Feature Data Briefing

Does poor health justify NHS reform?

BMJ 2011; 342 doi: http://dx.doi.org/10.1136/bmj.d566 (Published 28 January 2011) Cite this as: BMJ 2011;342:d566
  1. John Appleby, chief economist
  1. 1King’s Fund, London W1G 0AN, UK
  1. j.appleby{at}kingsfund.org.uk

Andrew Lansley claims radical NHS reform is necessary to drive up the UK’s poor health outcomes compared with Europe. But is our record really so bad, questions John Appleby?

On the basis that if it ain’t broke don’t fix it, England’s health secretary, Andrew Lansley, has said that his reforms for the NHS are needed because the country’s health outcomes are among the poorest in Europe. But are they?

The official ministerial briefing for the Health and Social Care Bill states that despite spending the same on healthcare, our rate of death from heart disease is double that in France.1 Although statistics from the Organisation for Economic Cooperation and Development (OECD) confirm that in 2006 the age standardised death rate for acute myocardial infarction was around 19/100 000 in France and 41/100 000 in the United Kingdom,2 comparing just one year—and with a country with the lowest death rate for myocardial infarction in Europe—reveals only part of the story. Not only has the UK had the largest fall in death rates from myocardial infarction between 1980 and 2006 of any European country, if trends over the past 30 years continue, it will have a lower death rate than France as soon as 2012.

These trends have been achieved with a slower rate of growth in healthcare spending in the UK compared with France and at lower levels of spending every year for the past half century. The most recent OECD spending comparisons show that in 2008, the UK spent 8.7% of its gross domestic product on health compared with 11.2% for France—28% more.2

The epidemiology of the downward trend in deaths from myocardial infarction is of course more complicated than a simple function of increased NHS spending—just as comparing countries’ population health outcomes needs to be approached with caution. The trajectory for many causes of death swoops up and down over decades—often linked to changes in lifestyle behaviours rather than spending on healthcare.

Our apparently poor comparison with other countries on cancer deaths has also been a key argument for reforming the NHS. However, comparisons are not straightforward and depend where you look. Death rates for lung cancer in men, for instance, rose steadily to a peak in the UK in 1979. But since then they have steadily fallen, mirroring long term changes in smoking patterns, and are now lower than for French men, where the peak death rate occurred over a decade later in the 1990s.2 Similar long term trends are evident for breast cancer mortality. Since 1989, age standardised death rates per 100 000 in the UK have fallen by 40% (from 37.8 to 24.4) to virtually close the gap with France, where they have fallen by just 10% (from 25.5 to 22.0).2 Again, if trends continue, it is likely that the UK will have lower death rates than France in just a few years.

Mortality is one thing, survival another. The most comprehensive ongoing study of cancer survival across Europe is the Eurocare study.3 As Cancer Research UK has pointed out, although the Eurocare data often feed headlines that the UK is the “sick man of Europe” for many cancers, trends from Eurocare actually show improvements in survival rates for the UK.4 These are confirmed by the Office for National Statistics, which last year reported improvements in five year survival rates between 2001-6 and 2003-7 for nearly all cancers.5 But Eurocare is problematic; the latest study includes diagnoses only up to 2002, and coverage is patchy (French data cover around 10-15% of people with cancer, the UK, 100%).6 Furthermore, differences in survival rates may reflect variations in how early diagnoses are made, not the state of healthcare in different countries.


Cite this as: BMJ 2011;342:d566


  • Competing interests: The author has completed the unified competing interest form at www.icmje.org/coi_disclosure.pdf (available on request from him) and declare no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; not externally peer reviewed.