The NHS: excellence and efficiency

The NHS is a world leader.

Update: 09.11.2011 Commonwealth Fund survey finds people in Britain have among the fastest access to GPs, the best co-ordinated care, and suffer from the among the fewest medical errors, of 11 high income countries surveyed. Reported in the Telegraph

Update 18.8.2011 UK healthcare system is one of the most efficient in rich countries. BMJ

As a system of universal healthcare it exceeds all others. Some have said that it is the worst of all systems of universal health care … apart from all the others that have been tried. It stands out in the following areas in particular. I want to highlight them because as the BMA pointed out at its SRM last week, the government are constantly denigrating its achievements to justify their reforms.

1.Inequalities: fewer adults went without recommended care, did not see a doctor when sick, or failed to fill prescriptions because of costs in the UK than in any of the other 11 countries surveyed by the Commonwealth Fund last year. They also found that:

adults in the United States are by far the most likely to go without care because of costs, have trouble paying medical bills, encounter high medical bills even when insured, and have disputes with insurers or payments denied.

We should be very concerned about the health bill because most people who understand the health bill believe that we are heading for an insurance scheme modelled on the American Health Management Organisations. See this excellent analysis by John Lister and straightforward explanation about the effect of abandoning practice boundaries on this blog.

2. We have the lowest inequity in the world for access to a GP or a specialist according to the OECD

This OECD graph shows that money is less of a barrier to access a specialist in the UK than in any of the seventeen OECD countries surveyed.

The point of the NHS is to provide care on the basis of need. Since health problems are more frequent and more severe among people from lower socio‐economic groups access to care should not be a privilege for the rich. In many countries inequitable access results in wealthier, healthier people having better access to GPs and specialists. This is an example of the Inverse Care Law, which states that “The availability of good medical care tends to vary inversely with the need for it in the population served. This … operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.” (Hart, 1971)

The health bill hastens the conversion of a public service into a series of competitive markets and will widen inequity of access to care.

3.UK healthcare costs per capita are amongst the lowest in Europe. According to the OECD They are less than countries our politicians commonly compare us with, including France, Netherlands, Germany, Sweden, Belgium, Austria etc.

Given that our healthcare costs are so low, we ought to be asking on what basis the Government can claim that they are too high. We ought also to make sure that international comparisons of health outcomes take into account disparities in spending on health care. The government are fond of mentioning the differences in outcomes for heart attacks between England and France, but omit (amongst other confounders) to mention the huge disparity in health care spending. Nor do they mention the crisis the French are facing. More importantly we need to be aware that forcing one of the cheapest universal healthcare services in the world to make the deepest and most sustained cuts of any healthcare system in the world cannot occur without catastrophic effects.

4. Satisfaction has never been higher. Two-thirds of people are now either very or quite happy with the state-run health care, the largest proportion since the in-depth British Social Attitudes study began in 1983. The attempt by the government to suppress this data has been described, rightly, by health policy expert Andy Cowper as “suspect in the extreme”

5. Desire for change is the lowest in the world:  Members of the public were surveyed from 11 countries; UK, Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland and the US.

They were asked that if they looked at the health system as a whole, do they think it needs minor changes in the system; fundamental changes; or do you think it should be rebuilt completely.

3% in the UK think the system needs to be rebuilt completely (the lowest in the world). 34% think there needs to be fundamental changes, and 62% think that only minor changes are needed. The UK public think their health care system needs changing less than any of the other countries surveyed.

The areas in which the NHS leads the world are highly specific for a system of health care. Health outcomes on the other hand, are to a significant degree a consequence of the social determinants of health, factors such as economic, environmental and lifestyle factors. Valid criticism of the NHS has to take this into account.

Efficiency of health care.

The first question Steven Dorrell asked me at the health select committee last year was how to make the NHS more efficient. According to the Commonwealth Fund 2010 report the UK comes out first for efficiency. The US, last. If Mr Dorrell or anyone else says the NHS needs to be more efficient, they need to firstly explain their basis for claiming the NHS is inefficient. They need to compare NHS efficiency with other systems of universal healthcare. They also they need to define efficiency.

