Healthcare delivery and utilization in the United Kingdom differs from the U.S. system in several ways, not least in terms of expense. In 2016, healthcare expenditures in the United Kingdom were estimated at 9.7 percent of GDP, compared with 17.2 percent in the US. One reason for the discrepancy is the influence of the UK’s single payer system, the National Health Service. Another reason is the UK’s system of home-based healthcare services provides a lower cost alternative to acute care and long-term facilities. In 2013-14, approximately 400,000 British seniors received community-based care and services at home. There is much the US can learn from the UK about how to care for our elderly and chronically-ill neighbors.
Assessment: what do the people need?
Under British law, the local authorities are obliged to assess the healthcare needs of any individual that comes to their attention. But an essential part of the assessment process is the input of the patient: the UK asks patients what they want as well as making an independent assessment of what they need. If the patient or family are unable or unwilling to contribute their point of view, British law mandates that an independent advocate be appointed to speak for the patient. Then the local authority comes to an agreement as to the services that may be provided. These services include everything from assistance with activities of daily living to administration of therapies and medications.
An important piece of every needs assessment is means testing. Above a certain threshold, all such services are paid for jointly by the state and the individual. Periodic re-assessments track the patient over time so that adjustments in level of care may be made as needed.
Provision: home-based services in the UK
A broad range of home-based services are provided by contracted homecare providers in the UK. Services, or sessions as they are sometimes called, range from 15-minute visits to 24-hour assistance, and everything in between. Urgent care services are also provided at home. General practitioners commonly make house calls in the UK.
Unpaid caregivers in the UK are also eligible for support. The Care Act 2014, for the first time in UK history, provides services and support for family and other unrelated individuals providing care to others in the home. The aim of the act is to prevent unnecessary, and expensive, escalation in needs.
Independent care agencies
Despite having a single-payer system, approximately 10 percent of Britons purchase their own healthcare insurance. A number of independent care agencies will provide home-based services payable by private insurance or fee-for-service.
An important feature of the British system is a well-defined process for filing complaints regarding provision of home-based services. Local authorities are mandated to hear and adjudicate complaints ranging from denial of services to dissatisfaction with individual caregivers.
As the demand for home-based services rises, so do the costs. In the UK, as elsewhere in the developed world, the elderly population is rising rapidly, placing additional pressure on an already financially strapped system. The UK is also facing a skilled nursing shortage as tougher immigration regulations squeeze the supply of willing foreign-born caregivers. An increase in the Britain’s minimum wage has also had a costly impact on service providers.
In the UK, homecare providers bid for local authority contracts to provide services to elderly or disabled persons. The contractors must then find the resources available to provide the contracted services. This has become increasingly difficult for homecare firms in the UK as demand grows faster than the supply of the homecare workforce.
What we can learn from the UK
There has been a lot of talk in the US about “patient-centered” care, but very little in the way of actually placing the patient at the center. In the UK, the law mandates the patient be at the center. The patient advocate mandate ensures the wishes of the patient are prioritized. It seems like an obvious approach. The patient is, after all, the individual in the best position to express her own needs. But it may require an Act of Congress to mandate such a move in the US.
The financial support given to unpaid caregivers is another compelling concept. The policy makes sense from a practical as well as a financial standpoint. Millions of Americans every year care for a family member or a friend, at least for a brief period. Providing respite and support to unpaid caregivers may turn out to be cost-effective and in the long run may prevent the need for care in expensive acute-care settings. Well-designed cost-benefit analyses can help determine if the UK’s solutions are right for America.
The UK system is far from perfect, and financial and human resource challenges remain. The US has the potential to avoid the pitfalls that face the UK by investing in big-data and technologies such as remote monitoring. Modern data-crunching and emerging technologies can help apportion scarce resources efficiently and safely, improve the quality of care, and help keep patients out of the hospital. A well-designed system will enable homecare providers to improve their own businesses as well.