A sign hangs in the waiting room of my doctor’s office.  It advises patients how many appointments were missed in the previous month and how many work hours this cost the staff.  The practice has no recourse against patients who fail to turn up.  There was no cost for the appointment in the first place.  So all the staff can do is hang up that sign, to accuse patients silently as they sit in the waiting room.

These guilt-mongering signs are a common sight in medical facilities of Britain’s National Health Service (NHS).  I became quite familiar with them because I lived in the southwest of England for nearly three years, and during that time I received all my medical care from the NHS.  We recently relocated to South Africa for my husband’s work.

Founded in 1948, the NHS is now the world’s largest single-payer public healthcare system.  Its budget for this year is £116.4 billion.  Nearly everyone in Britain gets his healthcare from the NHS.  Only 11 percent of the population has some form of private health insurance.  With 1.5 million employees, the NHS is the fifth-largest employer in the world.

I would sum up my three years as an NHS patient by saying upfront that the NHS is not that bad.  When Americans hear about the NHS, they usually think of long waiting lines and death panels.  When I resigned my job in the United States for the move to Britain, the company benefits administrator told me I was eligible for COBRA because the NHS was not considered equal to the standard of care I had been receiving.

In retrospect, I am not sure that assessment was fair.  American medical care and Britain’s NHS are like apples and oranges.  The biggest difference for me as a patient was that in the NHS I didn’t pay directly for my care—with a few exceptions that I’ll explain later.  Even though I had excellent health insurance through my employer in the U.S., there was always a copay of some sort.  In England, I didn’t pay anything for a basic appointment with a general practitioner.  I delivered my first child at an NHS hospital via caesarean section.  I received no bill of any kind.  A German friend of mine needed emergency hospitalization shortly after she moved to our city.  She summed it up pretty well when she told me, “I kept expecting this huge bill to arrive in the mail, and it never came.”

This concept is referred to as “free at the point of use,” and it is one of the central tenets of the NHS.  Every so often, some group of experts makes a proposal to introduce charges.  This leads to handwringing in the media and talk of the “end of our NHS”—and inevitably it goes nowhere.

The widespread impression among Americans that the NHS has long waiting times is certainly true.  It’s normal to wait two weeks for a GP appointment.  However, I found ways around this.  I could call my GP and say I have an “emergency.”  The receptionist would slot me in the same day.  Also, the NHS has an extensive network of walk-in clinics.  Finally, there is the emergency room of the local hospital, although, as in American ERs, one can wait for hours.

During my years in Britain, I learned that the NHS does some things well and some things badly.  The process of getting an appointment is often bureaucratic and inefficient.  But once I actually got to see a nurse or doctor, the experience was usually very good.

The NHS performs well when dealing with straightforward, common conditions.  A good example is my pregnancy.  I was assigned to a midwife for prenatal checkups.  She did an excellent job of reassuring me that the various aches and pains that terrify a first-time mother were normal and nothing to worry about.

Pregnant women in Britain receive most of their care from midwives.  However, I developed a complication that resulted in frequent visits to the hospital.  I saw a different gynecologist nearly every time.  I would receive a letter from the hospital inviting me to an appointment, and I had no clue who would be sitting in the consulting room.

I learned that to get good care I had to be an active participant.  I typically had to start each consultation by summarizing the previous one.  If one gynecologist told me something should be checked up on, I had to tell the next one to do it.  This worked fine for me.  I have no problem following up, making phone calls, and even being aggressive sometimes.  But I wonder how this would go for, say, an elderly person or someone with a poor command of English.  In the NHS, you need to stay alert, or you might fall through the cracks.

The birth itself was a wonderful experience.  I can’t imagine that Catherine, Duchess of Cambridge, received better care when delivering her two children at St. Mary’s Hospital in London, which is private and costs £5,215 for the first 24 hours.

After reaching that high-water mark, my NHS experience began to decline.  I needed some follow-up care for the complication in my pregnancy.  Up until the birth, my case belonged to the maternity ward of my local hospital, and they kept things moving along fairly well.  Once the baby was born, I belonged to no one.  I fell into an NHS bureaucratic black hole.  After two months, I was referred for a procedure at a specialist hospital in Birmingham, over 150 miles from our home.  I asked if the procedure, a fairly common one, could be performed at my local hospital instead.  That was a bridge too far.  Despite relentless phone calls on my part and some letters from my GP, my request went nowhere.  After another three months had passed, I became desperate and asked Birmingham to do the procedure.

Per their instructions, I arrived at 7:30 a.m. on the appointed day.  I then had to wait five and a half hours before I was called for my procedure.  Since I would be going under general anesthesia, I couldn’t eat or drink water, and I had been fasting since the night before.  At one point, I felt so unwell that I lay down on the floor of the bathroom.  Once I was finally called, however, the procedure went smoothly, and the care was excellent.

My contact with NHS hospital staff was conducted either via phone or—more commonly—letter.  I was constantly amazed at how low-tech the NHS is.  My GP practice offered a clunky website that let me renew prescriptions and sent appointment reminders via text message.  This puts them light years ahead of nearly every NHS hospital in Britain.  When I was packing for my move, I threw out a one-inch stack of letters I’d received from the hospital.  I kept nearly as many for future reference.

This reliance on snail mail causes a host of inefficiencies.  For instance, I once needed a test performed at the hospital.  I spoke to a scheduler in person and told her that, as I was about to go on a lengthy trip abroad, the test needed to be conducted either in the next week or after a month, once I had returned.  When I returned from my trip there were two letters from the NHS in my mailbox.  One, dated shortly after I left, informed me that my test was scheduled during the time I was away.  The second, dated a few weeks later, informed me that I had missed my appointment.

