How the NHS measures up

doi:10.1136/bmj.a385

BMJ 2008;336:1469-1471 (28 June), doi:10.1136/bmj.a385

Analysis

NHS at 60

How the NHS measures up

Tony Delamothe, deputy editor

¹ BMJ, London WC1H 9JR

tdelamothe{at}bmj.com

In the fifth article in his series, Tony Delamothe examinestwo important factors in judging the success of the UK healthsystem: the satisfaction of its users and how it rates compareswith other countries

The previous four articles in this series have dealt with howthe founding principles of the NHS have fared over the past60 years.¹ ² ³ ⁴ I have judged them against the utopian aspirationsof 1940s Britain for a national health service that was universal,equitable, comprehensive, high quality, centrally funded, andfree at the point of delivery. Much of my attention has thereforebeen directed backwards and inwards.

In this article, I want to look outwards. Firstly, I want tocapture what the British public thinks of the NHS today. Andsecondly, I want to see how the NHS compares with other healthcaresystems that share many of the NHS’s underlying principles.

What does the UK think of the NHS?

People seem happy with their NHS care, with more than 90% consistentlyrating their inpatient care as good, very good, or excellent(fig 1).⁵ In a 2006 survey for the Department of Health, 74%of those who attended a general practice or local healthcarecentre were completely satisfied that their main reason forattending had been dealt with. Of the others, 22% were satisfied"to some extent" and only 4% were not satisfied at all.⁶

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Fig 1 Adult patients’ ratings of inpatient care, England, 2002-7⁵

Although the general public tends to have a somewhat lower opinionof the NHS than patients with recent experience of NHS care,British Social Attitudes surveys show net satisfaction withthe NHS is at its highest for 20 years (fig 2

).⁷ Net satisfactionvaries—between 62% for general practice and 27% for hospitals.Nevertheless, these proportions obscure a deep vein of dissatisfactionwith the NHS. In 2007, the Commonwealth Fund found that 15%of the public agreed with the statement that "our healthcaresystem has so much wrong with it that we need to completelyrebuild it" and 57% agreed that "there are some good thingsin our healthcare system but fundamental changes are neededto make it work better."⁸

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Fig 2 Satisfaction with "the way in which the NHS runs nowadays," 1983-2006⁷

This appetite for radical reform doesn’t extend to overturningits funding base. Public support for a universal, tax fundedNHS remains high. In 2006, 74% opposed the idea that the NHSshould be available only to those on lower incomes, which wouldmean lower taxes and most people taking out private medicalinsurance. This proportion has remained at 71-78% since 1989.⁷British Social Attitudes surveys have consistently shown thatpeople rate health as their top priority for extra governmentspending. Every year since 1984 at least 70% have chosen itas their first or second priority.⁹

When presented with a forced choice between three options regardingtaxes and social spending, fewer than 10% favour reducing taxesand government spending on health, education, and social benefits(fig 3).⁷ Social solidarity still trumps private interest whenit comes to the public’s attitudes towards the NHS.¹⁰

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Fig 3 UK public’s choice regarding taxation and social spending, 1983-2006⁹

Comparison with other healthcare systems

Life expectancy and infant mortality are too blunt to be usedto measure the performance of health systems, as many non-medicalfactors may affect them. Economic, demographic, social, andcultural factors may be just as relevant as medical factorsto health outcomes.² ¹¹ For example, smoking, lack of exercise,obesity, and alcohol may account for half the preventable yearsof life lost in the UK.¹²

More sensitive measures have therefore been devised. A currentfavourite is mortality amenable to health care, defined as deathsthat should not occur in the presence of timely and effectivehealth care.¹³ In a recent survey of European countries, womenin the UK had the third highest, and men the fifth highest,mortality from amenable causes (fig 4).¹⁴

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Fig 4 Age standardised mortality in men (per 100 000) from causes amenable to health care, 2002-3¹⁴

For cancer, survival rate is the preferred global index of thequality of care as it reflects speed and accuracy of diagnosisas well as timely access to effective treatment and clinicalexperts.¹⁵ In a recent study of age adjusted relative cancersurvival in 21 European countries England, Northern Ireland,Scotland, and Wales came in the bottom third (fig 5

).¹⁶

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Fig 5 Age adjusted five year relative survival, all malignancies, women diagnosed 2000-2¹⁶

There is a mini-industry in conducting comparative studies ofhealthcare systems, with the most controversial in recent memorybeing the one published by WHO in 2000. (It ranked the UK 18thin the world.¹⁷) Even if its multiple imperfections hadn’truled it out of consideration,¹⁸ its age would. Fortunately,there’s a more rigorous and recent comparison, producedby the Commonwealth Fund, a private US foundation with a missionto promote a high performing healthcare system.¹¹ ¹⁹

It grouped indicators of health processes and outcomes intofive broad categories: long, healthy, and productive lives;quality; access; equity; and efficiency. The first four of thesewould have been instantly recognisable to Bevan as foundingprinciples for the NHS. Based on data assembled by the CommonwealthFund between 2004-6, the UK emerged in first place, ahead ofGermany, Australia, New Zealand, Canada, and the United States(table).

