The UK and US Public Healthcare Systems - Essay Example

Compare the management of a public service in the UK to that of one other country of your choice. What does the comparison tell you about the factorsthat shape public management in each country? January 04, 2013 Table of Contents Compare the management of a public service in the UK to that of one other country of your choice. What does the comparison tell you about the factors that shape public management in each country? 1 January 04, 2013 1 1. Introduction 3 2. UK and USA Comparator context 4 3. Comparative Analysis of NHS of UK and Medicaid 9 4. Factors that shape public management in UK and USA 12 4. Conclusions 13 References 14 1. Introduction The public service selected for this paper is the public healthcare system. The two healthcare systems and nations that will be compared are NHS of UK and Medicaid of USA. The US government has two systems, Medicaid, that provides healthcare to low income groups and their dependents and Medicare that provides healthcare for people over 65 years. This paper will discuss Medicaid. Healthcare system refers to the government-supported system that offers partly paid health care and financial protection to members of the national schemes. These systems are designed to provide specified benefits, financial risk cover, and improved access to health services with the goal of improving the health outcomes (Baum, 2009). The healthcare programs are not meant to provide coverage for all people of the country and neither are they meant to provide treatment for all ailments. The healthcare policies are decided by three important dimensions. These refer to the people who are covered, the services that are covered along with the extent of costs that are covered. The topic of healthcare is selected since it affects all citizens of a nation. While rich people can afford to take private medical treatment and healthcare, the poor and middle class people, retirees and those with disabilities depend on the social healthcare systems to survive and lead a meaningful life. These are the reasons for selecting the topic. UK and USA are two nations that have a very effective and much debated healthcare system that are advanced and equitable in the application (Rogers, 1997). Hence, these two nations are selected. Next chapters will examine various issues related to this subject. 1.1. Role of International organisations and their impact As a matter of policy, NHS collaborates and works with international organisations such as WHO, UNO, UNICEF and other health and social care agencies. NHS has a sustainable development unit called NHS SDU and this department takes up projects with WHO to develop support packages for WHO European Member States. NHS provides projects help on two components. These are the technical guidance for sustainable health systems and the international route map. As such, NHS does not obtain any funds from international organisations and its activities are guided by the NHS board (NHS SDU, 2012). 2. UK and USA Comparator context This chapter provides a brief comparison of UK and USA with reference to politics, culture, economy and other important factors. These are discussed in the next sections. 2.1. Hofstede’s Cultural Dimension Comparison Hofstedes cultural dimensions provide an indication of the national culture of a nation. It indicates the manner in which citizens of a country would respond to certain situations, the manner in which they react to positions of authority and power and the manner in which they react as a group. Hofestede has provided five dimensions Power Distance Index - PDI, Individualism - IDV, Masculinity / Femininity Index - MAS, Uncertainty avoidance Index - UAI and Long-term orientation Index – LTO (Geert, 2012). These will be compared for UK and USA. The reason for discussing this topic is that national culture is regarded as a major determinant of work attitudes. In relation to organisational culture, administrative culture is also an important aspect of international public management. Culture is ‘the interactive aggregate of common characteristics that influence a human group’s response to its environment. National culture also affects upon organisational culture and in this case, the organisation refers to NHS or Medicaid. National culture, together with administrative culture, shapes the conduct of public management Administrative culture is derived from politics and authority relationships. Most governments practice bureaucratic management that is hierarchical due to political control and accountability (Yeh and Lawrence, 1995). The comparison of UK and USA is given in the following figure. Figure 2.1. Comparison of UK and USA for Hofstede’s cultural dimensions (Geert, 2012) The indexes and values are compared and explained as below. It is seen that the values for all the indices are very near to each other. Power Distance Index – PDI: The dimension specifies the extent to which members in a society with lesser power accept that they power distribution is unequally distributed. A lower score indicates that the society believes and accepts that inequalities are present and that these should be minimised. UK with a score of 35 shows that people feeling that societal differences should be reduced and the gap between rich who have better access to healthcare must be treated at par with that of poor people. USA with a higher score of 40 indicates that the society accepts differences and social inequalities are a part of life. This means that there is more discrimination in USA than in UK for healthcare and other social welfare schemes (Albers-Miller and Gelb, 1996). Individualism – IDV: The dimension specifies the extent to which interdependence among members of a society and it shows if a society is defined by individual feelings such as I, me or group feelings such as us and we. Higher