Mirror, mirror on the wall, who is the fairest of them all?

Mirror, mirror on the wall, who is the fairest of them all?

By Bernard Merkel

Nowadays I don’t often get surprised by articles on how national health systems are performing, or how they compare. Usually I find they simply tell me things I already know or suspect: they are all trying to cope with the growing demand for health services, particularly from their ageing populations, they are experiencing pressure on resources, there is a lack of integration and communication between the various organisations and health professionals involved in care, healthcare is full of silos, there are difficulties in introducing e-health, there is a need for a more patient-centred approach, there is a lack of priority given to public health, etc. etc.

But I was genuinely astonished when I read reports in the media that a Commonwealth Fund study[1] published in July had ranked the UK’s health system first in a comparative analysis of 11 countries’ health systems. This US think tank had apparently arrived at the same result in a similar study three years ago, which I had missed.

I had better explain straight away why it was that this ‘UK victory’, ahead of Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the U.S. came as such a shock to me. Well, the answer is simple: it is increasingly clear to anyone who knows anything about the UK’s health system (the NHS) that the system is rapidly and visibly deteriorating to the point where some people are beginning to doubt whether it can survive in its current form in the future. The system is beset by a range of problems – inefficiencies and waste, over-complexity and administration, inadequate staffing, lack of capacity, fragmentation, substantial variations in practice and outcomes between different locations, to name just a few.

But the NHS has one overwhelming problem which underlies most of the others: a chronic lack of resources. It is true that in real terms spending on the NHS has been increasing over the years and the UK government constantly claims that more patients are being treated than ever before, more operations are being carried out, and more nurses are employed. However, total spending is tightly controlled and the increases in the last decade have not been anywhere near sufficient to match the rising demand. The UK thus spends less as a percentage of GDP than the other countries on the Commonwealth Fund’s list, and in many cases , far less.

The issues this miserliness creates are that many thousands of nursing and medical posts remain unoccupied , there are not enough professionals being trained to replace those leaving; general practices are being merged or closed ; waiting times to see general practitioners or to be referred for hospital care are lengthening; waiting lists for operations are growing, there is a shortage of hospital beds; there is inadequate investment in new technologies, and what is offered to patients – the drugs and procedures available, and the time to needed to access them, will be determined by budgetary considerations as well as by clinical need.

So how can the UK health system be considered so good? I thought I’d better have a close look at the Commonwealth Fund’s study to see how they could have arrived at this apparently perverse result.

The analysis ranks countries on five criteria. First is what they call ‘care process’ which includes a number of diverse topics: prevention, safety, coordination, and patient engagement. Second, is access. Third, ‘administrative efficiency’. Fourth, equity.   Fifth and last, health care outcomes. The final score awarded is an amalgam of the score for each section.

The UK does very well on care process, (ranked 1st) and this no doubt reflects the UK’s well-established focus on preventive measures eg vaccination campaigns, screening, optical and hearing tests, as well as its concern with hospital safety and the involvement of patients in their care. Similarly, it comes top on equity, which in the study is about the degree of difference between what is available to lower and higher income groups. Given the small size of the private sector in the UK, it does seem evident that access to health care and the way in which it is provided do not differ much on the basis of individual’s socio-economic standing. They do however vary enormously on the basis of geography.

The UK is also reckoned to be quite good on access (which means both affordability and timeliness of care). I can only imagine that its fairly high score here is because NHS healthcare is provided either free or at very low cost. It would certainly not do very well if timeliness were the decisive factor. On administrative efficiency, which includes barriers to care and amount of paperwork for patients and doctors, the UK also does relatively well. Clearly, the fact that pricing and billing are largely absent from the NHS may have something to do with this.

It turns out, however, that in one category – health outcomes – the UK does not do so well. In fact the survey ranks it 10th out of 11, with only the US doing worse. At the top end of the rankings sit Australia, Sweden and Norway. At first glance I took this to be a ranking of how well the health systems were doing at improving people’s health – which after all is what their business is supposed to be! I was not particularly surprised therefore to see the UK doing quite badly by this yardstick. There is a wealth of evidence that UK outcomes for the treatment of various serious conditions, such as five- year survival rates for certain cancers, lag behind those of other countries. Indeed this makes perfect sense if one thinks about the likely consequence for health outcomes of the delays in diagnosis and referral and the waiting times for treatment, not to mention the restrictions on access to expensive drugs and equipment, and the geographical variations in practice and quality.   What did surprise me more was the US coming last in this category. There is a great deal to criticize in the US health system, but one of its better features is the fact that throughout the country there is considerable capacity and expertise in specialised health services with consequent high standards of care delivery and quite good outcomes.

The explanation for this anomaly, I discovered, is that the ‘outcomes ‘ category is not just about outcomes of health care, it also covers general public health measures, such as infant mortality and life expectancy rates as well as mortality amenable to health care. On these measures, the UK does not perform well, while the US, with its very wide variation between wealthier and poorer groups, performs very badly.

Indeed, the US performs badly in nearly all the study’s categories, coming last in three and second to last in one. Its best score is a middling fifth place for care process – and in this context it certainly does have strong traditions both in patient engagement and patient safety. But its overall last place serves to highlight the nature of the comparison. This is not primarily intended as an objective ranking of health systems’ performance (if such a thing is in fact possible!); it is aimed more at demonstrating to US policy-makers and opinion leaders that despite spending vastly more money on its healthcare system than any other country, the US system is not particularly good and needs to be rethought; and other countries can show the US better ways of doing things. The statistics, definitions and categories used in the comparisons would appear to be chosen with this end in view. From this perspective it does not really matter which country comes first, second or third. The important point is that the US should come out of the comparison very badly. Accordingly – and you should not be too surprised to read this –   the US occupies a firm last place in all six of the Commonwealth Fund’s comparisons exercises undertaken since 2004. Now that’s what I call being consistent!

[1] The Commonwealth Fund: Mirror,Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care, July 2017

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