Bmj Usa Editorial

Quality of care in the NHS of England

BMJ 2004; 328 doi: (Published 15 April 2004) Cite this as: BMJ 2004;328:E288
  1. Sheila Leatherman (, research professor,
  2. Kim Sutherland (, research associate in health
  1. School of Public Health University of North Carolina Chapel Hill, NC
  2. Judge Institute of Management University of Cambridge Cambridge CB2 1AG, UK

    Any progress? Any lessons?

    The United Kingdom's National Health Service (NHS) was established in post-war Britain (1948) as a social contract between the government and the people, based on explicit values of universality and equity. It is an icon worldwide, both as a social insurance system and as a nationalized health delivery service. The NHS has been remarkably frugal; over four decades the UK has been among the lowest health care spenders of Organisation for Economic Co-operation and Development countries, in absolute terms and as a proportion of gross domestic product (GDP).1 The relatively low expenditure, once feted as a virtue achieved through efficiency, has increasingly been seen as under-investment that has compromised the system's ability to meet the population's health care needs.

    In 1997-1998, government policy documents acknowledged the magnitude of problems, pledging to place “quality at the heart of the NHS.”2,3 In November 2003, we published an evaluation of the resulting 10-year quality agenda at its midpoint.4 We characterized the quality agenda as being the “most ambitious, comprehensive, systemic and intentionally funded effort to create predictable and sustainable capacity for improving the quality of a nation's health care system.” Two research questions were fundamental to our evaluation: whether the policy initiatives for building predictable systemic capacity for quality improvement were coherent and cogent, and what evidence of impact existed to date.

    National Health Service

    • Health care for England's 50 million people is primarily funded by tax revenues. A wide range of services, largely free at delivery, is provided by the NHS, an organization of 1.2 million employees. Around 12% of the population have private health insurance to supplement NHS provision, primarily for elective procedures. Access is mediated by a tradition of “surreptitious rationing” based on the “5 D's” of delay, defer, deter, dissuade, and decline. …

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