Great Britain: National Health Service

As the home of the Industrial Revolution, Britain for many decades was a leading industrial power. Along with its industrial strength came a strong labor movement as workers united to gain political power within Britain’s parliamentary govern- ment. As a result, a commitment to protecting its citizens, including a commitment to universal health care coverage, has long been central to Britain’s identity. Beginning in the 1980s, however, the nation’s economy declined while health care costs rose. To restrain those costs, subsequent governments instituted a series of reforms designed to introduce market principles into the health care system while retaining universal health coverage. Currently, GNI per capita in Britain is $42,100, compared to $58,030 in the United States.

Structure of the Health Care System Whereas Canada provides its citizens with national health insurance, Great Britain since 1948 has provided care through its National Health Service (NHS). In Canada, the government provides insurance so individuals can purchase health care from private practitioners. In Great Britain, on the other hand, the government directly pays virtually all health care costs. As a result, the two systems look quite similar to health care consumers but differ substantially from the perspective of hospitals, health care workers, and the government. This section focuses on the structure of the NHS in England, one of the three countries that (along with Scotland and Wales) make up Great Britain.

Purchasing Care Unlike U.S. citizens, most English citizens rarely see a medical bill, an insurance form, or any other paperwork related to their health care. The NHS uses tax revenues to pay virtually all costs for a wide range of health care services, including medical care, visiting nurses for the homebound, homemakers for chronically ill persons, and some aspects of long-term care.

The NHS receives its funds almost solely through general taxation, with small supplements from employers and employees. As in Canada, because the health care system is paid for through graduated income taxes, it is financially progressive.

Paying Doctors and Hospitals As in Germany, almost all medical specialists work as salaried employees of the NHS at hospitals or other health care facilities, although they can earn extra income by seeing private patients. In contrast, most English general practitioners work as private contractors, increasingly in large group practices. General practitioners are paid by capitation, a system in which doctors are paid a set fee per year for each patient in their practice regardless of how many times they see their patients or what services the doctors provide. In such a system, doctors lose income when they provide more services. In addition, general practitioners receive financial supplements if they have low-income or elderly patients, practice in medically underserved areas, or meet government tar- gets for preventive services such as immunizing more than a certain percentage of children in their practices.

The vast majority of hospitals in England belong to the government (although some now include beds for private patients). The hospitals operate semi- autonomously, but regional NHS officials and hospital administrators work to- gether to ensure that each hospital can offer quality care to patients.

Access to Care Under the NHS, individual financial difficulties no longer keep English citizens from receiving necessary medical care. Waits can be uncomfort- ably long for nonemergency care, but any case delayed more than 18 weeks is reported to national authorities for further action. In addition, the NHS has reduced substantially the geographic inequities that for generations made medical care inaccessible to many rural dwellers, although access to care remains a problem in poor, inner-city neighborhoods. Britons average five doctor visits per person per year compared with four visits for U.S. citizen. Access to high-technology care and expensive new drugs, however, remains lower than in the United States. That said, in the United States access to treatments is limited only by the ability to pay, whereas in England a national panel of medical experts decide which services should be offered to citizens based on their effectiveness and then sets the prices for those services. Those prices are considerably lower than average prices in the United States and must be honored by drug manufacturers, private practice doctors, and anyone working under NHS auspices. For example, until it was taken off the market in 2011, many U.S. health insurers (including Medicare) paid up to $100,000 per patient per year for the anticancer drug Avas- tin, even though strong evidence suggested it was ineffective (Kolata and Pollack, 2008). In contrast, the NHS decided against covering it from the start, arguing that NHS money would be better spent on less expensive drugs with better track records. In sum, both the American and British systems limit access to care but in different ways with different consequences.