Introduction

The English NHS is of significance among health policy observers around the globe for various reasons. The NHS is particularly noteworthy for the fact that, for many, it represents the high-income world's best attempt to have built and maintained a ‘national’ health system with a focus on universal access to care that is free at point of service. Compared with, say, the United States, with its multiple competing health insurers and funding mechanisms paying multiple competing providers, the NHS is a very straightforward system: national government funds, generated through taxes, are paid over to a predominantly public system of providers (albeit with various caveats such as GPs who are mostly private business owners, but funded largely by the NHS) (Wendt et al, 2009). Despite the ‘Obamacare’ reforms in the US, implementation of which commenced around the turn of the decade, thousands of North Americans continue to die every year through inability to pay for the costs of required healthcare. Many thousands more go bankrupt. Indeed, studies have shown that inability to pay healthcare costs as the number one reason for bankruptcy in the US (Himmelstein et al, 2005; 2009). By comparison, the NHS has historically represented values of civility and compassion for the fact that it is designed on, and underpinned by, principles that no-one should miss out from needed care simply because they do not have the personal funds or insurance required to pay a provider's invoice. This said, these values have come into question in recent times, notably via the Frances inquiry into lapses in patient care at the Mid-Staffordshire NHS trust (Francis, 2013; Spence, 2013) (Chapter 16).

The NHS and US health systems are, in many ways, polar opposites. The NHS is often categorised as a ‘national’ health system (Blank and Burau, 2010) in which healthcare is viewed as a state responsibility. The NHS is effectively a large government department which traditionally has delivered services in a one-size-fits-all model in that government has provided the directions for everything from policy around structure and goals of hospitals through to pay scales and payroll services for its very large workforce. There has also, historically, been a focus on delivering the same standard services in the same way across the entire country. For its part, the US is the most prominent example in the high-income world of a ‘market’ system with few rules or certainties (Blank and Burau, 2010).