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Using Evidence to Restructure Healthcare: Lessons for US Lawmakers from the UK

In a recent Tweet, President Donald Trump seemed to misunderstand the motivation behind recent protests in the UK regarding funding for the National Health Service (NHS). Trump claimed that thousands of people in England were marching in protest of the NHS because the “system is going broke and not working.” In reality, most of the responses on Twitter from UK government officials and media reframed the protests as highly supportive of increasing funding for a system generally beloved by the public. We felt like this would be a perfect opportunity to feature a piece by Tasnim Elmamoun, undergraduate student in psychology and English education at IUPUI, that describes the fundamental differences between the NHS system and the US system of healthcare, as well as the role of data analysis in informing healthcare policy. Our hope is that President Trump and US lawmakers can learn from this reasoned approach to help the US move forward on much-needed healthcare reform.

England’s 2012 Health and Social Care Act (HSCA) included one of the leading health care reforms in the history of the National Health Service (NHS). It gave control of the NHS budget for secondary care to general practitioner (GP) led Clinical Commissioning Groups (CCG) with the hopes that it will lead to an increase in outpatient referrals. The net result, it is hoped, is that patient care would shift from expensive hospitals to less expensive community-based care centers. A 2017 study published in PLOS Medicine examined the effects of the HSCA by reviewing whether there was a change in hospital activity, including outpatient and inpatient visits. This research found that, while there was no decrease in inpatient visits as a result of GP led CCGs, there was an increase in outpatient referrals.

What can we learn from the HSCA, and in particular, what aspects of the UK’s NHS system can help inform US policy? For one, the HSCA illustrates the incentive that practitioners have in lowering expensive costs of healthcare.  It also shows how data analysis can help us prioritize ways to better serve the public efficiently and quickly, making healthcare a right rather than a privilege. Lastly, the UK system has taken great strides in reorganizing their health care system through the 2012 HSCA; contrast these strides with the comparative disorganization of the healthcare system in the US.

Many Americans find the UK healthcare system difficult to comprehend. Yet, it has some similarities to the Social Security and Medicare programs in the US. The main difference between the healthcare systems in the UK and US is that the British National Healthcare System treats affordable healthcare as a right, not as a privilege. Healthcare is not free of cost in the UK; access is free, yet it is paid through taxation. In the US, the healthcare system is largely structured as a privilege, rather than as a right. Although some segments of the population are provided private services through Medicare or Medicaid, many people pay through expensive healthcare plans or out of pocket altogether. Because healthcare is expensive in the US, it is common for employers and insured individuals to share the cost for healthcare. Therefore, the high cost of healthcare in the US can limit access to healthcare, especially preventative healthcare, to individuals who can afford insurance; those who cannot afford it are left behind.

Access to healthcare is also an issue in the UK, although it is of a decidedly different flavor. Currently, the UK is experiencing a shortage of general practitioners (GPs), making access to healthcare service the issue, not access to insurance to pay for it. According to Lopez Barnal and colleagues (2017), this has led UK patients to wait for a prolonged period of time in order to see both GPs and specialists, increasing wait time from one week to three weeks.

The problem with access to healthcare and the differences between the UK and US can be illustrated by looking at the differences in how chronic diseases (chronic respiratory diseases, cardiovascular diseases, cancers, asthma, and diabetes) are treated. In the US, patients with chronic diseases are treated in medical facilities like hospitals and outpatient clinics, which have high costs associated with care. In the UK, patients with chronic diseases are able to receive treatment through social care programs, which enable treatment outside of expensive hospital settings, and reduce expenses to the NHS that would arise from long hospital stays. Patients with social care are provided self-care benefits including home renovations and mobility aids, with which they can support and manage their own lives. These social care investments can make a huge difference in the quality of patients’ lives, taking them from long-term hospital admissions to relative independent living.

The 2012 HSCA has worked to shift financial responsibility for chronic care from hospitals to clinical commissioner groups (CCGs) who  are charged with securing services on behalf of their patients. However, as Lopez Bernal et al.’s study indicates, decreasing and shifting control and resources from the hospital sector to the front-line care has not lead t0 a reduction in hospitalizations. Instead, it has led to an increased number of specialist outpatient referrals. What does this mean for the NHS? Moreover, what does this tell US citizens about their own healthcare?  In an editorial to PLOS Medicine, Sheikh (2017) contends that the more important outcome is not about hospitalization decrease, it is about the approach to data analysis, itself.  The author explains:

More promising is that in many contexts it is now possible to exploit routinely collected data, thereby greatly reducing the time and costs of evaluating major policy initiatives on the restructuring of health and social care.

Should the US take steps toward a more public healthcare system? Or does the private system work in the US? The answer to these questions likely lie in data about how healthcare is delivered in the US.

The GOP’s efforts to repeal Obamacare in 2017 were not fruitful, meaning that Obamacare is still alive in 2018. The Trump administration focused on cutting off financial assistance to lower-income individuals who are helped by Obamacare, and reduced efforts to get people to enroll in Obamacare while also shortening the time period to do so. Additionally, they passed a tax bill that eliminated the requirement for the individual mandate, which required people to purchase health insurance or risk paying a penalty. What does this mean for our nation? Should we start to look elsewhere for guidance? It remains to be seen how Obamacare will fair in the next year, and whether individuals across the nation will stand behind this 2010 health care law. Hopefully, Congress will act as British lawmakers have acted, and will enact evidence-based healthcare policy decisions. Sheikh (2017) explains why and how this approach is important in healthcare reform:

As the United Kingdom’s data assets continue to mature, in addition to major recent government investments to make routine data more liquid—by improving access to and the ability to link data—and developing data science capacity, it will become possible to answer an increasing array of health policy questions within rapid timeframes at minimal costs. There is thus now, at least in the United Kingdom, the opportunity for a step-change in our ability to move towards evidence-based policymaking. What remains is the political maturity to see the value in such evaluations and, where necessary, iterate the policy approach in the light of their findings.

Edited by Jason Organ, PhD, Indiana University School of Medicine and Krista Hoffmann-Longtin, PhD, Indiana University Purdue University Indianapolis.

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About the Author
  • Tasnim Elmamoun

    Tasnim Elmamoun, an undergraduate student at IUPUI, is double majoring in Secondary English Education and Psychology, while also minoring in Arabic and a certificate in Pre-Art Therapy. She hopes to write, teach, and participate in community work in her future. Tasnim is working on SciCommPLOS through the IUPUI Life-Health Sciences Internship program, which connects undergraduates to high-quality, structured internship experiences that encourage career exploration, skills development, and professional growth.

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