I work regularly in the USA and I even wrote this article in Boston. I started it because I never fully had the measure of the US health care system. So, I decided to find out a little and compare it with the UK.

Patient engagement plays a vital role in improving outcomes and fostering trust between patients and providers. While both the United States and the United Kingdom value patient engagement, their approaches differ due to healthcare system structures, policies, and cultural attitudes. The US operates a market-driven, insurance-based system that offers more patient choice but also greater financial responsibility. By contrast, the UK’s National Health Service (NHS) prioritises universal access and standardised care. This shapes a different model of engagement. These differences influence shared decision-making, digital health adoption, clinical trial participation, and access to medicines.

The US healthcare system includes private insurance, employer-sponsored plans, and government-funded programs like Medicare and Medicaid. This affects engagement by offering patients more choices of health provider. However, access to these can be limited by insurance networks. There is something of a patient burden: the individual is   expected to research treatment options and look into whether they can afford it. This can lead to delays or even avoiding care altogether. This decision not to choose any cover is based on affordability. Thus, by taking this option, the individual is denied any scope for engagement.

By contrast, the NHS provides healthcare free at the point of use, removing financial barriers but requiring patients to follow a gatekeeping model, where general practitioners (GPs) manage referrals to specialists. The GP decides the care pathway for the patient, with the unsaid expectation that the patient agrees to be shepherded onto a treatment decision, a care pathway or nothing at all. This is all dressed up as shared decision-making, when really, the GP is the one in control of the interaction. While this ensures consistency in care, it can limit autonomy. NHS guidelines standardise treatment approaches, but sometimes restricting patient choice.

Shared decision-making also differs significantly. In the US, patient autonomy is emphasised. Individuals are encouraged to seek second opinions and use online resources to make informed decisions. However, time constraints during appointments can hinder meaningful discussions. Also, direct-to-consumer pharmaceutical advertising influences patient choices, sometimes leading to unnecessary treatments.

Digital health adoption reflects another key difference. The US leads in digital health innovation, with widespread use of patient portals that allow access to test results, appointment scheduling, and direct communication with providers. Telehealth has also grown significantly, driven by competition and cost-saving measures. However, concerns about data privacy persist due to the fragmented nature of private healthcare providers. The UK has been slower to adopt digital tools, though the NHS App provides a standardised platform for medical records and online consultations. The NHS’s centralised data system ensures continuity of care, but patient access to records remains more limited than in the US Telehealth expanded during the COVID-19 pandemic, though its integration into routine care remains inconsistent.

Participation in clinical trials also varies. In the US, a competitive, commercialized research environment provides patients with greater access to experimental treatments, but financial barriers exclude many uninsured individuals. Patients can often enrol by themselves in trials without a doctor’s referral, increasing participation but sometimes lacking oversight. The UK integrates clinical research into the NHS, ensuring equitable access but requiring patients to be referred by their GP. While this guarantees medical oversight, it can limit patient awareness of available trials. Research priorities in the UK focus more on public health needs and cost-effective treatments rather than commercial incentives, ensuring a broader benefit to the population.

Ultimately, patient engagement in the US and UK is shaped by their healthcare systems, financial structures, and cultural perspectives. The US emphasises patient choice, autonomy, and digital health innovation but struggles with affordability and equity. The UK provides universal access and standardised care but limits patient autonomy through its gatekeeping model. While the US offers more flexibility and rapid adoption of new technologies, it faces financial barriers that reduce engagement. Meanwhile, the UK ensures equitable healthcare but can be slower to integrate digital tools and new treatments.

In addition, too many people in both countries fall outside of the demographic of ‘empowered’ and ‘engaged’ patients. Those who cannot access care on the basis of cost or those who have low health literacy.

Both systems have strengths and weaknesses. The U.S. could learn from the NHS’s focus on accessibility and affordability, while the UK could benefit from the US’ patient autonomy and digital engagement. A balanced approach that combines accessibility, affordability, and empowerment would enhance patient engagement in both countries. This would improve healthcare experiences and outcomes.

Thank you for reading!

Mark Gibson

Boston, USA, November 2024