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Hours-long waits in the emergency department, patients treated in hallways in the midst of an intense flu season, and canceled elective surgeries are only a few of the problems the National Health Service (NHS) England, which provides health care to all Britons, is facing this winter.

At first glance, the struggles of NHS England appear to embody conservative arguments against the kind of single-payer health care system that many progressives in the U.S. have rallied behind as a way to expand health insurance to all Americans. In this view, the troubles of NHS England clinch the case that universal health insurance is a fool’s errand.


Not so fast.

Let’s begin with what is actually happening at NHS England, where the primary problem this winter has been that demand for care — compounded by a severe flu season — is surging past the system’s ability to supply care. Despite the shocked reporting about this in both the U.K. and the U.S., the crisis was widely predicted months ago, and was potentially preventable.

In the U.K., the Conservative-led government is continuing an austerity regimen for NHS England. Its funding is projected to increase a meager 1 percent per year from 2010 to 2020, compared with an historic average of 3.8 percent per year since the NHS was founded in 1948. This transpired against a background of relative parsimony in overall health spending in the U.K. Britain allocates 9.9 percent of its gross domestic product to health care — about average for industrialized countries — compared to more than 18 percent in the U.S.


Adding to the pressure on NHS England was a simultaneous 7 percent real reduction over the last decade in spending on social services, such as care at home or in residential or nursing homes. This cut has increased the demand for health services, especially among frail elders with no place else to turn. To make matters worse, worries about Brexit are sparking an exodus of essential European Union doctors and nurses who were staffing an already under-resourced NHS England.

The unique structure of this system also leaves it more vulnerable to political whims. Unlike most other industrialized countries that provide universal health coverage, the U.K. government owns a large proportion of the hospitals and employs many of the health professionals who provide daily care to its citizens. This control can easily turn into continuous meddling in the health system’s organization and financing. Every change in government — and even a new Secretary of State for Health — seems to unleash another major reorganization that risks distracting and confusing health care providers.

Despite these significant stressors, the U.K. has built a much stronger primary care sector than the U.S., and its health care system is typically ranked one of the best among wealthy nations. In addition, the NHS remains extremely popular. Satisfaction with the system hovers around 60 percent, with low levels of dissatisfaction. And even though 92 percent of residents of England, Scotland, and Wales believe that the system is facing a funding problem, survey data show no appetite for major changes in the structure of the NHS. This suggests that, from the public’s point of view, the system is still doing its job.

So, what does all of this say about the how the U.S. health system should expand health insurance, if it chooses to do so?

In answering that question, it is essential to keep in mind that every country’s health care system is a unique reflection of its history, politics, and culture. Wholesale importing of one nation’s approach to another is both unlikely and unwise. But that doesn’t mean the U.S. can’t learn from other nations’ successes and failures.

First, regardless of how a nation’s health care system works, it must be appropriately funded. Health systems need sufficient resources to meet the predictable needs of their patients, especially when facing an epidemic.

Second, underfunding social services risks inflicting pain and suffering on sick and needy citizens and can be self-defeating when it causes health care costs to rise. The U.S. currently invests little in social services compared to what it spends on health care. It should reevaluate this imbalance and its effects.

Third, providing universal coverage does not require government ownership and control of the health care delivery system. As the NHS England example suggests, that approach presents enormous political and technical challenges. Given the strong affinity in the U.S. for non-governmental solutions, building on its largely private delivery system is the direction it will almost certainly take.

Whether you favor or oppose expanding health insurance coverage in the U.S., don’t conclude from the U.K. experience that universal coverage can’t work. Health insurance coverage is essential to the health and well-being of millions of Americans, and to the success of its health care system. There are many ways to structure a system that provides Americans with the coverage they need and deserve.

The U.S. can learn from the National Health Service — and other health systems — about paths forward and paths to avoid as it designs a uniquely American approach to its immense health care problems.

David Blumenthal, M.D., is president of the Commonwealth Fund. Jennifer Dixon, M.D., is chief executive of The Health Foundation in the United Kingdom.

  • Good article but you missed one very important point. The conservative government, in the Heath and Social Care act 2012, imposed external market mechanisms on the NHS. This means that NHS commissioners (CCGs) had to put many contracts out to competitive tender. NHS providers (trusts) and private healthcare providers can bid, but the odds are heavily stacked in favour of the latter, who have huge resources to put bids together (legal, management consultants etc). If they don’t get the contract they are liable to sue (as with Virgin Care). Administering this system costs £4 to £10 BILLION a year. (

    This system is also highly unstable (companies may choose to walk away at the end of the contract and the NHS must fill the gap – starting over with new systems, training etc etc) and in order to make a profit standards are pushed down (hiring fewer less experienced staff for example). This crass privatisation was not in the manifesto of any party and has no public support. It is 100% ideological – pushing the idea that private sector is always more efficient when the evidence suggests the exact opposite, especially where healthcare is concerned.