score indicates higher individual feelings. UK with a score of 89 is slightly below the score of USA that stands at 92. This means that in UK, people give more importance to self for issues related to healthcare and other policies and they are not very much concerned about other people. This explanation also holds true for USA. Both nations have high levels of consumerism and self-indulgence, self-comfort along with concern for ones own healthcare. Consequently, healthcare policies are aligned for individuals and not group, hence the cost burden is high (Kirkman, et al, 2006). Masculinity/ Feminist Index – MAS: The interpretation of this score is that a masculine society, defined by a high score means that people are motivated by people who are high achievers and want to be the best. It defines the proverbial rat race where people, men and women want to be the best. The feminine society, as defined by a low score indicates that people like ‘what they want to do or doing what they like’. It is seen that UK with a score of 66 means that people give importance to success and are driven by goals and objectives, whether they like it or not. US with a score of 62 is slightly less masculine than UK and people do what they like best. The relation with healthcare systems in both nations is that people want the best care that medical technology can provide and this often becomes an important factor. The costs and delays for availing healthcare are also increased (McSweeney, 2002). Uncertainty Avoidance – UAI: The dimension indicates the extent of readiness to accept or avoid uncertainty in life. A low score means that people are ready to accept uncertainty, change, try out new concepts and face new challenges even though they do not know the outcomes. A high score indicates that people are very rigid in their outlook and they would not be willing to accept changes and uncertain events. UK with a score of 35 indicates that people are willing to accept change and challenges, more than USA that has a score of 46. This means that UK citizens are willing to accept policy changes in healthcare and willing to try new treatment and medicines. USA citizens would be slightly averse to accepting changes, unless the changes are supported by evidence (Sondergaard, 1994). Long term Orientation Index – LTO: The dimension indicates the extent to which a society is future oriented and adopts a short term or a long-term view. A low score means that people are interested in short term and quick results. UK with a score of 25 means that people want quick results from healthcare policy changes. They are interested in quarterly results. If any changes are proposed in healthcare and other policies, people would want immediate results and they would not be willing to wait for a longer rime. USA with a score of 29 means that the citizens would have a slightly longer perspective in waiting for benefits (Fang, 2003). 2.2. Political structure comparison UK and USA are both democracies. However, there are important differences between the two. UK follows a parliamentary system and the Prime Minister is elected among members of the winning party or the party that has won the largest number of seats. UK has two houses, the House of Commons that is filled by elected representative and the House of Lords, made up of special appointments. Bills and policies are introduced by the government and any acceptance of the policies must be approved by both the houses. In UK, the judiciary is independent of the government and appointments to various benches are done by the judiciary representatives and board. Consequently, any judgement and ruling is free from political interference and pressure. Candidate for the PMs post is selected from the elected party members and the selection is an informal and internal process without much public animosity (Bennett, 2001). USA follows the presidential method of election and the President and his governors appoint other members of the cabinet. Both houses, the Senate and the House of Representative are directly elected. In USA, all bills and policies are introduced by a member of the congress. The healthcare bill of Obama was introduced by the house of representative of the Democratic party led by Obama. In USA, the Supreme Court judges are appointed by political parties. I some cases, certain judgements have been regarded as political and partisan. Candidate for the president is selected after almost 2 years of primaries, intense debates and fights between the candidates. The candidate must win in all the states where the party members vote for a candidate of their choice. Healthcare is a hotly and fiercely debated issue in both nations with candidates taking a position on various issues and promising solutions when they are elected (Grilli, et all, 1991). 2.2.1. How the structure impacts NHS The political structure of UK is such that there is no single owner for the agency but many ‘advisors’ and ‘critics’. As a result, when new bills, policies and services are to be provided, it is put to vote, debated and the end result is that the bills undergoes a number of changes and amendments and it may sometimes be delayed. However, partisan politics is usually not seen when the good of the public is in question. The elected representatives do not hold up the bill or place hurdles to score a political point. While decisions are delayed, they are well thought of and argued from all possible perspectives (Maybin, et al, 2011). 