to medical bills."

I went to buy a car here in the UK yesterday (yes, I'm finally comfortable enough with my driving to make the leap) and I saw a sign for the "Motability Scheme." I asked what that was. The salesman told me that it is a program where people receiving a certain level of disability payment can actually get a powered wheelchair, scooter or even a car paid for entirely by the disability/NHS system.

A car? I couldn't believe what I was hearing. I looked the system up online and sure enough, if you are disabled, or are caring for someone who is disabled, you can get a brand new car every three years. Here is a link to the Website: www.motability.co.uk/main.cfm?Type=HHSW

I understand the rationale for this. If someone is able to get to their medical appointments, then they are more likely to stay well and not decompensate to the point of crisis. If people can get out and about they can fend off depression and be more active in the community. As a caregiver, one loses time and income in the process of providing care therefore risking the ability to keep and maintain a car. I just wonder how rife with abuse this system may be.

I actually have a new friend here with a neurological condition who has used the program and drives a specially adapted car, which enables her to tend to her own appointments and errands. I wonder how much the car costs the system vs. the cost of an aide of some sort?

It is an interesting idea. What do you think of it?

The bureaucracy continues to delay my start to work here so there is no news to report on that front.  

And that is just the PT related stuff! After 10 days I was finally able to open a bank account but haven't been able to put any money in it yet. I applied for a provisional driver's license but can't get that without sending away my passport for review, which I can't do until the work situation is sorted out.

...the courage to change the things I can, the serenity to accept the things I cannot and the wisdom to know the difference. I'll be saying that quite a lot this week too.

I have just undergone neuro rehab in the form of driving lessons here in the UK. I thought that because I've been driving for thirty years, completely without incident I might add, driving here would come easily. Not so.

The amount of motor learning that I must unlearn is remarkable. No longer do I look left to see if I can merge, I must look right. No longer do I look over my right shoulder when backing up, I must look over my left. Hazards don't approach from where I'm used to and I need to end up in different places when I turn at an intersection. All of this is in addition to learning that my left foot and hand now have a necessary function to shift gears and engage the clutch. Now put that all together and navigate something called a roundabout (traffic circles for those of you from the North East) except they're all moving about clockwise instead of counter-clockwise. This all sounds very amusing until you realize you could die or kill someone else if you get it wrong.

My instructor has been profoundly patient and I can tell that he's been teaching driving for a rather long time. The one thing I did very well from the start was parallel parking. This perplexed the instructor until I explained that I've been doing this maneuver in New York for thirty years. Finally something that didn't need complete motor retraining! He gives me lots of positive feedback but he sometimes helps too much with his own clutch pedal not letting me screw up and learn for that experience.

What does this mean to a therapist? Well the next time you're feeling frustrated with a patient who just isn't "getting it" or seems down, try doing something that really challenges you're established motor patterns; take a dance lesson, learn to knit, learn tai-chi and feel how truly difficult it is to learn a new motor skill. Try providing some positive feedback to your patient because everybody can do something well and needs to know that. Lastly don't help too much, let people make mistakes safely so they can learn from the experience and move on.

My US license is good here for 12 months, but I must get a UK license if I am to stay longer. I'll let you know when I pass my test. Hopefully it won't be a year from now!

I arrived in England early on Monday the 14th, rather jet-lagged. I then drove 5 hours north to Newcastle and collapsed. The next day I had a scheduled interview with the Sunderland Care Trust for a position in their intermediate care program. Intermediate care and home care are relatively new concepts in the UK. It really started a decade ago when the health ministry realized that people would be discharged from a hospital and be back again in a very short time. Amazing considering the last place I worked in New York has been around nearly 120 years.

I was pleasantly greeted by 2 nurses, seated at a table, given a glass of water, and instructed that each would ask me 4 questions. They each had notebooks and scribbled furiously each time I so much as breathed. The questions were fairly predictable: What do you bring to this position? What challenges have you successfully met in the past? How to you manage to bring balance to your work? Etc.

I think I did rather well and they seemed truly engaged in my answers. After my 8 questions were answered, I was allowed to ask them questions. I asked how long each had been with the program, what their vision was for the program, Why only now were they incorporating a PT into the schematic, where their funding was coming from and how long it would last, and then if there was anything else they wanted to ask of me. That startled them. Apparently they are not allowed to ask anything that has not been screened by Human Resources beforehand and all applicants must be asked all the same questions. Wow! I see the rationale for being fair, but how does one then probe when answers seem unclear or dodgy? How do you truly know you made the right choice with this type of technique? It was up to me to ask questions of them, which then they could elaborate on with me. That is tough to do and not appear a braggart or narcissist.

