Monday, January 30, 2012

What’s So Bad About Socialized Medicine?: The British National Health Service

The health care reform debate in America seems to reliably raise the specter of “socialized medicine,” complete with fears of long lines, “cookbook medicine,” rationing and--a more recent canard--the Death Panel. However, the United Kingdom has been somehow surviving under a system of universal, publicly-funded health care since 1948. Riding the post-World War II election of the Labour Party, social reformer Lord William Beveridge’s plan for a National Health Service (NHS) was passed in 1946. A son of generations of poor coal miners, parliamentarian Aneurin “Nye” Bevan then implemented the plan with his unique mix of political strong-arm tactics and artful compromise, achieving the cooperation of insurance companies, hospitals, general practitioners (GPs) and other stakeholders.

Now entering it’s seventh decade, the NHS is still widely popular with the British public. Its organization and governance has changed, but the experience for the patient has not - almost all medical care, from a common cold to a coronary bypass graft, is free. As originally designed, the NHS was divided into three main branches: (1) government-owned hospitals with salaried specialists; (2) GPs and dentists practicing in independent offices, but paid by the NHS; and (3) the public health authority. Reforms in the 1970s and 1980s under Thatcher’s Conservative government simplified layers of administration and improved integration and coordination of services. Further reforms in the 1990s created Regional Health Authorities (RHAs) which received disbursement of tax funding from the Department of Health. The RHAs then distributed funding to smaller District Health Authorities (DHAs), which contracted with hospitals and specialists, and Primary Care Trusts (PCTs), which contracted with GPs for services. More recent reforms have increased competition between hospitals for GP referrals, decreased waiting times, and resulted in improved physician and patient satisfaction.

The philosophy behind the NHS seems to be that, in a system into which everyone pays (with 15-17.5% sales taxes, and higher income and social security taxes than in the US) and by which all are served, it benefits everyone to stay healthy. The NHS incentivizes primary and secondary prevention. Primary prevention is encouraged by a system that pays GPs for implementing proven preventative strategies (e.g., “flu jabs [shots]”). Secondary prevention is promoted by a system that ensures universal access, very low cost (e.g., although a $10 fee is “required” for prescription drugs, this fee is waived for children, pregnant women, anyone over 60, and the chronically ill--that is, 85% of those who take prescription drugs), and evidence-based screening strategies vetted by the National Institute for Clinical Excellence (NICE).

In contrast to the US system, which spends one-sixth of its GDP (the greatest proportion of any industrialized nation) on care heavily weighted toward tertiary and hospital-based care, the NHS salaries specialists--the average specialist in the UK makes less than the average GP! Furthermore, 60% of physicians in the UK are GPs, whereas only 35% of physicians in the US are generalists. The NHS’s distribution of resources and specialties removes the incentives for high-cost tertiary care and shifts the emphasis toward cost-saving (and life-saving) preventive, public and primary health care.

But does it work? The NHS is certainly popular with the British public. As journalist T.R. Reid writes in The Healing of America, “There are private health insurance plans in the United Kingdom, but few people bother with them. Nine of out ten Britons get all their health care from the NHS.” The culture of “no medical bills” is also a point of national pride, as evidenced by the resounding defeat of a 1990s suggestion by the British Medical Association to institute a low copay for all patients. Not only is it popular, the NHS is also cost effective: it provides care for a population one-fifth the size of the United States, for one-fifteenth of the cost. Yet the UK has lower child mortality rates, longer healthy life spans and better recovery rates for most major illnesses.

Not that the UK or NHS are perfect, by any means. Before the reforms made by the Blair administration, a common complaint about the NHS were long waits to see consultants (i.e., specialists). There were several British popular press reports of patients dying while they waited for speciality treatment. However, this problem has been largely ameliorated by Blair’s infusion of funds into the NHS and the implementation of payment-for-results to hospitals and competition among hospitals for GP referrals. The UK, like the US, also continues to suffer healthcare disparities between its social classes--and also as in the US, these health disparities are greater than would be predicted simply from health factors alone. The NHS has not yet closed these gaps.

Despite these shortcomings, the NHS experience would seem to belie the notion that “socialized medicine” is an evil to be avoided. And how un-American can it be? The Veterans Administration system and the Indian Health Service in our own country are quite similar to the NHS: government-paid physicians working in government-owned hospitals for patients who pay little to nothing for the care they receive. It works there, it works here, it lowers costs, it improves outcomes, and it shifts the focus from tertiary to primary prevention.


Turnock BJ. Public Health: What It Is and How It Works. 4th ed. Sudbury, MA: Jones and Bartlett, 2009. [Chapter 3: Public Health and the Health System.]

Safra JE, et al. Encyclopaedia Britannica. 15th ed. “National Health Service,” vol 8, p 534. Encyclopedia Britannica Publishing, 2003.

Tulchinsky TH, Varavikova EA. The New Public Health. 2nd ed. Elsevier, 2009. [“Chapter 13: National Health Systems,” pp. 482-486.]

Reid TR. The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care. New York: Penguin Press, 2009. [“Chapter 7: The UK: Universal Coverage, No Bills,” pp. 103-124.]