To measure efficiency you need to measure for example, how much it costs us for each cancer diagnosis, or how much we spend preventing or treating each heart attack, or how much it costs to deliver or vaccinate each child. You need to do so for a whole population, it is harder to manage patients who behave inefficiently. There need to be internationally agreed ways to measure these processes so that valid comparisons can be made. We know that lack of comparable data is a problem in comparing outcomes for cancer for example. 

Efficiency is not the same as productivity as Richard Blogger has explained.

There’s no point simply measuring how much stuff the NHS does. OECD data for MRI and CT scans shows that in the US they perform vastly more scans than any other country, suggesting one reason for their vastly higher healthcare costs. In my job as a GP one of the hardest parts is to explain to anxious patients why scans are unnecessary. One of the reasons healthcare is so cheap in the UK is because GPs are good at this.

The NHS excels in access to healthcare on the basis of need. It has controlled costs more than almost any comparable country and is probably therefore the most efficient system of universal healthcare in the world.

The denigration of the NHS by proponents of reform is not only inexcusable, but the motives are ‘suspect in the extreme’.

The aims of the reforms are to destroy a successful public service and replace it with a series of healthcare markets, risking the very core principles of equitable, needs based, cost-effective care for all.

Update 11.11.11

A few people have asked why this post is not about disease outcomes. The reason is because I wanted to focus on access, equity and efficiency. These are measures of a system of care rather outcomes which are significantly affected by social determinants such as deprivation, employment, childhood, diet, smoking, alcohol etc. Secondly there are significant differences in the ways different countries measure disease outcomes making comparisons very difficult. For a start …

… this blog, ‘Cancer Survival is complicated’ by an epidemiologist explains the difficulties of measuring and comparing outcomes for patients with cancer.

Latest OECD report december 2011

Surprising fact: only slightly above average increase in healthcare spending 2000-2009 (p.151)

Unsurprising fact: lowest levels of inequity for access to a specialist or a GP p.141

Inverse care law consideration: Could the NHS be more efficient if it cared less for inefficient patients?


7 responses to “The NHS: excellence and efficiency

  1. The Andrew Lansley Rap is now available from itunes. It was released 2 days ago and is already at number 64 in the download chart.

    Can any wealthy or not so wealthy doctors spare 79 pence to help get it into the the top 40 or even number 1?

    If it charts then the radio stations will be playing it on the airwaves and the message will be spread to lots more people.

    If you’re on Twitter – you could tweet the link too.

  2. Firstly, I’m going to put my hands up as a great sceptic of the ‘Glorious NHS’. Having experienced a number of healthcare systems personally, and found this one to be one of the most lacking with the rudest nurses, the slowest A&E departments and the greatest lack of customer-centric care.

    I remember one time when I was in casualty with a broken ankle, and wasn’t able to get a painkiller, or even to buy a painkiller, and was told that if I left, I would have to sign back in and start waiting for hours again. This is hardly what I consider to be a system of great quality.

    The argument that ‘desire for change is the lowest…’ is essentially a derivative of argumentum ad populum. By this argument, North Korea is great because most North Koreans support the rule of glorious leader Kim jong-Il, and there is no need for change there either.

    Tell me how many people with complete information about the NHS and how it compares to the world think it’s a ‘world leader’ (I see no citation from you on this point), and how this compares with the number of people who buy into the leftist false dichotomy and believe that our only alternative is a US-style laissez-faire free for all.

    The British spent $3,771 per capita in 2008 (WHO Report 2011); more than Greece ($3,110, which for some reason you said cost more than our service), Spain ($3,132), Italy ($3,343), Portugal ($2,434), Andorra ($3,331).

    Although you insulted your readerships’ intelligence by drawing comparisons with far wealthier countries than ours, such as Luxembourg, Denmark Norway and the Netherlands, several of which spend more than the USA, I will not be drawn into this game and start dredging up incomparable nations of my own which are far poorer than ours. Suffice to say, our healthcare system isn’t cheap by EU standards, it’s slightly above the average cost.

    You also cited ‘deepest and most sustained cuts of any healthcare system in the world’ with something suggesting a 0.54% cut over five years. Whilst this does suggest a cut, there are likely to be much larger cuts in Ireland, Greece and Portugal so your statement is incorrect and misleading.

