NHS number one in the world?

In a widely publicised report­­ from the Commonwealth Fund the UK was recently ranked as having the best health system in the world (or at least among the 11 nations studied). Countries have taken a wide range of approaches to setting up their health systems yet comparative studies of this kind are fairly infrequent as producing meaningful comparisons is difficult to do. So what do the results mean and what lessons are there for the NHS from this report?

As with many people reading the results my first thoughts were sceptical. Anyone familiar with school and university rankings among our British newspapers will know that league table always vary from one table to another. The differences mostly seem to be because the order of the participants depends on the formula used to score them and there is no “golden rule” for how to measure what is good in education or in healthcare. The authors even acknowledge that there is very little separating the middle-ranking countries in their report, meaning small differences will appear exaggerated.

Nevertheless the UK, along with Switzerland, was a clear outlier among the countries studied, all of which are high income countries that would be expected to have good quality healthcare. It also ranks first for many of the indicators the report used making it more likely that our top billing reflects a real difference in the quality of healthcare.

Finding comparable data for health systems in different countries is notoriously difficult. International organisations often collect data on figures that are easy to standardise and compare (like spending and mortality rates) but a lot of detailed system-level data is collected in different ways in different countries, if indeed it is collected at all. The Commonwealth Fund gets around this problem by drawing a lot from the surveys it has carried out on patients (in 2011 and 2013) and GPs (in 2012). Surveys may be a little less reliable, especially when asking people’s opinions, but most the questions asked were related to specific facts of medical care given and received.

Still we should be sceptical. The measures used to calculate scores in reports like this tend to reflect the underlying beliefs of those compiling them. People think different things about how good healthcare should be judged and this affects what they choose to include. For this reason it may be better to look more closely at the data we consider important rather than simply accepting the summary results. To do so is also to consider the question of what our health system is for.

So what is a health system for? Many would say that the most obvious answer is to make people healthier. It stands to reason that most healthcare related activity is undertaken for precisely this purpose. The report looked at overall mortality amenable to healthcare, infant mortality and healthy life expectancy at age 60. In fact this was the one area that the UK performed poorly in ranking 10^th out of 11 overall, second only to the US with France coming first. The reasons for this are not entirely clear but many comparisons have found that health outcomes in the UK are worse when compared to other countries. It is probably a little harsh to lay all the blame for this at the door of the NHS. Public health experts recognise that healthcare has a surprisingly small effect on health outcomes except in specific areas. Most people who seek care are already ill, meaning most of the illness people face is determined before the NHS can do anything about it. Prevention is therefore better than cure and summary outcomes like mortality and healthy life expectancy have lot more to do with the socioeconomic circumstances of the population and their ability (and willingness) to lead healthy lifestyles rather than the quality of NHS care.

In fact health systems are often structured with reference to economic reasons. The provision of health insurance and access to medical care when it is needed prevents people from facing unexpected and catastrophic medical bills. Globally this is key cause of people falling into poverty in countries without universal health coverage and this is why “equity” is considered an important feature of health systems. Equity means that people should be able to access healthcare when needed regardless of their personal circumstances. Clearly the provision of healthcare on the basis of need has been a key feature of the NHS since the days of Nye Bevan and this is why the UK performs so well on these measures. People are very unlikely in the UK to not see a doctor, have a treatment or fill a prescription because of medical costs and, importantly, there is little difference between those with different incomes on these measures (1%, 1% and 4% for below average income and 3%, 2% and 2% for above average income respectively) . This is not the case in much of the rest of the world. For below average incomes the equivalent proportions are 11%, 10%, 11% in France; 14%, 10%, 14% in Australia and a staggering 39%, 31%, 30% in the US. It is important to remember that these figures will not reflect some of the most recent changes to have occurred in some countries such as the Affordable Care Act in the US and the Health and Social Care Act in the UK. It will be particularly interesting to monitor their progress in the UK with ongoing pressures on funding and recent discussions around introducing charges for appointments.

Finally the quality and efficiency of the health service are worth considering. A poor quality service will provide inadequate care and an inefficient service is wasteful, imposing an unnecessary burden on taxpayers. This is the one area where the good performance of the NHS on many, though not all, measures is most surprising given the narrative most of us are used to of NHS failure and inefficiency. In fact the picture that emerges from the surveys is of care that is highly co-ordinated, least prone to mistakes and highly patient-centred (at least compared to everywhere else). GPs in the UK are most likely to be able to use information technology to easily identify patients overdue for tests and send computerised reminders to them or to be able to print out the total list of medications a patient is taking. Patients in the UK and Switzerland are least likely to report a medical mistake or medication error occurring in the last 2 years. NHS patients most often feel that doctors explain things in a way that is easy to understand and feel that specialists involve them in decisions as much as they want. All of this is done with a lower rate of spending than most of the other countries (9.4% of GDP). It seems that, despite the bureaucracy involved, the NHS has benefited from some of the initiatives undertaken to improve quality and efficiency.

So what messages can the UK take from the results of this report? I would narrow my conclusions to two areas. Firstly our NHS is a world leader in the provision of healthcare even when looking at the question from a number of different angles. We forget this at our peril as if we are already doing well, continued improvement should come from evolution not revolution. It is difficult to know which features exactly make the NHS great but it seems to have done well from across the board use of measures to improve productivity, ensure patients safety and to collect, publish and analyse clinical data. We might also speculate that its core values and a positive culture of care have played a part. Despite this, poor health outcomes in the UK remain a problem which public health and the wider political system need to address.

Secondly it is striking how even at the top end of the table there is so much room for improvement. Primary care practices in the UK are most likely to routinely provide written instructions to their patients with long term conditions. Yet this only happens in 61% of practices. Many patients are not satisfied with the care they receive and many wait too long for emergency care. My hunch is that a lot of these problems reflect variation within the service rather than a system-wide problem. Many of the recent reports into “failing” hospitals and individual instances of poor care reflect this variation. It means that for clinical leaders in the NHS much of the challenge is not to come up with new ideas but to find ways for existing ideas to permeate throughout large and complex organisations. In that sense every part of the health service requires such leadership.

Finally it is always worth acknowledging the limitations of data in assessing health systems. Even in surveys as comprehensive as this all of the inherent qualities of the service will not be reflected. Caring for another person occurs through conversations, emotions and the navigation of difficult choices as much as it does through the exact information and treatment given. In truth, very little of this is amenable to measurement and comparison with other places. Professional values such as compassion, trust and honesty must therefore be emphasised as much as any of the measures and initiatives mentioned here.

Read the full report here:

www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror

Rahul Bahl

FY1 Doctor

@Rahulbahl3