A Critical Evaluation of the Nationalised Healthcare System in the UK and the Free Market Healthcare

'A critical evaluation of the Nationalised health service in the United Kingdom V.S the Free market healthcare system in the United States’

This assignment will critically analyse and compare two health care systems from the United Kingdom (UK) and the United States (US). It will critically evaluate healthcare policy, funding and expenditure and performance within both systems. It will conclude by offering an evaluative assessment of these two systems drawn from that analysis.

Historically, prior to Universal healthcare within the UK, financial assistance to aid the poor and the sick was constructed under ‘The Poor Law’ in the 17^th century, later amended as The Poor Law Amendment Act (1834) in the 19^th century (Durbach, 2013). According to Healey (2014) this state-sponsored care was provided by private and or voluntary institutions. Into the industrial age despite The Poor Law Amendment Act (1834) still in place, David Lloyd George, introduced the National Insurance Act (1911) (Davis, 2005). According to Davis (2015) this act sought out to be the beginning of an early tax system we know, as workers would contribute for access to healthcare.

However, during the first world war, the demand for organised medical care on a national level began to grow and in 1920, ‘The civil servant's forward-looking Interim Report’ on the Future Provision of Medical and Allied Services was coined and published in May of that year (Marchildon, 2017). Commissioned by Christopher Addison – the Liberal health minister at the time, this report enabled organised medical care for soldiers who were injured in combat during the first world war (Graham, 2012). During the second world war (1939-1945), a means to redefine the support to the British public was investigated by William Beveridge.

Commissioned by the government as an economist, and liberal politician, Beveridge created his landmark ‘Beveridge Report’ or known as "Social Insurance and Allied Services" (Ashton, 2018). This report helped create an ideology that the UK could create a state with full employment, free education social security, housing and most importantly a ‘national health service’ (Whiteside 2014). From this, according to Mushgrove (2014), the infamous ‘Welfare State’ was created and in turn, The National Health Service Act of 1946 thus bringing about the birth of the National Health Service.

Contrastingly, within the US during the 18th and 19th century, the federal government had no legislative or public programmes to support those in need of healthcare, in fact it was left to the states within the US themselves and in turn private and voluntary programs to help those in need (Manchikanti et al, 2017). According to Hoffman, (2003), supported by a Republican presidential candidate, Theodore Roosevelt in 1905, raised the idea of the American Association of Labour Legislation (AALL) as the first form of health insurance at the time.

Policy Context

Influenced by progressivism, in 1915, the bill was passed which offered some form of health coverage to the working class (Chasse, 1994). In 1933, Democratic leader, Franklin D. Roosevelt aimed to include a publicly funded health care program with new recommendations from the Committee on the Costs of Medical Care (CCMC) within the Social Security legislation of 1935, however, failed (Markel, 2015). According to Hoffman (2003), the failure of national health legislation encouraged organised labour to meet needs of America’s workers. Encouraged by this, President Harry S Truman - classed as the pioneer of a universal health insurance system would influence his successor Lyndon B. Johnson to develop the Social Security Act in 1965 which created The Medicare and Medicaid act in 1965 (Markel, 2015).

Based on a free-market and third-party payer system in the US where healthcare providers reimburse healthcare professionals, ‘Medicaid’ has aim to cover those with low earnings people and those who suffered from disability, whereas ‘Medicare’ exists for those over the age of 65, those with disabilities or those who suffer from kidney disease (Obama, 2016). Unlike Medicaid, the federal health insurance ‘Medicare’ helps enrolees cover nursing home costs, acute care costs, hospitalisation and other institutional service costs, there are even noted drug and long-term care benefits (Feder and Lambrew,1996). Following this, 45 years later for the Patient Protection and Affordable Care Act of 2010 (PPACA) would achieve Truman’s goal of a more universalised healthcare insurance system (Markel, 2015, Obama, 2016).

 

Presently, the UK and the US face health systems face poor health outcomes as well as health inequity and inequalities (Squires and Anderson, 2015). With both health systems being significantly different, both work towards tackling these issues in the hope to improve health, manage health care costs and through the integration of health services (Briggs et al, 2018). The World Health Organisation (WHO, 2020) states that a ‘well-functioning health system’ is dictated by a ‘well-maintained infrastructure’ with a ‘reliable supply of medicines and technologies’, have ‘adequate funding, strong health plans and evidence-based policies’.

