A few years ago, the late Uwe Reinhardt, PhD, the witty, brilliant Princeton University economist, was asked to reflect on Bernie Sanders’ comment that the US should adopt a health system modeled closely after the system in Denmark. Defending the Danish system from criticism by those who referred to it as “socialized medicine,” Uwe is purported to have responded “I will happily take the Danish health system, but you must also give me the Danish political system … and it would surely help if you gave me the Danish people.”
The insight, that one cannot separate the structure and function of a health care system from the political system that governs it—or from the people whose hopes and aspirations that system is designed to meet—is crucial. And each nation’s political system is different—and, in many ways, so are its people.
This is the notion behind a recent project launched at the Harvard Global Health Institute. For this effort, called “Choices in Health,” my colleagues and I have been visiting 7 non-US countries to speak to patients, physicians, nurses, and others on the front lines about how the health care system works for them. We are exploring issues such as costs, wait times, and perceived quality. It is not an analysis of what experts think, but rather an examination of the aspirations of the people served by that nation’s health service and the professionals who provide the care.
The first stop on this journey was England, where I spoke with a patient who recently had elective surgery for a painful, chronic condition. After years of not feeling her physicians took her condition seriously, followed by a couple of additional years of conservative therapies, she was finally cleared for surgery. Then there was a wait of many months for the surgery itself. She was, unsurprisingly, very upset about the delays.
A major complaint of the UK’s National Health Service (NHS) is that it has excessively long wait times, especially for elective surgeries. But wait times are not the main point of this story. What is remarkable is what happened next. When I asked the patient what she thought about the NHS, she became very emotional. She grabbed my arm and said, “How do I feel about the NHS? I love the NHS.”
Stunned, I asked why. Because, she explained, the NHS was the sole entity that never gave up on her. Yes, there had been delays, but the NHS had stood by her during the whole ordeal when friends, coworkers, and family had not, caring for her and never asking her whether she was deserving. She was beyond grateful.
This love for the NHS will sound unlikely to most people in the US. But I learned that this patient’s love for the NHS is far from unusual, and most patients I have spoken with generally profess a similar kind of affection.
This affection is supported by data. In a 2014 survey of the British people, more people cited the NHS as what makes them proud to be British than anything else, well above their pride in the British royal family and even edging out the British armed forces. This love was on display in the opening ceremony of the 2012 London Olympics, which paid explicit homage to the NHS. And recently, the NHS’s 70th anniversary was celebrated at Westminster Abbey, officiated by the church’s leader, with hymns and prayers interwoven with the stories of the NHS. It is neither critical nor unreasonable to say that the NHS is almost a religion in the UK.
Why Do People Love the NHS?
Most respondents to surveys of the British people’s attitudes toward the NHS cite as key factors the system’s quality of care and the fact that no money changes hands at the point of use. But that does not quite capture it. Although the US Medicare program is popular among its beneficiaries because of its quality and affordability, the idea of Medicare patients expressing their deep love and devotion to the Centers for Medicare & Medicaid Services seems highly unlikely. The NHS means something more than a service provided by the government; its status as a major source of national pride is grounded in its history.
Founded in 1948, the service was born out of the ashes of World War II. The UK, like many European countries, suffered immensely during the war and that suffering was national and collective. In that sense, the NHS was a gift for surviving the horrors of the war. Of course, the history of the NHS is more complicated, as it was also imbued with key themes introduced during the Great Depression.
The NHS was built around 3 main values: free care at the point of delivery, comprehensive services accessible for all, and reliance on taxation as the source of funding. Today, more than 90% of the public still support these foundational principles. Even if dissatisfied with specific aspects of their day-to-day care, patients express a love for and commitment to the NHS as a whole. The NHS England Chief Executive Simon Stevens has referred to the institution as a “unifying ideal,” and a “health service that belongs to us all.”
What Does This Mean for Policy?
The history of the NHS and the love it elicits from the British people actually has implications for health policy for the US. The first is that timing is important. The NHS’s introduction right after World War II, an experience of collective suffering, along with a very strong sense of solidarity, engendered a willingness to act. The financial crisis in the late 2000s created such a window for the Affordable Care Act (ACA). Crises are not the only enabler of major reform, but for those who wish to see national health reform in the US after the 2020 election, it would be helpful to think through the context that will be needed to galvanize political will, and that can be hard. If the NHS did not already exist, it is unclear whether it could be introduced in the UK today.
Another critical element for policy makers is understanding core values and adhering to them. For the NHS, these core values are that NHS services are accessible to everyone, free at the point of care, and comprehensive. Timeliness and choice are important, but these elements do not rise to the same level of importance. This enables certain policy choices. Introducing cost sharing (co-pays, deductibles) would be a way to generate funding in such a system, but that would be anathema to the British people. When policy makers find themselves with limited resources, they are guided by the core values of the NHS and are willing to extend waiting times but not to take away key services or ask people to pay out of pocket for them.
In the same way, US policy makers need to understand what US consumers value most—which I suspect is choice and ensuring some degree of personal accountability. This is what the ACA tried to do, but it suffered politically when a small number of people could not, in fact, keep the insurance they wanted. Building on core values, US policy makers can far more easily introduce cost sharing (as they have in the Netherlands and Switzerland), but must largely stick with systems that offer the values that the US public cares most about.
A key lesson from looking at the health care systems of other countries is that a nation rarely adopts the entire financing model or delivery model from another country. Every system is homegrown and has a different set of values. The US can learn from others, and stories from abroad remind us that we can learn lessons from lots of other health care systems, but ultimately, we must build our own.
When considering what features to adopt from other countries, US policy makers must be guided by the values that matter the most to the US public. If we craft our policies to shape a health care system with those values at its heart, it can be something that we are proud of and that serves us well.
Open Access: This is an open access article distributed under the terms of the CC-BY License.
Corresponding Author: Ashish K. Jha, MD, MPH, Harvard T. H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115 (firstname.lastname@example.org)
Conflict of Interest Disclosures: None reported.
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Jha AK. Love of the UK’s National Health Service—and Its Lessons for Health Policy. JAMA Health Forum. 2020;1(3):e200320. doi:10.1001/jamahealthforum.2020.0320