What A Lecture Trip To England Revealed About The Country’s National Healthcare System

Doug Richie Jr. DPM FACFAS

During my recent trip to England, I participated as a faculty member at two podiatry and physiotherapy meetings. This was my third trip to the country in the past five years, giving me the opportunity to lecture and interact with colleagues. My experiences this time ran the gamut from dismay about the healthcare system in the United Kingdom to awe and respect for the level of care many of our colleagues offer in this country.

The Division of Podiatry and Clinical Sciences sponsored the first meeting, which took place at the University of Huddersfield. This year, the second Annual Musculoskeletal Research Conference focused on adult-acquired flatfoot. Podiatrists from the U.K. provided excellent lectures and covered assessment, ultrasound imaging and even surgical intervention for the musculoskeletal disorder.

My experience in the workshops, however, revealed how the national healthcare system in the U.K. has failed to provide adequate care for patients. I evaluated two middle-aged women who both had progressive, debilitating adult acquired flatfoot. They had each received little to no care at all while their condition worsened to the point that they could barely ambulate. In both cases, they had received simple prefabricated foot orthoses and nothing more. The notion of prescribing custom ankle foot orthotic therapy for adult-acquired flatfoot is not well accepted in the U.K. Certainly, the national healthcare system will not cover this service.

Previously, I wrote a blog about the current standard of care in the United States (see http://bit.ly/iUQtm3 ). Generally, custom ankle foot orthotic therapy begins before surgical intervention for the adult-acquired flatfoot. The success and avoidance of surgery for this treatment is at a rate of approximately 70 percent.1 The U.K. has yet to institute the use of ankle foot orthotic treatment for adult-acquired flatfoot despite the fact that there are at least six studies published to support it.2-7 Ironically, the British healthcare system will offer its patients surgery, which is generally tenfold more expensive than preventive interventions.

My next seminar was the Podiatric Biomechanics Symposium at the Royal Society of Medicine in London. This meeting had a fantastic lineup of speakers. The podiatrists who presented were among the best I have ever heard in terms of quality of content and delivery of their subject. Hannah Yirrell, BSc (Hons), who is an attending podiatrist at the Defense Medical Rehabilitation Center at Headley Court, provided a particularly inspirational lecture. This facility offers care to wounded soldiers from the U.K., who have served in Iraq and Afghanistan.

Dr. Yirrell presented amazing case studies in which she had been able to restore mobility in young men who had been severely injured by improvised explosive devices (IEDs). In many cases, she used ankle foot orthotic therapy combined with physical therapy to make dramatic changes in the ambulatory status of these unfortunate victims. At this facility, the defense budget covers treatments. The level of care is far superior to what is available to citizens who rely on the national healthcare system in the U.K.

Upon returning home, I realized how fortunate I am to participate in a healthcare system in which I can offer numerous, superior treatment options, not available in the U.K., to my patients. I often listen to colleagues who bemoan our own healthcare system and vent frustration over reimbursement challenges in private practice. However, in comparison to the situation in the U.K., we do not have it so bad.

I worry about what changes may occur in the future if the U.S. institutes a more nationalized healthcare system. The result may be denial of treatment options that might actually save healthcare costs. The massive government sponsored healthcare system in the U.K. has certainly verified that this can be a reality, particularly for our podiatric colleagues practicing there.


1. Nielsen MD, Dodson EE, Shadrick DL, Catanzariti AR, Mendicino RW, Malay DS. Nonoperative care for the treatment of adult-acquired flatfoot deformity. J Foot Ankle Surg. 2011; 50(3):311-314.

2. Krause F, Bosshard A, Lehmann O, Weber M. Shell brace for stage II posterior tibial tendon insufficiency. Foot Ankle Int. 2008;29(11):1095–1100.

3. Alvarez RG, Marini A, Schmitt C, Saltzman CL. Stage I and II posterior tibial tendon dysfunction treated by a structured non-operative management protocol: an orthosis and exercise program. Foot Ankle Int. 2006;27(1):2–8.

4. Augustin JF, Lin SS, Berberian WS, Johnson JE. Nonoperative treatment of adult acquired flat foot with the Arizona brace. Foot Ankle Clin. 2003;8(3):637–645.

5. Bek N, Oznur A, Kaviak Y, Uygur F. The effect of orthotic treatment of posterior tibial tendon insufficiency on pain and disability. The Pain Clinic. 2003;15:345–350.

