The NHS scores better than many other countries in terms of access to health – until you take outcomes into account
We are so used to reading bad news stories about the struggles of the NHS to keep up with patient demand, that it can come as a surprise when the UK health system continues to perform well in some international comparisons of access to healthcare. The important word, though, is ‘some’. In the past couple of months alone, the UK has come first in the Commonwealth Fund comparison of 11 developed healthcare systems, and a respectable equal fourth out of 60 in The Economist Intelligence Unit’s Access to Healthcare index. However, it came a more worrying 30th out of 195 in a comparison of healthcare quality and access published in The Lancet in mid-May.
Much depends on what is being measured. The Economist Intelligence Unit (EIU) index, which was developed in partnership with Gilead, aimed to measure patients’ ability to get access to the care they need. So the study scored countries based on whether they had policies and mechanisms in place to ensure access to different types of treatment. The study also took into account capacity issues, such as the number of medical staff, as well as funding barriers and disease prevalence. The UK scored well almost across the board, with only its treatment for infectious diseases scoring poorly. As a result it tied with Australia for fourth place overall, behind the Netherlands, France and Germany.
In the Lancet study, however, access to treatment was measured more in terms of outcomes. The researchers here used the Global Burden of Disease study from 2015 to compare amenable mortality rates – the number of deaths per 1,000 population that were avoidable given the right care – in 195 countries. They adjusted for geography-specific risks, then weighed the results against various indicators of health funding and access, as well as socio-economic indicators. The results allowed them to score each healthcare system according to how well it did on reducing amenable mortality for 32 diseases. The UK scored a mediocre 85, putting it on a par with poorer countries such as the Czech Republic and Portugal.
The contrast between these two studies points to an NHS that is fundamentally well-designed, but that struggles to deliver on its promises. As The EIU study points out, good access to healthcare depends on a strong social compact, where corruption levels are generally low and trust in the system is generally high. Innovation, good use of data and controls, a well-trained workforce, and a strong primary care system are also vital. The UK delivers in all these areas. Moreover, with its unified funding structure and low administrative costs, the NHS manages to get by with lower funding than its French, German and Dutch counterparts. Free care at the point of access makes it very equitable, too.
Yet on outcomes measures the NHS has often lagged behind. The Lancet study pinpoints some particularly poor disease outcomes, such as for Hodgkins lymphoma and lower respiratory infections, while EU studies have pointed to other cancers where UK outcomes are below par. The Commonwealth Fund’s study broadly confirms this split between the NHS’s good system and relatively weak outcomes. The study uses 72 indicators split into five categories: care process, access, administrative efficiency, equity, and healthcare outcomes. In the first four of these, the UK does well enough to come top overall, as it did when the Fund published the last version of the study, in 2014. In the last category, however, the country still comes a pretty miserable tenth out of 11 countries.
Fortunately, there is some progress. Like the Lancet study, The Commonwealth Fund looked at amenable mortality rates, although as one measure rather than 32. As in The Lancet, it found that the UK did poorly – but it was also the country that had improved the most over the decade between 2004 and 2014. Given this coincided with a prolonged funding squeeze and a series of NHS reforms, that is impressive. Jeremy Hunt, the health secretary, took the opportunity to boast that “the NHS has again showed why it is the single thing that makes us most proud to be British”.
Yet although this progress is welcome, it remains somewhat unclear why it has happened. Data in international comparisons tends to be several years old, and time-lags in health outcomes are even longer. So have the reforms of the past few years, which have shaken up the way the NHS funding is managed, already delivered results? Or are we getting the belated benefit of the boost in NHS funding before the financial crisis of 2008-09? We will only start to see the answer to that when more and more international comparisons emerge.
Ana Nicholls is chief healthcare analyst at the Economist Intelligence Unit