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Summary scores of health system performance in six countries, 2007*¹¹

The UK was marked down on patient centred care, access (generalpractice opening hours and delays for tests and elective surgery),and healthy lives (mortality amenable to health care and healthylife expectancy at 60). The UK had moved up to first place fromthird place in two previous surveys partly reflecting its efforts"to implement a health information system that supports physicians’efforts to provide quality health care and a payment systemfor primary care physicians that rewards high quality." Someof the British government’s recent initiatives—targetingwaiting lists and general practices’ opening hours—shouldbolster the UK’s ratings.

Despite the UK winning best in show this time around, not everyoneis happy. But, as former banker Derek Wanless reminds us inhis 2001 report to the UK Treasury, unhappiness with healthsystems remains a constant, regardless of the funding systemand how much money is spent.¹² In a comparative study in 2007of public opinion on the extent of change required in theirhealthcare system, the UK fell in the middle of seven countries(fig 6).⁸

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Fig 6 Public opinion on extent of change required by health systems, 2007⁸

Unique spectacle

My rating of the NHS against its founding principles has showna decidedly mixed picture. On a universal, centrally fundedservice, free at the point of delivery the NHS delivers accordingto plan, with the exception of (increasingly vestigial) patients’charges.² ⁴ The government has achieved this by fudging theissue of what healthcare needs are covered by the NHS,³ noteven (in England) mandating the implementation of decisionsmade by the agency it expressly set up to make these decisions(the National Institute for Health and Clinical Excellence).What’s provided is far less than what 21st century consumerswould deem comprehensive and is of widely varying quality. Alongany axis you choose—whether geographic, socioeconomic,or age—the distribution of health care is inequitable.Some inequalities among health outcomes—for example, lifeexpectancy and infant mortality—are actually increasing.³

And yet after meticulous comparison with the experience of similarcountries, the United Kingdom emerges in first place. Who’sright and who’s wrong? Is this discrepancy somehow analogousto an outwardly successful person who nevertheless falls farshort of his or her internal values. If so, what is the rightresponse if these values still have credence?

There’s a second discrepancy evident in this attempt atan NHS scorecard: the gap between patients’ rating ofthe NHS and the public’s, with patients generally morepositive. This raises the question of what influences people’sattitudes to an institution in the absence of direct experienceof it. Pointing the finger at the media seems too easy, giventhat the media are often only the conduit by which strong opinions,of whatever complexion, are conveyed to the public. Writingof his time as minister of health in the early 1960s, EnochPowell may have got nearer the truth: "One of the most strikingfeatures of the National Health Service is the continual, deafeningchorus of complaint which rises day and night from every partof it, a chorus only interrupted when someone suggests thata different system altogether might be preferable, which wouldinvolve the money coming from some less (literally) palpablesource. The universal Exchequer financing of the service endowseveryone providing as well as using it with a vested interestin denigrating it, so that it presents what must be the uniquespectacle of an undertaking that is run down by everyone engagedin it."²⁰

If things don’t seem quite that bad now, hardly a weekgoes by without the government, or one of an array of specialinterest groups, publicly criticising one or other aspect ofthe NHS, apparently motivated by the laudable aim of improvingthe service. Often there’s an ulterior motive that advancesthe critic’s agenda more than the public good. Nevertheless,patients and staff suffer collateral damage, and innocent bystandersassume there must be some substance to the criticisms becauseof the noise. But as long as people’s net satisfactionrating of their 274 million visits a year to primary care servicesis 62%, and 91% of 17 million hospital inpatients rate theircare as excellent, very good, or good, it’s hard for thenegativity to have much of an impact. For some, this resilienceis frustrating.

Next week, in the final article of this series, I will be assessingthe currents swirling around the NHS as it celebrates its 60thbirthday, and what these could mean for its founding principles.

This is the fifth of six articles marking 60 years of the NHS

I have benefited greatly from discussions with John Applebyand Jon Ford.

Competing interests: None declared.

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