Chanteuridze and Obermann (2016) imply that the UK embodies this ideology through the quality of service provided to patients and their care implemented through effective health care policies within the devolved nations. Recognised as a natural experiment in the UK in 1998, it became clear that devolution within the four UK health systems within England, Scotland, Wales and Northern-Ireland would go on to provide a clear example of organisation, funding management, variation and health policy (Greer, 2016).

Funding and Expenditure

Trench (2015) states devolution has created ‘autonomous, elected, governments’ for Scotland, Northern Ireland and Wales. A study commissioned by the Health Foundation and the Nuffield Trust (2014) found improvements across all four countries in, investment, staffing levels, and health outcomes as rates of amenable mortality exceeded half in both females and males  across the nations between 1990 and 2010 (Bevan at al, 2014).

With clear variation in performance within each country, promising legislation using an ‘Integrated Approach’ within the devolved nations are: ‘The Public Bodies (joint working) Act (2014) in Scotland, the ‘Social service and well-being act (2014) in Wales and finally, the ‘Integrated health and Social care act (1973) in Northern Ireland (Ham et al, 2013). The Kings fund trust (2013) carried out a report looking at policy initiatives promoting integrated care within the devolved governments suggesting success within this approach (Ham et al, 2013).

In Wales, the NHS and social services focus on ‘capturing the patient’s/client’s experience, measuring outcomes and empowering service’ according to Ham et al (2013). Like Wales, Northern Irelands success by ensuring service needs are evident through the Southern HSC Trust where the responsiveness of services and agreed strategies have benefited dementia care and mental health generally (Connolly et at, 2010).

Within Scotland, joint responsibility is shared between NHS boards, the health and social care partnerships (HSCP) and local authorities to tackle barriers within health and social care (Parry et al, 2015). With this, in 2016, Scottish government states that this legislation created ‘31 integration authorities who are now responsible for £8.5 billion of funding for local services’ to ensure quality improvement across Scotland (The Scottish Government, 2020).

In contrast, some legislation has been less effective within the devolved nations for example in England, legislation aimed at tackling the financial pressures brought about by global recession through the ‘Health and Social care act (HSCA, 2012) was introduced by the Conservatives and Liberal democrats (Ham et al, 2015). This legislation’s aims included making health service provision more patient-centred resulting in the promotion of choice and to improve the quality of care and health outcomes (Glover-thomas, 2013).

However, Speed and Gabe (2013) suggests the legislation undermines the funding of the NHS. Following this, Ham (2015) suggests this legislation has resulted in greater marketisation of the NHS. With this, research suggests the impact of changes to commissioning introduced through the HSCA has impacted on cervical cancer screening as Hammond et al (2019) found ‘conclusions arrangements’ for commissioning and delivering cervical screening were disrupted and made more complex by the HSCA.

Performance

Contrastingly, although this legislation has deemed less effective than initially aimed, within in the US it can be suggested health disparities exist due to equity issues within the health system due to sparse policy initiatives to protect those who are vulnerable, as research suggests the average life expectancy in the UK is significantly higher (81.3 years) in comparison to the US (78.8 years) (Papanicolas, Woskie and Jha, 2018. However, significant socio-demographic inequalities persist within the US and UK despite such policy initiatives (WHO, 2020).

Following this, one of the policy initiatives within the US used to tackle issues within healthcare coverage programmes, is the Patient Protection Affordable Care Act (PPACA) 2010 or known as, ‘Obamacare’ (Obama, 2016). Proposed by President Barack Obama in 2010, the PPACA was intended to lower federal government spending on health care and to make health insurance more equitable (Obama, 2016). Four years later, on the 1st of January 2014, the PPACA gained full implementation where individual and employer provisions would take place, creating more affordable care from ‘birth through to retirement’ according to Rosenbaum (2011).

Prior to this legislation, a study conducted by Amante et al (2015) suggests that 5,109 enrolees of Medicare and Medicaid experienced difficulties accessing healthcare or were faced with barriers. Early research suggests that these programmes were not designed to serve or meet all health care needs of those eligible (Tallon, 1990). With this, research based on a cohort study suggests that those with Medicare in higher spending states, do not have better health outcomes with those in lower spending states, as well as patient satisfaction (Fisher et al, 2003).

The PPACA embodies some aspects of universal healthcare like the UK, however this act is aimed to lower the number of uninsured citizens within the US and has not directly improved health outcomes (Feldman et al, 2015). Despite this, involving the government, individuals, and employers, Rosenbaum (2011) suggests through shared responsibility, this act has aimed to improve fairness, quality, and the affordability of health insurance coverage.