2.2.2. Learning and policy transfer from other nations The board and members of NHS welcome the opportunity to obtain learning’s from other nations regarding improvement for patient care and delivery. A separate team and cell called NES Patient Safety Multidisciplinary Steering Group has been set up that has the aim to search for any strategic documents within UK and the western world that will help to improve patient safety, education and training of the workforce and improvement of quality. The rationale is to learn from others, identify any benchmarks, establish the best approaches to work and identify if any risks exist in these practices. From these learning’s, a number of documents are prepared for different categories. These categories include international, Europe, other western countries, UK, NHS Scotland, Education reviews, quality improvement reviews and others (Howe, 2009). 2.2.3. New Public Management at NHS New Public Management – NPM is a new approach brought by the Blair government that focussed on reforms in the public sector firms. NPM presents a broad set of principles that identify an approach for a public service. The intention is to achieve a broad set of objectives such as performance management, equality, managing diversity, equal opportunities and so on. These have been brought into practice in various areas of public sector firms such as the London Metro, bus services, administration and other such departmental activities. NPM was forced into some areas and in some, the services and department activities were outsourced to contractors (Cutler, 2007). In NHS, the practice of NPM has not been very effective though efforts have been made. The problem is that NHS doctors and the management are fully bound down to budgets and patient care, getting funding and getting payment. In such a scenario, equality, avoiding stereotyping of minorities and other such activities has not been controlled with NPM (Carter, 2000). 2.3. Comparison of economy The UK economy is the seventh biggest in the world with a GDP of 2.48 trillion USD in 2011. The level of globalisation is high and the nation has strong industrial sectors such as construction, service, education, automobiles, power, hospitality, agriculture and other industries. The recession of 2007 had a sever effect on the nation and unemployment rose to more than 11.3% in 2007-2009. The economy is slowly recovering and in 2012, the GDP increased by 1% and unemployment fell to 7.8%. The percent of people living below the poverty line was 14% and these people depend extensively on public healthcare system to survive (Kirby, 2012). USA is regarded as the world’s largest economy with a GDP of 15.811 trillion USD in 2012. The level of industrialisation is very high and many of the worlds leading firms such as Ford, Chevrolet, Microsoft, AT&T and others are American firms. The recession of 2007 had its origins in USA and a large number of banks, financial institutions went bankrupt. Millions of Americans also lost their jobs, adding to the burden of the healthcare and other social systems. As of 2011, the percent of population that lives below the poverty line is 15.1% and unemployment is 16.1%. The prolonged recession and loss of wealth has placed many formerly prosperous citizens also on social healthcare (Jackson, 2012). 3. Comparative Analysis of NHS of UK and Medicaid The previous section has examined the Hofestede’s cultural dimensions of UK and USA and compared the political structure and economy. This section provides an analysis discussion of the two healthcare systems. 3.1. Critical Analysis of NHS, UK The National Health Service - NHS is the largest single payer, publicly funded healthcare system in UK with 1.4 million employees. It is funded mainly through the general taxes gathered from citizens of UK and various organisations that operate in the country. The core principle is to provide healthcare for all people who are legal residents of UK. The system provides all services free at the point of use for the members. The term legally resident means having UK citizenship, an NHS number, be legal immigrant. Such members can obtain access to the full range of non-critical and critical medical care and they will not have to bear any out of the pocket expenses (Boyle, 2011). Thus, people do not have to pay for visits to their doctors or nurses, avail of surgical procedures, receive appliances, they do not have to pay for costs of medications, plaster, medical investigations, MRI and so on. The person under treatment is not billed and the doctor or hospital that carries out the treatment raises the bills to the NHS and it is reimbursed. However, some charges must still be paid by the patient (Walshe, 2010). This includes prescription charges of 7.4 GBP, dentistry, optical services, injury cost recovery and car park charges. Overall, the NHS is regarded positively since a vast majority of people have access to high quality of healthcare. The system also provides a valuable learning place for trainee doctors who have exposure to a huge variety of patients (Enthoven, 2009). The NHS system appears to have a high level of public support and an independent survey suggested that 92% of NHS users showed high levels of satisfaction with the system. However, the press is critical of the system and a number of scandals, poor quality of treatment and wrong treatment are reported (Newdick, 2005). As per the NHS system, a patient must first visit a GP and can approach a specialist only when the GP recommends a specialist for treatment. This has given the GP, the role of a gatekeeper and it has provided an avenue for an internal market. It appears that GPs send patients to specialists of their choice and then demand a share from the payout. NHS has also not specified the limits of coverage and this has allowed some expensive treatments to be made available at certain centres while it is not available at others. While making profit is not the intention of NHS, it is expected that the services should not show deficit. However, improper budgeting and excessive billing by the healthcare centres means that NHS overspends. It is estimated that in 2010, NHS had a deficit of 7 billion GBP. NHS and its services are subject to intense political struggle and intrigue. Members of political parties put pressure on the body to increase spending and the services provided (Klein, 2010). 