6. Chao W, Wapner KL, Lee TH, Adams J, Hecht PJ. Nonoperative management of posterior tibial tendon dysfunction. Foot Ankle Int. 1996;17(12):736–741.

7. Kulig K, Reischl SF, Pomrantz AB, Burnfield JM, Mais-Requejo S, Thordarson DB, et al. Nonsurgical management of posterior tibial tendon dysfunction with orthoses and resistive exercise: a randomized controlled trial. Phys Ther. 2009;89(1):26–37.


I am podiatrist working in London at the moment and have worked all over the U.K. in the past few years.

I enjoyed reading your article and am very glad to hear that you have had a good time in the country. However, I wanted to make some comments on some of your statements.

You stated that surgery was often the preferred option for adult-acquired flatfoot because it was not available on the NHS and the notion of prescribing it was not common.
Very many people recieve custom made AFOs. However, this is usually provided by orthotists and prosthotists rather than podiatrists. The treatment is available on the health service at a great cost along with bespoke footwear when needed.

Your point about the soldiers treatment being funded by the defense dept. budget is not due to the health service not providing it. It is simply funding drawn from another source as part of the MOD package of care to wounded soldiers. We do have prosthetic teams and specialised rehab teams for limb loss in south London.

We do not deny patients the care they need based upon cost. If they cannot access treatments, this is usually due to not having the specialist expertise in their area. In these cases, particularly when it comes to footwear and prosthetics/orthotics, their treatment can be charged to their own G.P. if what they require is out of area.

If anything, it is totally stupid referral pathways that prevent people from accessing the orthotist or prosthotist who could provide them with the appropriate devices, that and not having enough podiatrists who are capable of making AFOs.

I resent negative comments about the health service because the service is made up of thousands of very dedicated people who provide excellent care (most of the time) to an ever growing population of more medically complex patients at NO direct cost to the patient.

There are not very many countries around the world where this is true, least of all the U.S., where morbidity is an industry governed by companies who are driven by the sole purpose of increasing profit margins.


Thank you for your comments and insights. Please note that I have made no negative comments about the dedicated people who provide care in the NHS. My observations are based upon three visits to your country and personal communication with at least a hundred podiatrists while lecturing there.

During my recent trip, I was asked to evaluate two unfortunate women who had severe adult-acquired flatfoot and who had both been treated by podiatrists in the NHS. They had recieved prefab foot orthoses only and had both failed. Both were given surgical options only. I asked the audience of U.K. podiatrists if this type of treatment was typical and most agreed that it was not. But the audience also agreed that use of custom AFO treatment for adult-acquired flatfoot was not common in the NHS.

I fully agree with your assessment that the difficult referral pathways make access to AFO treatment difficult for many patients and most podiatrists do not undertake AFO therapy on their own. I suggest that it is time for the U.K. podiatrists to accept this challenge and start providing AFOs to their patients just as we do here in the States.

This post represents a very narrow minded view of the health system in the U.K. Having lived in both countries, I can say that the level of care patients receive in the UK is at least comparable if not superior in ways to the U.S. AFOs are indeed available for U.K. patients and even if they weren't, one could use the argument that the money saved by not paying the exorbitant insurance premiums for a couple of months would cover the cost of the brace.

There are certainly problems with each system but I would be careful about making quick judgments based on limited experience. You would not find many British people who would trade their system for the U.S. system of health.


I have tried to make my observations specific to podiatric care for the adult-acquired flatfoot. I have had significant interaction with your colleagues and stand by my conclusion that there is a different standard of care when treating this disorder in the two countries. I am convinced that podiatrists do not personally dispense AFOs to their patients to treat adult-acquired flatfoot and that efforts to refer these patients for this treatment often lead to no treatment at all.

Finally, I have listed the major articles on conservative care of the adult-acquired flatfoot using AFOs and could not find any studies using these devices in the U.K. I have chosen to not make widespread comparisons about the overall benefits of one healthcare system versus another. I can only rely on my own direct experience within my specialty. I suggest that the U.K. podiatrists can assume the role of providers of AFOs to their patients and achieve the success we have enjoyed here in the USA without increasing the cost burden on the NHS.

HMO coverage of AFOs provided by DPMs here in the United States may not last long. We may be forced to refer them out to certified orthotists or other providers.

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