I’m a statriotic Minnesotan but I’ve lived in the UK for 12 years and I’m going to become a dual citizen.

After living abroad for 12 years, I see America’s strengths and weaknesses more clearly, just as I see Britain’s strengths and weaknesses more clearly as an outsider.

Life here in Britain has its problems – the cost-of-living crisis and the general decline post-Brexit are real and serious – but here are some tremendous strengths – and endearing oddities, too.

STRENGTHS  

There is interesting history everywhere. When I was a kid in Minnesota , we went on a field trip to one of the oldest grand houses in the state, which was built in 1891. Since moving to the UK, I’ve lived in a cottage that was built in the 16th century – 1578, to be precise. It had no closets. The floor was slanted. It was lovely.

Cities/towns are much more walkable than in the US and there are tens of thousands of miles of walking paths, fanning out in every direction. It really is extraordinary. Where I live, there are several long-distance paths where you can walk out of your door and continue on the same path for hundreds of miles. If baseball and apple pie are America’s national pastimes, having tea after a countryside walk on Sundays seems to be a fair nominee for one of Britain’s most cherished rituals.

Most villages are utterly charming. There are several bleak industrial towns and cities, but most British villages are picturesque, complete with at least one pub, a church (often a very old one), old terraced houses, and nice walking paths crisscrossing it, often near some body of water. (If there is no body of water nearby, you are, of course, welcome to swim in your own bin.)

Healthcare is a guaranteed right and it’s free at the point of service. The NHS has issues, but every experience I’ve had has been overwhelmingly positive.

British political humour is hilarious. (If you haven’t seen The Thick of It, watch it.) Whenever the prime minister is getting elected, they have to stand, flanked by crazy people and joke candidates, such Lord Buckethead and Count Binface.

There is virtually zero risk of getting shot. (It’s also a myth that stabbings are more frequent in the UK compared to the US; there are more stabbings per capita in America.)

There is tremendous social capital and people are, for the most part, friendly, polite, and terrified of social awkwardness. (The mathematical definition of a limit approaching, but never reaching, zero is the final morsel of cheese at a British dinner party, which subdivides endlessly, until it is approximately one micron long and one micron wide, at which point it will be thrown away.)

You can travel most places in Europe in an hour or two, often for under $100 if you plan ahead. (I once took a morning Eurostar train from London to Brussels – it takes around two hours – gave a lunchtime talk at the European Union, had some Belgian beer and a little walk around, then returned home by 5pm.)

Pubs are wonderful institutions. Enough said.

The London Tube [subway] is fantastic. It’s clean, safe, and reliable. Most of the time, it’s so reliable that waiting anything beyond two or three minutes for a train in central London is deemed an annoyance.

Most places, there are very few annoying bugs (Scotland’s midges are a notable exception). You can just leave your doors and windows open without screens.

Almost everywhere is dog-friendly: bars, restaurants, bookstores, you name it.

THE ODDITIES

To turn the light on in many bathrooms, you need not find a light switch, but a little string hanging from the ceiling, which you pull. Nobody knows why.

To get warm in the winter, many people – yes, even in the 21st century – boil water and pour it into a red rubber bag, sometimes with a furry cover over it if you’re extra fancy. These ‘hot water bottles’ are staples of British homes.

Tiny country lanes that would be considered sidewalks in America are supposed to accommodate two normal-sized cars going at speed in opposite directions, often flanked by unforgiving hedges. When you encounter another car, one of you will reverse, sometimes a great distance, often over tree roots, into a tiny little ‘passing place’. (Both drivers are obligated, by British social law, to wave. The punishment for failing to comply is deep personal angst for days that they might have thought you were rude, which, to many British people, is worse than death).

What an American would called a kids’ size popcorn at a movie theatre (sorry, ‘cinema’) would be the largest size available in Britain.

The word ‘quite’ is often used to reduce intensity in British English rather than enhance it. In America, ‘quite’ always means ‘very’, whereas in Britain ‘quite nice’ often means ‘sort of nice’ instead of ‘extremely nice’. (I learned this the hard way three years into my time in the UK, when complimenting someone. I was told I had been inadvertently rude.)

In Britain, ‘middle class’ refers to well-off professionals such as doctors and lawyers, not the middle of the economic bell curve, as in America.