    Of your five key arguments, two are essentially about equality of access, one about cost and two are argumentum ad populum, we’ve dealt with the last three (two?) so let’s address equal access, because it’s very important to end the scaremongering of the far-left with regards to universal access.

    First of all, we need to destroy the link between ‘state as sole provider’ and ‘universal access’. These two concepts are not equitable. It is true that if the state just stood by and did nothing, the poorest and most vulnerable would not get health coverage, but nobody is calling for that.

    Even in systems with significantly more privatisation than the Tories are calling for, health services are universal, the poor are given help in affording their premiums and the long-term ill are covered by state insurance. What they don’t do is offer free healthcare to millionaires and others who can afford to pay for insurance, on ideological grounds.

    Most of them simply make insurance compulsary, pay for those who can’t afford it (including the long-term ill), pay a little bit for those who need help, and let those who can afford it pay the whole amount.

    Of all the systems which achieve a greater statistic on survival to 60 per 1,000 AND healthy average life expectancy AND GDP/capita spend on health, none of them have a higher proportion of spending from government than we do. The idea that government must be the sole provider of healthcare in order for healthcare to be efficient and universal is a myth.

    Finally, something you didn’t really touch on, although one would presume it’s the most important factor when talking about healthcare, is outcomes.

    Adult mortality rate is a decent yardstick. 77 out of every 1000 people in the UK die between aged 15 and 60. This is higher than Australia (62), Canada (70), Cyprus (61), Germany (76), Greece (76), Iceland (54), Israel (62), Italy (59), Japan (64), Kuwait (60), Luxembourg (76), Malta (60), Netherlands (66), New Zealand (72), Norway (67), Qatar (65), San Marino (53), Singapore (59), Spain (68), Sweden (61) and Switzerland (58).

    Pulling out such a long list may seem irrelevant, but it is worth mentioning that with the exception of the US, the average person in every single country on your list which ‘desire change’ has a better chance of surviving to 60 than we do.

    It’s also worth mentioning that of these 21 countries, more than half (Cyprus, Greece, Israel, Italy, Japan, Kuwait, Malta, New Zealand, Qatar, Singapore and Spain) spend less than we do on healthcare, so the leftist myth that it’s all because we don’t throw enough money at the NHS is based in fallacy.

    All in all, the NHS may be the envy of the third world, but it’s definitely not the envy of the world, it’s not a world leader and it does need to be updated. Maybe if those on the ideological left would help in the process and make sure the reforms are right, instead of tribally battling against progress (some ‘progressives’), we might be able to ensure a better future for everyone using the British healthcare system.

    Typically, I’m not expecting this to go through moderation, so I’m saving it to post with a trackback.

    • Thanks for taking the time to write a detailed response. I don’t have the time to respond, but I’m happy to let readers make their minds up.

    • There are lots of suggestions for change on this blog. They are based on experience rather than ideology. The right seem to be stuck will a single ideology, small government, low tax, free markets. I think its called the Chicago school of economics. I’m sure you’re more familiar than I am. I’m less sure about the ideology of the left, I don’t think it can be characatured as the opposite: big government, high tax, no markets, though I expect you have examined it. The closest I’ve come to setting out my own principles are in previous posts, What is the point of the NHS? and The NHS needs reform.

      • For me the point of any healthcare system is to save lives and make people healthier. I don’t think that markets are perfect, and if they are to be allowed in, it needs to be on our terms with controls to make sure that the public still get free healthcare (at least for those who can’t afford it).

        The thing that really irks me in these debates is that people seem so scared of any privatisation, or any competition. Why should it matter who provides a service, whether state, NPO or for-profit company, as long as they offer the best combination of a good service and a good price?

      • abetternhs

        Good question and one that Tory MP Peter Bone was trying to argue with Evan Harris on BBC radio 4 today this morning (worth listening again) The answer is whether there are any associated costs. I think Evan Harris did quite an effective job at answering. In short the answer is the Inverse Care Law, which is explained through arguments from personal experience throughout my blog. Again, thanks for taking the time to comment, I think your the first person who disagrees and has commented that has really thought through their objections.

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