As the U.S. health care debate accelerates, it continues to be important to compare and contrast the U.S. health system with those of other countries as part of our learning journey.
Our travels for our Futures Task Force II work provided us with an opportunity to grow some knowledge of the health care delivery systems in both Canada and England.
The National Health System (NHS) in Britain is celebrating its 61st birthday in 2009. At face value, comparisons between the U.S. health care system and the NHS are stark and have caused quite a debate.
The NHS has a “socialized system.” Socialized medicine is a term more commonly used in the U.S. and usually refers to publicly financed and/or government-administered health care. It has taken on a pejorative meaning and evokes negative sentiment toward public control of a health care system. Ultimately, each system around the world, regardless of what it’s called, aims to find a solution that best meets the needs of its country’s population. One could argue that the U.S. has aspects of a socialized system with its Veterans Administration and Medicare and Medicaid programs.
Understanding the origins and evolution of the NHS helps to contextualize changes in U.S. health care and to highlight strengths and weaknesses in both systems. The NHS was established by the Labour Party in 1948 against considerable opposition as a small component of a wave of postwar nationalization. Before its creation, patients were generally required to pay for their health care. The founding principles of the NHS called for health care services to be:
• Provided free at the point of use,
• Accessed by all people (even those temporarily resident or visiting the country) and
• Financed from central taxation and not through national insurance.
The NHS has changed considerably in the intervening years. Organizational restructuring in the 1960s integrated NHS primary and secondary services under single regional bodies, a process which has continued. An end to economic optimism in the 1970s and 1980s led to the introduction of modern management processes, which still dominate the Service. Sustained investment by Prime Minister Tony Blair’s government during the 1990s aimed to modernize and streamline the Service through the introduction of internal and external competition, closure of surplus facilities and introduction of efficiencies (including the elimination of long waiting lists). In recent years, the achievement of efficiency in the NHS has placed a renewed focus on quality and innovation.
The NHS provides a vast array of services. An annual budget of £90 billion (U.S. $135 billion) has produced some impressive results compared with other health systems, and the NHS consistently ranks higher than the U.S. in several global health surveys. In 2007, the Commonwealth Fund compared the performance of five nations—Austria, Canada, Germany, New Zealand, The U.S. and the UK—on five dimensions of a high-performance health system: access, efficiency, equity and healthy lives. Overall, the UK ranked the highest across these metrics, and the U.S. the lowest.
What has probably been most surprising is the unique sense of ownership and social responsibility people have for the health service. Major initiatives, such as the closure of an NHS hospital, are presented to the community for public consideration. In another example, the board of a pediatric hospital in the North of England actively sought feedback from community children on what they value most in their experience at a hospital.
At the same time, there is the National Institute for Health and Clinical Excellence (NICE), which plays a unique and valuable role in prioritizing new technologies and drugs. But NICE also creates a culture of conservatism that results in slow adoption and sometimes limited patient choice for very innovative practices and technologies.
As the NHS continues to evolve its system of care (I.e., the entire care continuum of inpatient and outpatient services), NHS chief executives and managers are looking to the U.S. for leading practice approaches to more systematic and collaborative care that have been achieved by such organizations as Kaiser Permanente and Geisinger health. As the NHS has shaped its model over the last 61 years, it has done a good job learning from the past and from the experiences of others around the world while finding the best available evidence to support its planning.
An NHS model would be a radical cultural shift for U.S. health care. But ultimately, we will find a solution that makes sense for us just as other countries have managed to do.