Rapid responses are electronic comments to the editor. They enable our users
to debate issues raised in articles published on bmj.com. A rapid response
is first posted online. If you need the URL (web address) of an individual
response, simply click on the response headline and copy the URL from the
browser window. A proportion of responses will, after editing, be published
online and in the print journal as letters, which are indexed in PubMed.
Rapid responses are not indexed in PubMed and they are not journal articles.
The BMJ reserves the right to remove responses which are being
wilfully misrepresented as published articles or when it is brought to our
attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not
including references and author details. We will no longer post responses
that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Of benchmarking (and bashing) of healthcare systems
It is rather an uncanny coincidence that at the same time that the BMJ reports the latest Euro Health Consumer Index, as produced by the Swedish think tank Health Consumer Powerhouse in the news section, Des Spence, in his regular commentary takes head-on the (so-called) attack of right-leaning papers on the NHS and medical profession.1 In the Euro Health Consumer Index of 2012, the United Kingdom (i.e. NHS) ranks 12, an improvement over its previous rank of 14 in 2009. Whereas the UK still lags behind the (back-to-back) leaders, the Netherlands, Denmark and Iceland, it is now ahead of Germany and is faring well against Austria, which like Germany in previous rankings was placed ahead of the UK.
In this regard, it would be tempting to parlay the results of European healthcare league, as the BMJ called the benchmark, to support Dr. Spence’s claims about the NHS as healthcare system that is “very good at dealing with acute, serious, and chronic illness”. To do so, however, would be improvident not least because the ranking does not consider the of the role it places on the rights of patients and because it portrays the Dutch healthcare system as a “European model to copy not lease by abolishing single-payer systems”.2
The Euro Health Consumer Index, in ranking healthcare systems, uses a checklist of 42 indicators grouped into five categories or sub-disciples as: patients’ rights and information (12); accessibility (5); outcomes (8); prevention/range and reach of services provided (10); and pharmaceuticals (7). No country consistently performs well in the individual categories. In fact, top placer, the Netherlands, leads in only two sub-disciplines, patient rights, information and e-Health and prevention/range and reach of services provided. Finland, Switzerland and Sweden also secure top posts in two of five sub-disciplines.
As with the WHO ranking of healthcare systems3, the index suffers from scientific and instrumental weaknesses which have to be addressed lest harm be caused by absolute confidence in it. Instead of enumerating the weak spots such as the non-inclusion of “waiting-time from arrival at the practice to consult with the physician” as an indicator of accessibility, inclusion of “informal payments to doctors” as an indicator of prevention/range and reach of services instead of accessibility and focus on specific drugs as well as marketing among indicators of pharmaceuticals, a simple table is presented comparing the UK against selected healthcare systems using data from the World Bank and the WHO.
Based on Table 1, the favorable outcomes covering prevention, communicable disease and mortality by the Netherlands come with a relatively higher price tag compared to the UK, Italy, Germany, and Australia, which was included to explore the idea of lessons beyond Europe. Still, adult mortality is lower in relatively low-cost Australia and Italy. On the point of “inexpensiveness” of the healthcare raised by Dr. Spence, which by nature has to be relative, the UK is inexpensive compared to Germany and the Netherlands, indeed, but it is expensive compared to Australia or Italy. The question goes, can we afford to spend as much as Germany or the Netherlands and, ideally, buy better outcomes?6, 7
Since higher spending does not guarantee better outcomes, and well, resources spent on health care are disinvestment elsewhere, perhaps the challenge that confront us is making do with what we have and still improve on how we deliver care.8,9 Benchmarking of healthcare systems, to the extent that it spurs debate about health and healthcare between and across healthcare systems is warranted. Failing to recognize the limits of such a process, including the politics behind it, however, augers ill for us all. The same goes for incendiary discussions whether in the US on socialized medicine in Canada and Europe or about the distortions of free market medicine over here and the “sins” of stakeholders.