According to Dalen et al (2015) in the first year that the PPACA was implemented, the percentage of people uninsured decreased fell by 5.3% in 2013 to 2015. Dalen et al (2015) goes on to suggest the PPACA has enabled those with prior health conditions to access health insurance converage. The Kaiser family foundation (2019) shows that the PPACA have helped 27% of adults age ranged 18-24 with pre-existing health conditions would not have had help otherwise.

Healthcare Inequities

However, Politically, according to the European Heart Journal (2014) the PPACA has been challenged and opposed by the Republicans due to it being deemed as ‘inappropriate government intrusion’ within the healthcare industry and causes ‘disruption’ to personal liberty. With this, there is growing controversy suggesting the PPACA does not consider socio-economic demographics as research suggests, between 2011 and 2015 through the assessment trends in insurance coverage, socioeconomic disparities in health care access narrowed (Griffith, Evans and Bor, 2017).

Achieving universal health coverage requires an effective health financing system (WHO, 2020). The UK utilises a single-payer health-care system based on a model which embodies these values and through a progressive tax scheme and universal health coverage, allowing the NHS to exist (Webster, 1998). This model, known as the ‘Beveridge model’ has been in place since the birth of the NHS and is still thriving today (Light, 2003).

The WHO (2020) suggests this model of financing promotes efficiency and equity which reduces financial barriers and inevitably raises funds for health. With reference to ‘funding control’, Bevan et al (2014) states that throughout the devolved countries, a block grant from UK-wide taxes decides how much is contributed to healthcare expenditure, with the decision of additional funding from other sources. Bevan et al (2013) suggests through this method of funding control, a direct health outcome shows rates of amenable mortality were cut in half in by 2010.

In contrast to the UK model, the US health finance model is based upon mandatory health coverage from private insurers which has resulted in low level of public funding (Ridic, Gleason and Ridic, 2012). The US utilises a model known as ‘The National Health Insurance Model’ which finances healthcare through premium payments by households, regarded as private sources (Light, 2003).

Lorenzoni et al (2014) suggests unlike the UK, the US itself has no centralised power of negotiation towards healthcare fees or health expenditure plans as these are leveraged by the medical care providers. Despite this, private healthcare does exist in the UK and patients can access private treatment through the NHS (Doyle and Bull, 2000). However, this creates the argument of ‘value for money’ as those who purchase private healthcare insurance are up against treatments free through the NHS (Santandrea, Bailey and Giorgino (2016).

According to Porter and Teisberg (2004), it can be suggested that there is also a clear argument that patients in the UK have little choice of treatments they receive with little possibility to make informed decisions. However, a survey commissioned by the Health Foundation (2019), indicates the British public support paying more tax to maintain and improve health and social care. Further research shows only 11% of people think funding increases for should come from cuts to other services (Sussex et al, 2019). This suggests, despite having less control over treatment in the UK, the British public are still content in paying tax to allow a universal healthcare system to exist (Bielecki and Nieszporska, 2017).  

Conclusion

With regards to health expenditure and health outcomes within the US and the UK, the latest Gross domestic product (GDP) total spending on healthcare (US dollars/capita) from 2019 shows: 11,072 US dollars/capita in the United States (US) and 4,653 UD dollars/capita in the United Kingdom (UK) (OECD, 2020). Despite the GDP on healthcare spending being higher in the US, compared with thirteen other high-countries, the US has poorer health outcomes, including shorter life expectancy and greater prevalence of chronic conditions (Squires and Anderson, 2015).

Following this, a study comparing eleven countries found the US has the highest rates of obesity, lowest life expectancy and highest infant mortality (Papanicolas, Woskie and Jha, 2018). Therefore, despite higher spending, the US has worse health outcomes as in 2015, one-third of all healthcare and medical care spending was based on tackling poor health outcomes such as, heart disease, diabetes, mental issues and cancer (Biener, Decker and Rohde, 2019). In contrast, as mentioned previously, although the UK spends less on health care, life expectancy is higher (81.3 years) compared to the US (78.8 years) (Papanicolas, Woskie and Jha, 2018, Papanicolas, et al, 2019). To conclude, despite higher spending in the US, the UK delivers better health outcomes relative to health care expenditure (OECD, 2019).

Within the UK’s NHS, every person is covered with health care. Unlike the US, it is free from point of entry as there are no bills or insurance policies (Schneider et al, 2017). As a publicly funded system, prices of drugs, salaries of healthcare workers and professionals are controlled by the government and funded through taxation (Bevan et al, 2014). In contrast, fundamentally, the healthcare system in the US is based upon Capitalist principles where the main objective is to make profit as well as improving healthcare outcomes (Branning and Vater, 2016).

