Health Care and Culture: A Look at the British and American Systems 

Mobility magazine, November 2009 

Despite appearances and an intricately intertwined history, residents of the United States and the United Kingdom have different views of health care, many of which stem from subtle cultural differences and views toward the world. Marsh examines the two countries’ health care systems, and offers a no-hold-barred analysis of their differences.

By Donna Marsh 

As an American/British dual national, it is always interesting to consider the innumerable cultural differences between the two countries.

Of course, these differences extend far beyond your definition of football, when you think World War II began, or in which hand you hold a fork. The current debate concerning proposed American health care reform has provided a platform that clearly illustrates how different the two countries can be. 

Individualism Versus Collectivism

Americans are taught from an early age to take care of themselves, i.e., to pull themselves up by their bootstraps if necessary. Many Americans view health insurance—supplied by many but not all employers to their employees and their families—as something they individually earn, along with their wages or salaries. Some also are of the opinion that those who do not have health insurance should be motivated to find “better” work that does include this benefit. Indeed, there are a portion of Americans who view health care as a privilege and not a human right. Some Americans’ general mistrust of government-controlled social programs further fuel this attitude.

However, America’s scepticism is not as clear cut as it initially might seem. The American government has been sponsoring two important health programs since the 1960s. America’s Medicaid system provides health benefits to certain low-income groups. The Medicare system provides comprehensive health benefits to those older than 65. 

Both programs generate strong feelings in the American public. Some may feel resentment toward the Medicaid system for any number of reasons, mostly relating to a belief that these individuals have not “earned the right” to access a system paid by taxpayers’ dollars and thus “don’t deserve it.” This reluctance to help the less fortunate, especially if there also is a perception of “not pulling their weight” is a telling example of the Protestant work ethic and its belief in reward for hard work.

However, Medicare most often is seen as an entitlement to be accessed at the age most Americans retire from work, and often—not insignificantly—lose their work-related health care benefits, as well. It would take some effort to find many Americans who would argue against the availability of the Medicare system for their elderly relatives or for themselves at some point in the future. The shift from individualism to a more collectivist approach is being made, at least in this instance.

In the United Kingdom, the National Health Service is free at the point of need to all British residents, including foreign nationals with a legal right to remain in the U.K. (including expatriate Americans). The NHS is funded through the National Insurance system, paid by both employees and employers. It undoubtedly is considered a human right by the British public, expected to be provided for all by the government.

This approach also fits into the U.K.’s value system of fair play and characteristic support for the underdog. Although it is not difficult to find many British people criticizing their government, there is not an equivalent level of mistrust as found among many Americans.

Attitudes Toward Resources

It is not unusual for many Americans to look at many resources as being available in abundance, including health care. The British, with the days of post-WWII rationing still in living memory among its older population, are more pragmatic, recognizing that resources are limited and must be managed to maximize provision to all who need them. 

Of course, health care expectations can be quite different. Americans are still very likely to expect “whatever it takes,”—heroic levels of medical intervention; many patients and their families will not be shy in making their demands quite forcefully—putting the squeaky wheel adage to use. On the other hand, these heroics are not always in tune with the patient’s wishes, especially at end-stage terminal illness. In addition, seemingly endless diagnostic procedures are no doubt contributing to U.S. health care costs, likely in part because of a motivation to avoid potential malpractice lawsuits. And, of course, access to health care in the United States depends very much on what the patient’s insurance will cover—hardly an equitable system for a country taught to believe that “all men are created equal.”

The scaremongering found in some of the less responsible American media has little resemblance to the realities of the NHS. Access to comprehensive health care truly is available to all—this includes full services to the terminally ill and the elderly, contrary to some very ugly rumors. There is, however, an overhead of bureaucracy that is more transparent in the British system at the point of access. This includes how appointments are secured, as well as the realities of waiting lists for non-urgent yet medically necessary procedures where demand outstrips supply. Americans are more likely to face their bureaucratic nightmares post-treatment and over the legitimacy of insurance claims.