I must have answered the 8 questions right because they called me the next day to offer me the position. I'll be a band 7 physiotherapist.

Now I have to wait for my offer letter from HR, clear occupational health and my criminal record bureau review and then we can talk about a start date. Having this block of free time is a very good thing as I learn to drive all over again. That is a story for my next post..."My left sided neglect". Watch for it!

One of the things I haven't mentioned yet in these posts is that I've taken the GREs about two months ago and did rather well. I'm planning on going back to school for my Masters in Public Health. I envision my role in health care going forward to actually be less of a clinical nature and more based in policy and planning. I firmly believe that policy should not be driven by a group of medical doctors and/or registered nurses but rather from a variety of health professionals, rehab included.  I mentioned in a previous post that I'm a cantankerous geezer so I should be right at home in politics and policy.

What an advantage it will be to have working experience in two dramatically different health delivery systems! This can only assist in my future studies and give me a well-rounded base from which to evaluate systems and work towards improving our own model of health care.

I have an interview set up for the day after I arrive in England for a trust near my new home. It will be for a position in intermediate care. That is a program directed towards older adults who are transitioning from hospital to either sub-acute and/or home. The goal is to optimize outcomes and minimize risk of re-hospitalization. It sounds very much like the "transition coaches" that have been in the press here in the states over the past year, except it will actually involve some hands on care. I'm curious to find out more at the interview.

My visa has arrived! All systems are "go" for an on-time departure on the 13^th. Wish me luck!

They have a section for job postings on the NHS site where one can search for any position within the NHS. One can search by title, location, salary, etc. I've signed up for daily alerts when anything that contains "Physiotherapist" or "North-East" appear in the job description. I get about a posting a day, some days more, some days none. I applied for one position which was then retracted and I applied for another for which I received notification that I was "short listed" for. That means that they liked my application and CV well enough that they want to interview me.

Here's the catch, the interview is for the 7^th of September and I don't arrive until the 14^th. Hmmm. I email the HR department and explain the situation. I am advised that formality still prevails in correspondence in the UK and pleasantries and titles are necessary. This cantankerous geezer has managed to be the epitome of propriety. I am told that they would be happy to interview me on the 15^th, the day after my arrival in the UK.

I'm praying that my luggage actually shows up so that I'll have a suit to wear to the interview.  I hope that the jet lag will not be too debilitating as well. Not my ideal preparation for an interview, but I can do lots of research on the area and whatever "intermediate care" is in the mean time.

I have a lot to learn and that really excites me.

“This is the best place I’ve worked in my entire adult life.”

I've been working in staff training for the past year and a half. This was my opening when I introduced myself and the company I work for, the same company that I must now leave in order to move to England. It is not just a line. It really is the best place I've ever worked. It is a Managed Long Term Care plan (yes that means it is an insurance company) with an attached home care services agency. The state of New York and the Visiting Nurse Service of NY came up with a plan just over 10 years ago to reduce the costs of the frail elderly who sought out primary care in emergency rooms. These individuals usually didn't seek care until they were in crisis, and frequently wound up with an expensive admission and then long term placement. The program gets a capitated rate from the state to care manage these members who are over 65, Medicaid eligible, live in New York City, and upon assessment, would be eligible for long term placement.

Our mission is to keep them safe and functioning optimally in their homes for as long as reasonably possible by managing their chronic illnesses and preventing acute illness. It works! We care manage them across all settings including when they go into a hospital, short term rehab facility, or even placed in a nursing facility. The goal is that they get well and home as soon as possible and so that they don't fall between the cracks due to fragmented care. Teams of nurses, social workers, nutritionists and physical therapists all assess and work with members and their families, sometimes actually providing care and as needed, referring to other providers for the most appropriate services.

I've worked other places where I've met exceptional individuals but in this program, everyone is exceptional in their skill level, dedication, and ability to work in a truly interdisciplinary (as opposed to multidisciplinary) manner for the most optimal outcomes. The state is happy, the members are happy, and the staff does an amazing job.