You can learn much more about a person by their accent. Accents can change even in the span of a few dozen miles. (When I first moved to the UK, I once went cycling in Wales, encountered someone on the top of a big mountain climb, and couldn’t understand a word he said. I told him I didn’t speak Welsh. It turns out he was speaking English, albeit with a Welsh valley accent. I’m sure he still tells that story about the American idiot he once met.) There is even a special accent associated with Eton, a school for posh boys. Whereas when I talk, I sound like a generic suburban Midwesterner and could conceivably be from an area with a 1,000-1,500-mile radius.

This article was originally published on Brian’s blog site – The Garden of Forking Paths.

Dr Brian Klaas is Associate Professor in Global Politics, University College London. For more from Brian visit brianpklaas.com. His book Corruptible: Who Gets Power And How It Changes Us is out now, available from Amazon.

Patients facing long NHS waiting lists for scans and tests are plunging themselves into debt by signing up for loans and ‘buy now, pay later’ deals for private health care.

In exchange for rapid treatment, patients face years of paying off debts on instalment for their medical treatment – including MRI scans, X-rays, routine surgery and hip replacements.

Firms such as MRI Plus, which offers payback deals tells patients ‘Why wait in pain? Slash your waiting time for treatment on the NHS’, and ‘book now and pay later’.

Another loan provider, Chrysalis Finance, offers ‘quick and easy’ loans of between £350 – £25,000 – and allows payments to be spread over five years. 

Scan.com, which offers MRIs, CT scans, ultrasounds and X-rays at 150 centres nationally, is offering an interest-free BNPL option via PayPal.

The companies said the BNPL plans are ethical, interest-free options that help people manage their finances.

But debt campaigners and health experts are concerned that NHS backlogs could force people to use the deals in desperation.

David Rowland, director of the Centre for Health and the Public Interest thinktank, said: ‘Policymakers need to be aware of how the underfunding of the NHS is pushing unsustainable healthcare costs back onto individuals, potentially increasing their indebtedness. It’s a slippery slope.

Research by the StepChange debt charity found that nearly half of people with a BNPL loan had trouble keeping up with household bills and credit repayments, while 17 per cent met the charity’s definition of being in severe financial difficulty.

In some cases, customers face late-payment fees and risk damaging their credit rating or being referred to debt collectors. While traditional loans are regulated by the Financial Conduct Authority, interest-free loans repaid in less than 12 months – including BNPL products – are exempt.

For patients, having access to credit amid the current NHS backlogs can be the difference between enduring months of pain and angst or not.

NHS England figures show that as of May 2023, a record 7.47 million people were waiting to start routine hospital treatment, and more than 409,000 had been waiting six weeks or more for key diagnostic tests.

Anusha Stribbling, 25, a charity worker from Peckham, south London, said she paid £760 with Klarna for two scans after suffering abdominal pain and facing challenges accessing diagnostic tests on the NHS. She said the results helped her GP rule out other conditions and led to her being diagnosed with hypermobility and would use it again for treatment in future ‘without question’.

Klarna said BNPL was a fairer, low-cost alternative to credit cards, fewer than 1% of customers did not pay back the money they owed.

MRI Plus said it offered low-cost scans that helped people get ‘timely access’ to potentially life-saving care and customers had passed affordability checks.

A spokesperson for Chrysalis Finance said:

‘As a responsible lender authorised and fully regulated by the Financial Conduct Authority, we only lend to people who can demonstrably afford the monthly repayments.

‘We do not provide any buy now, pay later finance. By contrast, we have worked with regulators and the UK government to abolish unregulated buy now, pay later (BNPL) lending.

‘Every application for our finance undergoes robust checks for creditworthiness and affordability ahead of any loan, in the same way as with other large-scale regulated lenders.

‘Finance allows people to access privately funded treatment by spreading the cost into affordable monthly repayments, often without interest charges. This choice to spread the cost is welcomed by many of our customers and is reflected in our high Trustpilot score and online feedback.’

PayPal said it ‘believes in responsible lending’ and added its ‘pay in three’ deals were interest-free loans ‘designed to offer customers more choice and flexibility’, which carried no late fees or other charges. The firm said it worked to ‘encourage people to not purchase items they cannot afford’.

The Department of Health and Social Care said it was working with the independent sector to expand diagnostic capacity across the country ‘quickly, closer to home, and free at the point of need’.

Society

The People’s Hospital

by Dr Ricardo Nuila (Abacus £20, 371pp)

It’s a good job I had my heart attack earlier this year in England. 

Had I keeled over in America, I’d now be a corpse, as their medical system is unsympathetic towards anyone ‘poor and chronically ill’, which is pretty much the category I usually find myself in. 