Unlike their American counterparts, most British people are unlikely to make specific demands of their system—squeaky wheels are replaced by a “mustn’t make a fuss” attitude.  Instead, the British are much more likely to fall into place within the system—forming an orderly queue to access their health care resources. 

Attitudes Toward Time

The British often are described as patient—their reputation as a queuing nation exists for good reason. Americans are not known for having the same level of patience as their British counterparts. How this is manifested is another illustration of the differences in access to health care. Competitive Americans are happy to use the best health care insurance possible to avoid waiting, especially if they are given a choice of health care providers who honor their medical insurance. Most British people accept that their system might include a wait to access specialized health care, although this is not always the case. The British do have an alternative that also allows them to effectively jump the queue—through private health insurance. However, some Americans may not realize that using private insurance in the UK often is done precisely to jump the queue as opposed to gaining access to superior medical treatment, as in most instances, the same doctors are visited for the same procedures. In fact, only 8 percent of all Britons have private health coverage.

Further Cultural Differences Relating to Health Care

Americans who access the British health system for the first time often are shocked by a number of factors. In particular, Americans’ notorious hygiene standards are challenged in many British facilities, even when taking the relative age of most hospital buildings into account. The relative lack of privacy also can be uncomfortable for many Americans.

Britons who access health care in America for the first time often are shocked at being asked directly how they intend to pay for their medical treatment. Not only is this a totally irrelevant question in the UK, it also encroaches on the cultural insensitivities of discussing personal finances, which remains a private matter for most British people. The British also may believe they are being subjected to a battery of questionable diagnostic procedures that appear to have little relevance to their immediate medical needs.

The experience in the emergency room (U.S.) or A&E (U.K.) can be shocking for both cultures, at least when looking beyond true medical emergencies, such as road accidents. The number of indigent people found in American emergency rooms, often seeking primary care, may be astonishing to a British observer. On the other hand, the vast resources dedicated to alcohol-related medical treatment in a British A&E may be appalling to an American observer. Both systems, however, are faced with the same challenge of dealing with hundreds of languages, at least in major cities. The main difference will be whether the language challenge is in finding a speaker of Pashto, Yoruba, Khmer, or Quechua.

Biggest and Best Versus Understated Modesty

It is not uncommon to hear Americans boast that their health care system (at least for those who are insured) is the biggest and the best in the world. It also is not uncommon to hear the British complain about the NHS.

These behaviors should be considered within their cultural contexts. It is not unusual for Americans to value being the biggest and best in many walks of life; nor is it unusual for them to look inward without regard to or knowledge of the wider world. Nor is it unusual for the British to apply their talent for self-deprecation without regard to its misinterpretation elsewhere in the world—until they need what they have been so adept at criticizing. At this point, the NHS becomes “not so bad” after all. In fact, it is not unusual to see British abroad returning home specifically for the purpose of using the NHS, including those returning from the United States.

The cultural biases of both countries can be misleading. According to the World Health Organization, (WHO) there is no doubt that America’s health system is the biggest, given that the country spends approximately 16 percent of its GDP on health care, approximately double the 8 percent spent by the UK (which is in line with most of the developed world).

Being “best,” although somewhat interpretive, also has been quantified by WHO on more than 100 indicators. The results from the most recent available figures: the U.K. system is ranked 18th, the U.S. system is ranked 37th.

The British cherish their universal health coverage and, in their understated way, would not compromise either access or government support. For Americans, any change to their system that protects individual choice and is perceived to maintain access to the full range of medical care will have a better chance of being accepted.

Finally, it might be an idea for both countries to remove their own cultural blinders and to have a look around the globe to see what other countries may be doing better. Maybe it is time for both countries to look toward France, who holds the number one position on the WHO list—that should be interesting from a cultural perspective.


Donna Marsh is the author of “Yanks in Blighty: Tips for Americans on Adapting to All Things British.” She is also the founder of Culture Unveiled (, Windsor, United Kingdom. She can be reached at +44 7900 213355 or e-mail