According to the Commonwealth Fund’s latest report “Mirror, Mirror on the Wall: How the Performance of the US Health Care System Compares Internationally” which compares 11 industrialised countries, the UK has won the ‘World Cup’ of health care systems.
It was a close thing with Switzerland and Sweden – but we managed. Sadly, the United States lost. After the events in Brazil, we should really be celebrating the success of our NHS. Especially, as we spend so little on the ‘NHS team’ compared to the US. But if it only was that simple, we would see crowds in the streets, right?
Any type of international performance ranking easily attracts attention and becomes an excellent topic of pub conversations. If a debate needs to be started, this is a great way to do so, as has been done by the World Health Organisation’s (WHO) report in 2000 as well as the FIFA football rankings since the early 90s.
We need to examine the raw scores more closely even if we do rank at the top
However, if countries actually want to learn from each other, it is essential to break down these composite rankings and analyse the data that was used to inform the results. As always, the devil is in the detail. A paper that looked at the spurious association between the WHO and the FIFA rankings highlighted these complexities.
The Commonwealth Fund ranked countries’ health systems performance in five areas – quality of care, access, efficiency, equity and healthy lives. Arriving at a common understanding of what these five areas capture is a huge task. Then defining how best to measure the performance of each of these domains and deciding what data to use can only get more complicated.
The report uses patients’ and physicians’ surveys which ask about experiences with care – or in other words, individuals’ perceptions. As the authors of the report rightly acknowledge, these results provide only a partial view of health care quality and how patients and physicians answer the questions may be affected by their own experiences and expectations; which are likely to differ across countries, cultures and population groups.
For example, if the British are generally positive about their health care system and have lower expectations than say the Norwegians, the UK system will score better.
So, we need to examine the raw scores more closely even if we do rank at the top. We may have scored first in co-ordinated as well as patient-centred care, but on some selected indicators we performed very poorly. In the report these were weighted equally – but some indicators may be more important than others.
For example, only 59 per cent of UK respondents had been with the same doctor for five years or more (i.e. continuity of care) compared to 57 per cent in the US, resulting in the UK being ranked 9th and the US 10th. So a simple composite score is easy to understand but much more difficult to act on. Equal or differential weighing of indicators has important considerations for where to focus policy attention.
We see examples of this effect in our QualityWatch programme with the Health Foundation which looks beyond the difference between countries in one year for various indicators. For example, when we recently analysed cancer screening coverage in the UK we found a worrying decline in cervical cancer screening. However, international comparison still suggests that we are performing better than most other countries in this area.
So, if we only looked at that, we would get a good night’s sleep. On the other hand, in cancer survival rates despite improvements over time, the UK continues to lag behind. Additional indicators about cancer (waiting times for cancer treatment, cancer waiting times after urgent referral) further illustrate the complexities in measuring the quality of care provided to cancer patients.
An additional important consideration is that a UK high score may cancel-out some large variations between the devolved UK countries, and the absolute value may not actually be considered as a true representation of the UK’s performance. So you could be deemed first – but individual UK countries could still be performing at a level that some would judge as mediocre.
The Commonwealth Fund did not intend to provide definite answers but managed to get us all thinking again. While we should celebrate the great performance of the NHS, we should not become complacent.
I only wish the World Cup of health care systems was as simple as following the England team. If you would like a simple story, better stick to football.
Kossarova L (2014) ‘We won! The World Cup of health care systems’. Nuffield Trust comment, 27 June 2014. https://www.nuffieldtrust.org.uk/news-item/we-won-the-world-cup-of-health-care-systems