US and UK Health Systems – Not So Different?

This guest post is part of the Festschrift of the Blogosphere celebrating HealthBlawg’s Tenth Blogiversary. Festschrift posts are appearing throughout the month of June 2016.

For many Americans, the UK National Health Service is the example they reach for when talking about European style “socialized medicine,” and all its supposed successes and failings. For many Brits, the fragmented American healthcare system is the example they reach for when talking about the perks and perils of an “all-private” system.

My observations are that the distorted views across the Atlantic in both directions could use some fact checking. Both countries have much to learn from each other, and the systems in both countries are both stronger and weaker than the myths suggest. You will find similar (and less anecdotal) observations in this 2012 U.S. article.

What do the British think about the NHS? Often noted as “the closest thing to a national religion,” Britain loves its National Health Service. Brits think it is fair, it is reasonably high quality, it is provided by the government, and free. Brits also think that the government interferes too much (or not enough), that the waiting times are too long, and that it is financially mismanaged. (For a detailed understanding of British satisfaction of the NHS, start here).

Many British people think that the American system is bloated, expensive, and only cares for the rich. Driven by profit it unfairly benefits those with money, and ignores or even harms those without. Others in Britain (mostly England) think that a dose of competition will lead to faster access to care, faster adoption of new technologies, and better choices for consumers/patients.

What do Americans think about the American system? That it’s the best in the world, and void of government (or other bureaucratic) restrictions on treatments, and almost entirely privately run. Americans think it is expensive, complex, complicated, and opaque in decision making and especially billing, pricing, and payments. (There is no equivalent wide-ranging survey to the UK case cited above, but try this.)

Many American’s think of the NHS as “socialized” (which is not a term used in the UK, so no-one knows what that means), low quality, and where government rations care, mostly arbitrarily, or even capriciously. Others see it as a “single payer system” (which is not a term used in the UK, so no-one knows what that means) offering the best pattern to solving the American system’s problems.

Here are some interesting facts about the role of government and the private sector in the two countries:

• Public funds in the US covers about half of health care spending (Medicare, Medicaid, Veterans Health, and more) – certainly more than many people think.
• In the UK public funds cover a little over 80% of healthcare spending – certainly less than many people think.
• The US private insurers tend to follow government (Medicare/Medicaid) in deciding when to cover new treatments, and so the government exerts more influence than many realise.
• In the UK, almost all primary care physicians (General Practitioners) are effectively small businesses, contracting with the local NHS “payer.” They are certainly not NHS employees (although most hospital physicians and staff are).

And how about use of data for both care and for research:

• In the UK there is a national NHS number which should allow very easy integration of data, but in many places if you are admitted to your local hospital they have very little access to your primary care records. When you are discharged, the primary care physician has very little access to your hospital records. (In Scotland, which runs under separate governance, the data sharing infrastructure for delivering patient care, and even for research, is much better.)
• In the US a growing number of patients are in integrated delivery networks which share medical record systems (so all your healthcare providers see your records), and beyond that certain areas have Health Information Exchanges specifically designed to ensure the right data from all other providers that a patient sees is available at the point of care. Accountable Care Organizations (ACOs), which are responsible for outcomes and costs of care also require more complete data sharing so that they can manage the totality of a patient’s care.
• In the UK when patients are asked about whether they want to allow their data to be shared for their own care, they are surprised to hear that is not a standard practice, and that (among many other factors) makes them suspicious about being asked to allow their data to be anonymized and then used for research purposes (even by academics, let alone by commercial organizations).
• In the US the disclosure forms (under the law called “HIPAA”) are signed by every patient at every doctor. Patients can feel they have no choice in signing the disclosures, but they know that their data, at least theoretically, can be shared for their care (and, when de-identified, for research).

In both countries people are trying to understand anonymization or de-identification of data to allow for research. Can medical data be shared to support legitimate research in a way that it cannot be used to the detriment of the patient? What are the statutory, regulatory, contractual, governance, technical, and operational best practices to win the trust of patients and providers for the use of medical data for research? In the US, patients are more comfortable that the safeguards are in place, even where the private sector controls much more of healthcare, and so the possible “misuse” of data might be more of a worry. In the UK, the worry that governments or outside entities (life insurers are often cited) might misuse the data leads to a lower acceptance of garnering the large benefits of health data research, even where there is a national system with a national ID number for all patient records.

In conclusion, the UK and US systems are more similar than many realize. Best practices that work in one system are more applicable to the other than you might think, and lessons learned in one system can also point to weaknesses in the other.

This is Richard Dale’s personal opinion and not that of his employer.

Richard Dale (Twitter: @rdale) is COO at OptumLabs, an open research and innovation center dedicated to improving patient care and outcomes in the healthcare industry. Previously Richard was a Principal at Sigma Partners, an early stage Venture Capital firm. Before that, Richard was involved in several startups in the Boston area and co-founded and had various leadership roles at Phase Forward, a provider of software services for pharmaceutical clinical trials which went public and later was sold to Oracle. Richard’s career began as a software engineer and database expert.