Intended for healthcare professionals

Education And Debate US and UK health care: a special relationship?

Why is the grass greener?

BMJ 2005; 330 doi: (Published 24 March 2005) Cite this as: BMJ 2005;330:727
  1. Barbara Starfield (, university distinguished professor1
  1. 1 Johns Hopkins School of Public Health, 624 North Broadway, Baltimore, MD 21205, USA

As well as learning from each other's existing systems, US and UK researchers have potential for collaborative research into improving health care


Almost a century ago, the UK and US health systems diverged in a dramatic way. In the United Kingdom, parliament legislated on health insurance; subsequent seminal governmental reports and actions, such as the Dawson report on primary care after the first world war and the enactment of the NHS, set the stage for the current health services system. Despite several notable attempts at reform in the United States, particularly in the early 1930s, mid-1960s, and early 1990s, the US healthcare system remains much like it was a century ago, mired in a market oriented private system with private financing. The system makes only a nod towards public responsibility, mainly in the form of guaranteed financial access for elderly people (Medicare) and a fragmented and unstable system of financing and direct service for care of poor people (Medicaid and community health centres, respectively).

As a result, the United States lacks system-wide health policy making. By contrast, the NHS assumes responsibility for national health policy, the quality of care (for example, the National Institute for Clinical Excellence), and banning direct to consumer advertising of prescription medicines. The United Kingdom has a national director for primary care who, besides being responsible for policy in various aspects of primary care, is the country's official representative in international deliberations on primary care. The United States has no comparable position.

Despite these enormous differences between the two health systems, there remain possibilities for two-way learning. These fall into several groups: the importance of primary care as the infrastructure of a health system; information technologies for health services; quality of services; and equity in the attainment of health of populations.

Primary health care

World Health Organization documents on …

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