3.2. Critical Analysis of Medicaid, USA Medicaid is a social healthcare system for US citizens that are somewhat similar to NHS but differences exist. Source of funding is the state and federal government agencies and the program is managed by each state. The program benefits about 13 million people. To qualify for medical treatment, patients must be US citizens, children, pregnant women and people suffering from disabilities (Green Book, 2004). This has created a burden on individual states that often pay up to 16.8 to 22% of the state funds. Unfortunately, the excessive spending has brought a huge debt of more than 14.3 trillion USD on the system. Under the scheme, a person who wants to avail of Medicaid must register with all documents and then indicate that he has not gifted more than 2000 USD. While the services are free, patients have to pay a small fee in certain cases. The federal law limits the coverage to medically essential services (Krol and Wolf, 2009). Recent policy changes have increased the amount of co-payment that patients need to pay for medical services. This will increase the expected payment from patients to about 1.3 billion spread over five years. As a result, low-income people who need the treatment will be forced to drop out. A survey that was conducted indicated about 30% increase in satisfaction and visitations over a five-year study (Benjamin and Epstein, 2010). Overall, less than half the number of dentists have registered with Medicaid to provide treatment. One of the reasons is the high amount of money they make from treating private patients. HIV patients are the largest single group of more than 50% who take up Medicaid treatment. The subject of assets has created controversies. To qualify for treatment, the patient should not have assets of more than 2000 USD. However, a house owned by the patient is exempt being counted in the assets. This has given rise a group of lawyers who provide consultancy on medical planning. This means converting all assts to an exempt category of asset (Baicker and Finkelstein, 2011). 3.3. Comparison of NHS and Medicaid The above sections have analysed NHS and Medicaid. Both programs are social welfare programs meant to provide critical and non-critical healthcare. However, NHS of UK is universal in its application since it does require the patient to be poor. The patient must be citizen of UK. A small amount must be paid by the patient to cover some minor charges. The policy is framed by the government and the details are debated in both houses. Medicaid of USA on the other hand is available only low-income people. The policy is framed by the federal and state governments that provide the required funding. Some inherent rules on assets owned, minimum income can serve to bar people who otherwise qualify for the program. 4. Factors that shape public management in UK and USA The previous sections provided a comparison of US and UK and critically analysed features NHS and Medicaid. In this section, factors that shape decision making in policies are discussed. From the analysis given in ‘section 2.1’, it can be seen that values for Hosfetedes dimensions are almost the same for all the factors. This indicates some similarity among the two nations. However, it is apparent that UK with its parliamentary system sees much mode debate and consensus among opposition parties. The UK political and policy decision making body is highly structured and regulated. While policies are framed by the government, the benefits and other impacts of policy are often debated. The opposition would try to find gaps and indicate that their suggestions are better. However, before a bill or policy is passed, public consultation is taken and any changes suggested must be evaluated. While politics plays an important role in the decision-making, the policies must have the desired benefits. As seen in ‘section 2.1’, the US system of policy making in the case of Medicaid is done by the federal government and the respective state governments. The bills are then introduced by senators who then attempt to get it passed. In some cases, senators may lobby for some firms and try to get the bills passed. In case of healthcare policies and bills, the topic is debated by presidential candidates who are questioned by expert panels. Candidates must implement what they promise, if they are elected or else face wide censure. The policies are generally well planned and detailed and provide the desired benefits. 4. Conclusions The paper has examined the social healthcare systems of UK and USA. UK has implemented the NHS system that provides critical and non-critical medical care to UK citizens. The Medicaid healthcare program of USA was also examined. This program provides medical care to people of low income who need treatment. It was seen that both policies are implemented with the intention to help those in need of medical attention but who cannot afford the care. While NHS system needs some level of payments from the patients, Medicaid expects some more co-payments. It appears that both the systems are subject to some level of political pressure. Since the issue is very important to voters, politicians try to obtain the maximum benefits for their people. Since USA is much larger than UK, it is more efficient to have a separate system for people of low-income groups. UK provides an umbrella cover all groups of citizens. However, it would appear that the policy of appeasing voters with allowing excessive spending on patients has placed a burden on the systems. It is recommended that ways need to be found to either increase eligibility requirements to qualify for aid or make the patients to pay a higher percentage of the costs. 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