In Sussex, the NHS clicked into action stations — helicopter, emergency services, surgical and nursing teams giving instant and unstinting attention. 

But had I been in Texas, and never mind being unconscious, I’d first have been required to produce a valid photo ID, a utility bill (as proof of address) and a bank statement proving gross income for the last 30 days.

A list of assets is also needed, including the value of one’s house. Without a down payment of $5,000 (£3,900) the patient literally might be left for dead.

Ricardo Nuila, a doctor who teaches at the Center for Medical Ethics in Houston, tells a horrible story of a man packed off in a taxi, going from one hospital to another with a note pinned to him stating, ‘This patient is sick with meningitis, please treat him’. None did. He died in a clinic forecourt.

‘Excellent care is apparently available,’ says Nuila, ‘but it’s not reaching all the people.’

No wonder, when the exorbitant costs and faff are examined. Though they have Medicare and Obamacare, the paperwork involved in making applications is so baffling, the system so ‘arbitrary and vague’, few get through the processes.

Before you sit down in the waiting area for an initial consultation, the receptionist will demand a starting fee of $639 (£503) from an insurance company or the patient’s wallet. 

Orthopaedic surgery starts at $15,000 (£11,800), and a liver transplant is half a million.

Kidney dialysis is $53,000 (£41,750) a year, and needles for a diabetic to inject insulin are charged at $4,800 (£3,780) annually.

Prosthetic limbs are $30,000 (£23,600) each, cash. A prostatectomy, including pre-operative consultations and aftercare, is $241,000 (£190,000), though hospitals may charge insurance companies $700,000 (£551,500).

Clearly, only the wealthy can stump up. Everyone else endures wheezes, dry heaves, muffled sobs, sits about in sweat, blood and bile, unable to admit themselves to what we call Accident & Emergency.

If the rate of mothers dying in childbirth is rising in America — it doubled between 2011 and 2012 —this will be because the bill for having a baby is ‘just north of $15,000’ (£11,800). For each check-up, add another $2,000 (£1,575).

People are understandably ‘left to wonder if seeing the doctor is worth the trouble’. Sixty-six percent of bankruptcies in America are due to medical bills, affecting 530,000 families in 2019.

The answer is meant to be insurance, but that only makes matters worse, as cover is often insufficient.

Employers pay the cheapest rates they can locate for their employees. Workers then find, when they fall ill, that insurance firms quickly intercede, preventing tests which could help with a full diagnosis. 

MRI, PET and CAT scans, electrocardiograms, these are all charged as an extra. Those reliant on employer healthcare schemes are frankly routinely ripped off.

With coverage denied, people become even more ill than they need to be. Kidney disease or colon cancer, for example, can lead to septic shock from blood infections. With treatments unaffordable, patients ‘endure their sickness’.

What’s to be done in each individual case is tailored to the depth of a patient’s pocket, rather than what’s best for them. 

Doctors in America focus on how (and on how much) they might be paid, rather than on the patient’s quality of life.

Surely this is unethical? It’s certainly unspeakable. Courtesy and kindly attention are things of the past; for all the loot changing hands, a patient is lucky to be given ten minutes; they are merely ‘numbers on a spreadsheet’.

Healthcare in America is evidently a scandalous maelstrom of greedy doctors, hospital administrators, stockholders, intransigent insurance companies, pharmaceutical concerns — with everyone chasing profits, ‘clawing and charging’, inflating their invoices.

‘Optimising a bill,’ says Nuila, ‘determines a doctor’s success more than their surgical or diagnostic prowess.’

Promotion depends on being a good businessman or businesswoman, bringing in the money.

Nuila, himself still a busy doctor, or ‘hospitalist’, working pro bono at the Ben Taub Hospital, ‘Houston’s largest hospital for the poor’, seems like one of the last altruistic men left standing, looking after the ‘crushed, the burned, the dismembered, the stabbed, the shot up.’

He is unconcerned about patients’ wherewithal. It’s why he feels free to write this frankly terrifying whistleblowing book.

What money buys, he reflects sadly, ‘is comprehensive healthcare for some, but mostly ineffective emergency care for those who cannot afford the high-end’ treatment, where the cheapest professional advice — or rather warning — given by Nuila is that it won’t matter if you end up dead.

We are always told the NHS is in crisis, yet nothing remotely similar to the American model or protocol must be allowed to come in here.