  • Why not have a look into European healthcare systems superior to NHS? For long the annual Euro Health Consumer Index (EHCI) indicates that NHS is mediocre, compared to healthcare in the Netherlands, the Nordic countries and Continental Europe (almost all with various kinds of public funding). It probably is easier to Americans to study something in English than Dutch, German or Danish but ignoring the rest of the world might be harmful?

  • “First, regardless of how a nation’s health care system works, it must be appropriately funded.”

    Well, yeah. Irrespective of the country and the nature of the health care system voters tend not to appreciate the dissonance between their actual needs and their willingness to pay for them. The article compares a NHS satisfaction rate of ~ 60% with an estimate of ~ 90% of the UK’s population expressing a view that funding for the NHS may not be adequate. An interesting third piece of data would have been the % of the population willing either to 1) pay more in taxes if the increase were earmarked for the NHS; or 2) hold MPs accountable for shortfalls in NHS funding. Back in the day there was a crusty old guy named Fred Langone who served on the clown car known as the Boston City Council and the advice he gave to every newcomer on that body was the same: “First thing you gotta know is that everybody wants to go to heaven but nobody wants to die.”

  • Good article. The last line makes a great point. Here in America let’s learn from what other countries do, both the good and the bad. Let’s not have blinders on. This is much the same point made in the book by TR Reid, “Healing of America.”

  • As a Brit, I’m aware that the NHS has certain shortcomings, mainly as a result of meagre funding compared to comparable countries.
    However, in stark contrast to friends in the US I have never, and if the NHS continues will never, have any concerns about being provided with at least decent quality healthcare, absolutely free (being over 60 I do not have to contribute to prescription drugs).
    This is such a huge benefit when I hear of Americans who are (for example) trapped in abusive marriages because the abuser is the one who provides health cover for the children from his job.

  • We can thank the NHS for demonstrating 25 years ago that using claims data to monitor quality is ineffective. They, along with all of the other 33 developed nations, for many years have demonstrated the importance of Primary Healthcare. We continue to ignore both attributes of quality and cost demonstrated by all of the OECD nation’s. Most of the OECD nations allocated @12% of their economy to health spending. We are at 18%. Regardless of how we solve that problem, we must first implement a strategy of arranging Primary Healthcare that is equitably available to each citizen, as promoted community by community. For such a plan, it would define, on average, a community as representing @400,000 citizens. Some larger and some smaller, based on population density, representing nearly 800 nation wide. DECENTRALIZED governance should apply using local stakeholders to collaborate with currently available healthcare institutions for planning and implementing equitably available Primary Healthcare.

  • I just finished reading the article on caregiver treatment and burnout in the US, elsewhere in this Stat News. It is ironic that the opening paragraphs of this article sound exactly like the experiences of the people who made comments in that article – waiting all day in ER to be seen, catching flu from the other ER seekers in overcrowded hallways…how is the American experience that much different from UK these days?
    I also think it would be interesting to see how the Canadian system of care compares to the US and UK.

  • I can’t figure out the motive or point of this article. But as someone who’s lived under both systems I can tell you I’d pick the UK’s NHS any day over our dehumanizing, pay-to-live system, where 10s of millions are left to die or go mad or rot, and the rest of us can wait 2 or 3 months for a test (or test results!) or a visit with a specialist, longer for surgery. In both countries, especially since Trump’s administration began its assaults on Obamacare, you can wait hours in the ER (you didn’t when Obamacare was allowed to work, but you can now–and btw, when I needed help in the UK last year I waited only 30 minutes!), both healthcare systems have been overwhelmed by this year’s bad flu and ineffective vaccine, and elective surgeries are postponed (not cancelled, btw) in both countries by disasters and epidemics. But as the authors point out, one country pays twice as much for that–and covers 25% fewer people. I’m sorry to say it, but the physician who wrote this article and his private-philanthropy co-author from Britain sound as smug and incoherent as the AMA did in its opposition to universal healthcare, or the neoliberal privatizers who set about wrecking Britain in the 70s for all but a few and never looked back. Was the article edited into its foggy condition, or did it start that way? Might the authors try to clarify? Why is it couched as though it meant to say we had something to learn from Britain, when it takes pains to suggest the opposite? And why Britain?–Britain has almost as much to learn as we do from France! It’s not history and culture that make us unwilling to spend money on guaranteeing and equalizing health care. It is greed on the part of those who have. It’s a lack of political will. Which shames me deeply, as an American who’s received so much free or cheap and excellent, prompt, humane health care in Europe.

    • Well said!The NHS covers all for about half the cost of the US system. No advertising, marketing, huge shareholder profits or insane CEO salaries to pay for. This is great for everyone – the economy benefits because no one is unable to work for lack of medical treatment or at least not for long. No medical bankruptcies which I believe run at several hundred thousand a year in the US – think of all the harm that causes to individuals and their families and what a huge cost that is to society, directly or indirectly. Private healthcare is a disaster – that is what the US could learn but the trillion dollar healthcare lobby will not ‘allow’ then to ‘learn’ that lesson.

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