I am the first non-nurse to become a staff development specialist in this company. I credit the management with the creative vision to realize the potential of looking beyond nursing to all other disciplines to bring a more rounded and holistic approach to the program and the training of the staff. It has allowed me to not only bring the rehab point of view to care management, but to better understand the global concepts of care management and the complex issues facing the older adults that we serve. It has improved my practice in Geriatrics immensely.

...and I'm leaving.

I will say my goodbyes on Friday this week. It will be very hard. I so truly believe in this program and my colleagues and the work that they do for people who need it so badly. I became a PT to help make the world and the people in it better. This place accomplishes that and it has made me proud to be part of that process.

I already have an interview for a position in England on the 15^th of September. It is exciting to begin this new process and to learn a whole new way of delivering care within the British National Health System.

I suppose the only way to embrace something new is to let go of what I already have. I shall miss my colleagues and I salute them

In my next post I'll share how very different the approach to finding work is within the NHS.

P.S. I'm still waiting on the visa

We're getting close to departure now. I submitted my application for a spousal visa online on the day of my wedding. It was then a 3 week wait to have my bio-metric measurements taken which included electronic fingerprinting and high resolution photographing. I went to a US Homeland security office and completed the task in less than 15 minutes last Friday.

Now it was time to submit the application in hard copy as well. The application itself is 9 pages of questions completed online which then one must print out. The supporting documents are the real challenge! I had to include my passport, my original birth certificate, my marriage certificate, my pay stubs, my bank statements, evidence of savings, property statements, certified copies of my BS diploma, my acceptance into the HPC, certified copies of my spouse's passport and birth certificate, bank records and property statements, evidence of contact over the past year including copies of travel itineraries, emails (over 550 of those!), photographic evidence of our relationship, and testimonial letters from both sides stating that indeed there is a real relationship going on here and I'm not marrying only to gain entry into the UK.

When I was finished the application was over 2 inches thick. I marched it over to my local post office to express mail it 30 blocks uptown (the British Consulate does not accept hand delivered packages). I had a tracking number for my package and believed I was all set.

Then came Monday morning, I had received an email on Saturday saying that delivery was attempted but the office was closed so the recipient would have to reschedule delivery. I had paid for "No Weekend Delivery" for exactly this reason. Off I go to the post office, a mere 2 doors away from the Consulate, to see if I can get my package redelivered.  I am assured that the package was re-sent and I will get an email about the delivery later. Then came Tuesday morning and I still have not received confirmation. I call the office and a pleasant person informs me "Yeah, we really don't know where that is right now." I am now ready to code. All those original documents floating around in the ether, just imagine. I take off for the post office once again. I must say, they are very pleasant at the FDR station post office. A lovely woman takes control of the situation and after an hour discovers that the package was delivered to the Consulate the morning before. The carrier neglected to scan the documents, which is why it wasn't coming up in the computer system.

My application is now being processed by the UK border services and I should know the outcome before too long. Why do I tell you this story and what does it have to do with my PT work? It is because I have begun to apply for positions in the UK and although I've received praise for my experience and CV, few employers want to tie up a position for someone who hasn't secured a visa that allows them to work yet.

And now I wait.

Was the job market really that bad over there? No, I just forgot that now I am a "physiotherapist." That yielded much better results. Most of which were from placement agencies. Just like here in the States, there are tons of agencies willing to place PTs in positions around the country. I started reading some of the ads, they read like this:

Locum Band 6 under the AFG scheme MSK Physio required in large Midlands hospital maintained by the NHS such and such a county trust.

Well, I was able to figure out that MSK meant musculoskeletal, but what is "Locum" and what is "band 6?"

I've made my living over the past years by being very well versed in Medicare and Medicaid issues, concerns and entitlements and how they relate to rehab. All of that is now useless in my new country. Now it is time to learn first hand about the socialized health care system in the UK, the National Health Service or NHS. After a quick search, I discovered that many companies claim to be the fourth largest employer in the world, including UPS and Siemans, but here is a bit from the NHS site directly:

Scale

Nationwide, the NHS employs more than 1.5m people. Of those, just short of half are clinically qualified, including some 90,000 hospital doctors, 35,000 general practitioners (GPs), 400,000 nurses and 16,000 ambulance staff.

Only the Chinese People's Liberation Army, the Wal-Mart supermarket chain and the Indian Railways directly employ more people.

The NHS in England is far and away the biggest part of the system, catering to a population of 50m and employing more than 1.3m people. The NHS in Scotland, Wales and Northern Ireland employ 158,000, 71,000 and 67,000 people respectively.