The idea of profiting from illness provokes ethical and moral issues, especially as the US has the highest spending on health care and the poorest health outcomes (OECD, 2020, Squires and Anderson, 2015). QuintilesIMS Institute (2016) states that the US spending on pharmaceuticals is $1.1 trillion, three times as much as in Europe. Despite such spending and implementation of legislation such as the PPACA to assist Americans, with a free market economic system within the US, most remain uninsured or underinsured (McWilliams, 2009).

Although the UK’s spending on pharmaceuticals is three times less than the US, in 2006, it was suggested, 26,260 people died due to having no health insurance (Tanne, 2008). Expanding on this point, according to the OECD (2020), the US remains the greatest consumer of health care across the OECD, however regarding access to care and coverage only 91% of the population is eligible for a core set of services in comparison to the UK, where 100% of the population is eligible, the lowest being Mexico (89%). One of the largest groups of people excluded from access to insurance coverage under the PPACA is unauthorized immigrants which accounts for around 12 million according to Onarheim et al (2018).

References

Like the US, the UKs migrants and ethnic minorities face issues accessing health-care services (Alder and Rehkopf, 2008), this suggests adequate monitoring should be in place (WHO 2010). Following this, with efforts to replace PPACA with other reforms to reduce market regulations and the mortality rate associated with this healthcare system, it can be suggested that perhaps less focus on pharmaceutical expenditure and more on health insurance equity would ultimately minimise health disparity (Sofer, 2019, Holahan, Wengle & Elmendorf, 2020).

Focussing on healthcare quality for better health outcomes, the UK prioritises the quality of service provided to patients and their care (NHS, 2019).  According to Chanturidze and Obermann (2016), governance in UK healthcare is concerned with the provision of appropriate environments for patients, recruitment of suitable staff to the role, good patient experience and other areas such as safety of clinical practice.

However, in contrast, McMillan (2006) suggests the principles of clinical governance do not apply to private healthcare providers. Using clinical audits, performances can be measured against a standard to identify an opportunity for improvement (NHS, 2019). This measure shows effectiveness as the Commonwealth Fund (2014) states the UK has ranked 1st in: quality of care, access, equity of care and efficiency. However, in contrast, despite the US ranking one of the lowest countries regarding service coverage in primary care with only 65% of the population were able to access a doctor when required, the US ranked one of the highest in preventative care services, such as cervical cancer screening (80%) (OEDC, 2020).

In contrast, the UK performance in cervical screening was much lower at 63% (OEDC, 2020). This is evident through The Health and Social Care Act (2012) which had presented issues with cervical screening within the UK (Hammond et al, 2012). However, it is clear within the US, there is racial health disparities which persist due to mortality rates in Black woman being higher and more than half with detected cervical cancer failed to be screened (Safaeian, et al, 2007).

With this, like cervical cancer screening according to Anandaciva and Thompson (2017), they suggest within the UK, the NHS has poor waiting times in contrast to the US. Research conducted through the Health Foundation (2019) shows that in 2018/19, cancer waiting times performance hit a record low with only 79.1% (below target) and with Elective treatments, only 86.7% of people had been waiting for 18 weeks or less, down from 94% (Thorlby et al, 2019). However, unlike the US, the NHS have developed a ‘Long term plan’ to tackle long waiting times in the UK Murray (2019). This plan aims to tackle other issues within the NHS, such as social exclusion, and socio-economic deprivation issues (NHS, 2019).

Conclusion

In summary, despite implementation of legislation to improve health, manage health care costs and integrate health services, the UK, and the US health systems both present challenges. Although the PPACA has closed the gap of uninsured citizens, there are still moral implications that exclude immigrants and those that are socio-economically deprived. Despite such legislation, there is still vast health inequality as well as being driven by political agenda.

Unlike the US, the UK health system is clearly more accessible due to its ‘Free point of entry’. With this, the devolved nations within the UK focus on their own health issues through integrating services. However, some legislation has not been as successful as intended as there seems to be poor health performances within the UK today. As the US is based upon a profit-based system, it is clear health expenditure is vastly higher than the UK, although research shows, health outcomes are poorer and access to medical care is limited. Ethically and morally, the US’s ideology of monetary gain within healthcare potentially poses as a human rights issue, as every person in the UK has access to ’Free’ health care.