Remember those posters informing patients how many appointments were missed recently and how much that cost the NHS?  I sometimes felt an urge to grab a pen and write “It’s your own fault!” on one them.

Nearly all NHS care is “free at the point of use.”  There are three exceptions: prescriptions, and dental and optical care.  The charge for prescriptions is something of a joke.  First, it applies only in England.  There is no charge for prescriptions in Scotland, Wales, and Northern Ireland.  Second, even in England, there are myriad ways to gain an “exemption certificate” that excuses one from paying.  NHS figures show that 90 percent of all prescriptions dispensed in England are not paid for.  Earlier this year, a scandal erupted over the revelation that the NHS spends millions on prescriptions for items that can easily be purchased over the counter.  For example, last year there were four million prescriptions for basic antacids at a cost to the NHS of £26 million.

I experienced this firsthand.  I was eligible for the maternity-exemption certificate, meaning I got free prescriptions during my pregnancy and until my baby’s first birthday.  During one appointment, my GP advised me to start taking a dietary supplement—something very common that I could buy over the counter.  With a friendly smile, he said, “I’ll write you a prescription so you don’t have to pay for it.”

An area where Britons do have to open their wallets is dental care.  It’s much harder to gain an exemption from dental charges than from prescriptions.

Despite all the jokes about English people’s bad teeth, dental care is the stepchild of the NHS.  In England, it amounts to only around £3.5 billion of spending per year.  The NHS partners with private dentists, who agree to offer a specific number of treatments via the NHS.  The patient pays part of the cost, and the rest is subsidized.  Some treatments that Americans would consider standard, such as teeth cleaning, are not covered.  The number of treatments is not affected by type—e.g., a checkup and a root canal are each considered one treatment.  Once a dentist has met his quota, he may stop offering NHS care.

Less than half the population of Britain had an NHS-subsidized dental appointment in the last two years.  The British media is full of horror stories about patients who can’t get an appointment or who have to travel 200 miles.  Personally, I experienced no difficulty registering with a practice located one block from my house.  I only required basic checkups.  The dentists, who were all from Eastern Europe, were competent professionals.

In my experience with Britons, the stereotype of the “stiff upper lip” is still largely accurate.  Taken as a whole, they are more reluctant to complain than Americans are.  Thus, when the NHS provides suboptimal care, there is less “pushback” than there would be from American patients.

An English friend of mine had an outpatient procedure at our local hospital.  The hospital was busy that day, so they sent her home too early.  Her wound became infected.  She was out-of-action for months.  Her GP wrote a letter of complaint on her behalf, but she herself never considered seeking any kind of recourse.

I chatted with an elderly lady who told me that the previous year she had suffered heart failure while visiting Hong Kong.  Since she had excellent travel insurance, she received a state-of-the-art pacemaker.  “I’m rather lucky because I probably wouldn’t have gotten it here on the NHS.  It would have been too expensive.”  She said this with a mischievous smile, like a child who has gotten away with stealing a cookie.

Everyone knows the British love discussing the weather.  In my experience, the NHS comes second as the national favorite topic of conversation.  Not only do virtually all Britons receive their healthcare from the NHS, many of them work for it as well.  The NHS employs 1.5 million people in a country of 60 million.  I’ve met families where every member is employed by the NHS in some capacity.

Britons love the NHS.  They blame its problems on political meddling.  I lost track of how many times I heard a statement along the lines of “If only the politicians would keep their hands off the NHS.  It should be run by doctors.”  There may be some truth to this, but it shows ignorance of the nature of politics.  It is not possible for politicians simply to funnel money and not attach any strings, and that’s particularly true for an institution as central to British life as the NHS.  Every election campaign centers on the NHS.  Every prime minister tries to build his legacy on it.

One common view is that the Labour Party is “pro-NHS” and the Conservative Party is “anti-NHS.”  An acquaintance proclaimed solemnly in 2014, “If the Conservatives are reelected, the NHS will be privatized.  That’s their goal.”  This view has no basis in reality.  Under Conservative Prime Minster David Cameron, the NHS’s budget has grown to unprecedented heights.  Margaret Thatcher, considered the greatest privatizer in modern British history, left the NHS largely untouched.  In fact, some of the toughest, market-based reforms in NHS history were made by Tony Blair’s Labour government.

It’s a cliché among Britons to say that the NHS is their national religion.  If that’s true, then it’s like a cult where the questioning of doctrine is not permitted.  I’ve tried to tell friends that the NHS is a subsidy for businesses because they don’t have to provide health insurance for their employees.  They look at me as if I’m speaking Greek.  Many Christians see the NHS as an important way of caring for those in need.  A Welsh friend who identifies herself as a libertarian told me that the NHS is “our most precious national treasure.”  I couldn’t even begin to explain to her that you cannot call yourself a libertarian while supporting a £116.4 billion government social-welfare program.

My own view is that, since Britons are happy with their NHS, then it’s fine for them.  They just have to find a way to pay for it.  Personally, I believe in small government.  But if you’re going to have a large state and high taxes, I’d rather the money was used to provide healthcare to citizens than to drop bombs on foreigners.  The budget for the U.S. Department of Defense is over $550 billion.  The NHS budget pales in comparison.  As I settle into life in South Africa, I look back on mostly good memories of my time in England.  Goodbye, NHS.  I’ll miss you.