The Second World War left the United Kingdom in ruins and in debt, yet just three years later in 1948 every household received a leaflet telling them that they were entitled to free health care. This marked the birth of the National Health Service, funded from general taxation and available to all according to their clinical needs, regardless of income.
By and large, the same arrangements remain today. Satisfaction with the NHS has increased over the past few years, with 60 percent of those surveyed in 2015 saying they were quite or very satisfied with the NHS.
According to the Commonwealth Fund’s recent survey, 63 percent of those from the U.K. said the NHS worked well.
In contrast, only 25 percent of those from the U.S. said the same about their health system.
The British, take more pride in the NHS than anything else, the royal family included.
International comparisons show that the NHS outperforms other countries, including the U.S., in terms of quality of care, efficiency, access and equity.
Despite this, the NHS receives bad press in the U.S., perhaps for two main reasons. First, the NHS is underfunded; and, second this means some people have to wait to be treated.
NHS funding doesn’t match the need
Under the NHS there are no insurance premiums to pay, and people don’t have to worry about their health insurance policies when changing jobs.
Copayments are made only for dental care and for prescriptions (at about US$10.60 per item), but people under 18 in full-time education, people over 60, and expectant and recent mothers don’t have to pay anything.
Funding for the NHS is decided by the government of the day, which means that overall expenditure is tightly controlled and the generosity of funding varies according to whichever political party is in power. At the moment, the government is led by the Conservative Party, which is pursuing an austerity program of cuts to public services.
The NHS has been spared budget cuts, but funding increases over the next five years are among the lowest since the mid-1970s.
In 2015, the total health budget amounted to $145 billion and the budget will be $5.7 billion higher in 2020. But costs are expected to be $38 billion higher because more people will need care. The NHS is supposed to improve efficiency to make up the difference. But it is failing, with most hospitals in deficit.
The U.K. currently spends 9.9 percent of GDP on health care, with 80 percent of this spending on the NHS, the remainder being private health expenditure. This places it 12th among the 35 countries that are members of the Organisation for Economic Co-operation and Development.
But the U.S. takes the top spot, total health spending amounting to 16.4 percent of GDP.
The higher level of spending in the U.S., though, doesn’t translate automatically into higher levels of health. Life expectancy is lower in the U.S. than the U.K., and people in the U.S. have higher rates of chronic disease than those of the same age in the U.K.
Instead of detrimental health effects, low spending levels in the U.K. create delays in how quickly people receive treatment.
How long are the waiting lines?
One of the main ways that the NHS tries to live within its financial limits is by prioritizing emergency care ahead of treatments that are planned in advance such as hip or knee replacement. This means that some people have to wait a long time before receiving advice or treatment.
Because of this, NHS waiting times are monitored and reported regularly – routine statistics simply aren’t available in most other countries including the U.S. But people do have to wait for treatment in the U.S., with surveys showing waiting times vary by specialty and across the country.
The latest figures from England show that 1.1 percent of patients waited more than six weeks to have a diagnostic test, 9.6 percent of nonemergency patients waited more than 18 weeks before admission to hospital, and 18.9 percent of those with suspected cancer waited more than 62 days before beginning treatment. And, once they’re in hospital, ever more patients are having to wait on gurneys until a hospital bed is available.
People have to wait for NHS treatment because there aren’t enough staff or facilities to meet demand. Accounting for population size, the U.K. has fewer doctors, nurses and hospital beds than the OECD average.
The number of doctors and beds in the U.S. is also below average. But instead of using waiting times to manage access to these resources, some people in the U.S. struggle to access care because of the financial barriers they face. And financial barriers, more than waiting times, appear to determine public discontent with the health system.
A tale of two cultures
From my perspective as a professor of health economics based at the University of York in the U.K., I don’t think there will ever be an NHS-style system in the U.S., and not just because the powerful health insurance industry would resist it. Americans simply won’t tolerate having to wait for treatment like the British do. Nor would Americans let politicians have such a big say about how much to spend on health care.
But, by the same token, the British will never be convinced that the health system in the U.S. is superior to the NHS. The principles of the NHS are that it offers universal health care coverage, meets the needs of everyone, is free at the point of delivery, and is based on clinical need, not ability to pay.
These principles formed the foundation stones of the NHS when it was created after the desolation of the Second World War, and the British public remains committed to them today.