A difficult patient can be unreasonable. Unrealistic. Entitled. Demanding. However, not one is “unreasonable, unrealistic, entitled, and ridiculously demanding” without reason, (mis)informed, and being cultured into.1 The same goes for the doctor who is hurried. Authoritarian. Paternalistic.10 And of health care systems? Some are publicly-funded either by taxation (i.e. Beveridge model) or wage income deductions (i.e. Bismarck model) or privately funded through premiums for health insurance coverage. One performs well in certain areas while lags in other areas be they spending, productivity and health outcomes. Considering the institutions that shaped and (continue to) define healthcare systems, we tread a fine line in judging values that societies hold in painting healthcare systems as exemplar for the rest to embrace.11
Re: Medicine is our vocation
Of benchmarking (and bashing) of healthcare systems
It is rather an uncanny coincidence that at the same time that the BMJ reports the latest Euro Health Consumer Index, as produced by the Swedish think tank Health Consumer Powerhouse in the news section, Des Spence, in his regular commentary takes head-on the (so-called) attack of right-leaning papers on the NHS and medical profession.1 In the Euro Health Consumer Index of 2012, the United Kingdom (i.e. NHS) ranks 12, an improvement over its previous rank of 14 in 2009. Whereas the UK still lags behind the (back-to-back) leaders, the Netherlands, Denmark and Iceland, it is now ahead of Germany and is faring well against Austria, which like Germany in previous rankings was placed ahead of the UK.
In this regard, it would be tempting to parlay the results of European healthcare league, as the BMJ called the benchmark, to support Dr. Spence’s claims about the NHS as healthcare system that is “very good at dealing with acute, serious, and chronic illness”. To do so, however, would be improvident not least because the ranking does not consider the of the role it places on the rights of patients and because it portrays the Dutch healthcare system as a “European model to copy not lease by abolishing single-payer systems”.2
The Euro Health Consumer Index, in ranking healthcare systems, uses a checklist of 42 indicators grouped into five categories or sub-disciples as: patients’ rights and information (12); accessibility (5); outcomes (8); prevention/range and reach of services provided (10); and pharmaceuticals (7). No country consistently performs well in the individual categories. In fact, top placer, the Netherlands, leads in only two sub-disciplines, patient rights, information and e-Health and prevention/range and reach of services provided. Finland, Switzerland and Sweden also secure top posts in two of five sub-disciplines.
As with the WHO ranking of healthcare systems3, the index suffers from scientific and instrumental weaknesses which have to be addressed lest harm be caused by absolute confidence in it. Instead of enumerating the weak spots such as the non-inclusion of “waiting-time from arrival at the practice to consult with the physician” as an indicator of accessibility, inclusion of “informal payments to doctors” as an indicator of prevention/range and reach of services instead of accessibility and focus on specific drugs as well as marketing among indicators of pharmaceuticals, a simple table is presented comparing the UK against selected healthcare systems using data from the World Bank and the WHO.
Based on Table 1, the favorable outcomes covering prevention, communicable disease and mortality by the Netherlands come with a relatively higher price tag compared to the UK, Italy, Germany, and Australia, which was included to explore the idea of lessons beyond Europe. Still, adult mortality is lower in relatively low-cost Australia and Italy. On the point of “inexpensiveness” of the healthcare raised by Dr. Spence, which by nature has to be relative, the UK is inexpensive compared to Germany and the Netherlands, indeed, but it is expensive compared to Australia or Italy. The question goes, can we afford to spend as much as Germany or the Netherlands and, ideally, buy better outcomes?6, 7
Since higher spending does not guarantee better outcomes, and well, resources spent on health care are disinvestment elsewhere, perhaps the challenge that confront us is making do with what we have and still improve on how we deliver care.8,9 Benchmarking of healthcare systems, to the extent that it spurs debate about health and healthcare between and across healthcare systems is warranted. Failing to recognize the limits of such a process, including the politics behind it, however, augers ill for us all. The same goes for incendiary discussions whether in the US on socialized medicine in Canada and Europe or about the distortions of free market medicine over here and the “sins” of stakeholders.
A difficult patient can be unreasonable. Unrealistic. Entitled. Demanding. However, not one is “unreasonable, unrealistic, entitled, and ridiculously demanding” without reason, (mis)informed, and being cultured into.1 The same goes for the doctor who is hurried. Authoritarian. Paternalistic.10 And of health care systems? Some are publicly-funded either by taxation (i.e. Beveridge model) or wage income deductions (i.e. Bismarck model) or privately funded through premiums for health insurance coverage. One performs well in certain areas while lags in other areas be they spending, productivity and health outcomes. Considering the institutions that shaped and (continue to) define healthcare systems, we tread a fine line in judging values that societies hold in painting healthcare systems as exemplar for the rest to embrace.11
Competing interests: No competing interests