The number of patients using the NHS is equally mind-boggling. On average, it deals with 1m patients every 36 hours - that's 463 people a minute or almost 8 a second. Each week, 700,000 will visit an NHS dentist, while a further 3,000 will have a heart operation. Each GP in the nation's 10,000-plus practices sees an average of 140 patients a week.

It is clear that this is a BIG organization. How on earth to begin to navigate through it?

I've searched the NHS site, which actually is rather user friendly and informative (take note CMS!). I've discovered that the pay scales in the UK are very regimented under the "Agenda for Change" and that different professions fall into different areas of the schematic. Physical therapist assistants start around Band 3 and can work up to Band 5. Physical therapists start at Band 5 and can work up to Band 9. So Band 5 is the equivalent of a new grad, Band 6 a senior staff therapist and so on. You can see the whole schematic here.

Now that I've figured out what a "band" is, I still have to learn about the "trusts" which include acute, care, primary, ambulance, etc. I'm assuming these are the governing bodies or plans for each locality and service. Here is a general description from the NHS home page:

Structure

The Department of Health (DH) is in overall charge of the NHS with a cabinet minister reporting as secretary of state for health to the prime minister. The department has control of England's 10 Strategic Health Authorities (SHAs), which oversee all NHS activities in England. In turn, each SHA is responsible for the strategic supervision of all the NHS trusts in its area. The devolved administrations of Scotland, Wales, and Northern Ireland run their local NHS services separately. 

The New York Times published an interesting article from someone who, like myself, has transitioned from the US to the UK but as a consumer.

The really amazing thing is how much I feel like a new grad all over again. I'm starting from zero in terms of how to navigate this health care system and how to position myself to start working. This move will also require that I start working at a lower band than would be my level here in the states until I learn the ins and outs of the system. That will be an adjustment. I'm sure I'll manage as this is something I really want to do, much like the challenges I read from my fellow bloggers as they graduate school or tackle advanced degrees, with some concern, fortitude and resilience.

I will be submitting my visa application tomorrow. Now that is a blog in and of itself. More about that later...

It was not an easy choice to pick up and move to another country at my current age (let's just call me a "geezer" and leave it at that) nor when I'm in a position that I particularly like in a company that I really believe in. I first had to find out if I could practice in England. Being a geezer, I'm educated at a BS level and have made an informed choice not to pursue a DPT. Would my education be sufficient? How would I find out?

I have a few mentors here in the US, one on each coast as a matter of fact. I have no professional contacts in the UK. Thank goodness for search engines! I was able to find out that most allied health professions in the UK are registered by the Health Professions Council and they offer guidance notes for people applying from abroad. The application is quite long and grows longer depending upon how much experience one has. I've been practicing for 17 years and they wanted to know, in depth, about each position I've held, how I practiced, who I reported to, and what specific PT skills I utilized in each setting. That took some time to document. The real challenge was the extent to which they wanted detail on my training.

Now I must pay Dr. Joanne Katz from SUNY Downstate Medical Center a huge note of thanks. I've never met Dr. Katz, she took over the PT program there long after I'd left and it is now nothing like the program I graduated from. She recreated for me my old curriculum including material covered in each module and methods of assessment. This document was the keystone to my application and I couldn't have done this without her assistance. After completing the application and providing about 40 pages of supporting documentation I was allowed to pay my scrutiny fee of nearly $700.00 USD. 

Four weeks later I was informed that I had met their requirements and I was now invited to join the HPC (yes, another fee). The registration is the equivalent of our state licensure, however the UK registration allows me to work in Scotland, Wales or England without separate licenses for each, unlike my maintaining licenses in Florida and New York, each with different fee schedules, CE requirements, and cycles of renewal. I do think the US would benefit, as would the profession from having this type of national registration and uniform practice acts. It would make it much easier to relocate for work and might provide more cohesion for the profession on the whole.

I've been an off-and-on member of the APTA over the course of my career. Being a geezer, cantankerous is another adjective that could describe me. I've joined the APTA to be part of the professional community, then left in protest when I've disagreed with the major positions taken by the association, and rejoined to stay abreast of what changes are occurring. It is wonderful to have the option to do that.

I had to find what organization is the equivalent over there and once again went to the search engines! I found the Chartered Society of Physiotherapy. I'm still exploring this organization and will fill you all in once I learn more.

Next post will be about learning the new terms like "banding" and "locum." They have a similar language to us but in reality, it is different!