The fairest of them all? Examining the NHS's global ranking

The UK came top of the Commonwealth Fund’s “Mirror, Mirror” league table of performance again this year. Our high placing is perhaps not surprising – as the title implies, it seems that the main purpose of the report is to allow the US think-tank to hold a mirror up to the US health system, and show how poorly it performs.

It is good to see that the NHS does manage to succeed in delivering some of its main policy goals. There is, however, one significant issue that the Department of Health managed not to mention as it scrambled to use the report to head off Sir Michael Marmot’s warnings on the slowdown in improvements in British life expectancy. 

While the NHS does well on a number of measures including efficiency, affordability, equity and some aspects of the process of care, it performs poorly in terms of outcomes. The domains in the Commonwealth Fund’s assessment are not weighted and because there are several areas of assessment, the UK’s relatively good performance in some of these swamps the effect of its disappointing outcomes on its overall score. This produces the paradox the Guardian described following the last instalment, of a health system with only one black mark against its name: “its poor record on keeping people alive”.

What are the outcomes the Commonwealth Fund looks at?

The components of the outcomes domain – which are each given equal weight – are:

• Population health: infant mortality, the number of adults with two or more chronic conditions, and life expectancy at 60.   
• Amenable mortality – i.e. mortality from a range of conditions in the under 75s which can be reduced by effective health care. This does not include mortality where wider public health programmes and prevention can reduce mortality or morbidity. The biggest items here are ischaemic heart disease, followed by breast and colorectal cancer. 
• Improvements in amenable mortality – it is slightly odd to mix an indicator about improvement with one about the absolute rate, and it is harder to make improvements in this indicator if performance is already good.    
• Five-year survival for breast and colorectal cancer and 30-day in-hospital mortality for heart attack and stroke. 

We could argue that amenable mortality may be sensitive to death certification practices or overlap with societal factors that the NHS cannot touch. We can quibble that cancer survival indicators lag five years and have comparability problems, or that some of the disease-specific outcomes are also picked up in amenable mortality. We could object to the weighting given to cancer survival by the design of the index. But none of this is likely to change the result very markedly. 

We have other data from several other sources that corroborates the story. Earlier this year, the Global Disease Burden collaboration of academics looked at avoidable deaths across the world and found the UK well behind most of Western Europe (although again, ahead of the USA). Our own work on international comparisons, part of our QualityWatch programme, found the UK to be middle of the pack at best. So how is it that the NHS does so well in some domains but is at best mediocre in key areas of clinical outcomes?   

Is it because the NHS is short of staff or money?

A popular explanation is that we are spending less than our European neighbours. While this is true of many of our more prosperous neighbours, a recent recalculation of how spending is calculated suggests the gap may be less than we thought. The argument is undermined by some lower spending countries that do better.

A notable difference between Switzerland, Germany, the Netherlands and France and the UK is the number of health professionals – in particular doctors and nurses. This does allow more elements of choice but also reduces the pressure that professionals are under. 

Is it because of the patients?

There is sometimes an attempt to blame the British population for its poor diet, high obesity rates and reluctance to go the GP with symptoms that require attention. There is some evidence that this last point is true. The higher rates of deprivation and the UK’s high rates of income inequality may be an issue in some cases.

There have been suggestions that we blame the UK’s system of gate-keeping, which might prevent patients from getting timely access to specialists. But again we have little firm evidence to support this. Other barriers could also be in play, like the difficulty British GPs have in getting diagnostic tests done.  

Is it because of the way the NHS is organised or run?

Right-wing think-tanks argue that we lack competition and choice. In their view, the top-down nature of the British “Beveridge” system funded from taxes and delivered by the public sector places a dead hand on the NHS compared to “Bismarck”-style social insurance systems, some of which have competing insurers. 

These arguments are somewhat undermined by the strong performance of some of the Scandinavian systems, which are run on similar lines to the NHS. And in some respects, the two types of system are starting to converge as social insurance systems increasingly cover all citizens and have a growing reliance on tax.

They also argue that the relatively low level of private sector involvement in the NHS compared with other systems is a cause of poor performance. Again this is not supported by much direct evidence and there is only a limited theoretical justification for it.   

However, the claim that the influence of Government on health in parts of the UK is malign does seem plausible. In recent years, the English NHS has undoubtedly had more reorganisation and restructuring than any health system in Europe – even those subject to some of the most rigorous austerity regimes post 2008. For example, there have been six reorganisations of commissioning authorities in the NHS in the last 20 years. Regional structures, workforce planning and community services have had similar amounts of often destructive tinkering. Scotland, as we recently pointed out, has had more continuity in the way it runs its health service, and seems to have a more coherent system of improvement.

A second difference might be the extent to which managerialism as opposed to professionalism is the main paradigm for how the English system is run. Reliance on regulation, inspection and performance management seems to be much more pronounced in the NHS than in some other health systems. This has been coupled with a very heavy emphasis on access goals and efficiency. The latter are reflected in the Commonwealth Fund scores but perhaps at the expense of continuous improvement and professional job satisfaction.

Other possible reasons can be suggested. One thing is clear though: just because a ranking system produces a result we like does not mean that it is the final word. And if we care about improving the NHS, we shouldn’t use it to deny challenging and inconvenient truths.