Health system report ranks UK first, US last

BMJ 2014; 348 doi: (Published 17 June 2014) Cite this as: BMJ 2014;348:g4080
  1. Michael McCarthy
  1. 1Seattle

The United Kingdom was ranked highest overall, Switzerland second, and the United States last in a new report that compared the health systems of 11 developed nations.1 The US, the report noted, spent more than $8500 (£5000; €6270) per capita on health in a year, while the UK spent less than half that, at $3400 per person.

The study was the fifth in a series produced by the Commonwealth Fund. It draws on international surveys that the New York City based foundation has conducted with patients and doctors, as well as data on health spending and outcomes from the Organisation for Economic Cooperation and Development and the World Health Organization.

The report ranked the 11 countries in this order:

  • The UK,

  • Switzerland,

  • Sweden,

  • Australia,

  • Germany and the Netherlands (a tie),

  • New Zealand and Norway (another tie),

  • France,

  • Canada, and

  • The US, which was ranked lowest for the fifth time in a row.

The report ranked the nations according to five measures of health system performance: quality of care, access to care, efficiency, equity, and healthy lives, which were based on indicators such as infant mortality or mortality amenable to healthcare. The US came last or nearly last in four of these five measures and scored in the mid-range for quality.

In terms of quality, on the basis of a system’s ability to provide “effective, safe, coordinated, and patient-centered care,” the UK was ranked first and Norway last. The US did well in providing preventive care and was ranked third in providing effective care overall, but it was ranked only average on chronic care management, the report found.

The report said, “The widespread and effective use of health information technology (HIT) in the UK plays a large role in the country’s high score on the chronic care management indicators, as well as its performance on system aspects of preventive care delivery.”

In the area of patient safety, the UK again ranked first and Norway last. The US ranked seventh but had shown improvement, the report said. “For example, the US now leads all nations with a relatively low number of sicker patients reporting an infection during a hospital stay or shortly after. Such progress could be indicative of the numerous safety initiatives under way throughout the country and recent imposition of financial penalties for hospitals with high rates of hospital acquired conditions.”

The US also did well in terms of provider–patient communication, the report said. “Among sicker adults who had been hospitalized within the past two years, American patients were the most likely to receive a written plan for care after discharge and to know whom to contact for questions about their condition or treatment when leaving the hospital.”

Lack of access to care continued to plague the US system, the report found. “Americans were the most likely to say they had access problems because of cost. Thirty-seven per cent said they did not get recommended care, fill a prescription, or visit a doctor or clinic when they had a medical problem because of cost.

“In the next highest country, the Netherlands, the comparable percentage was 22. Patients in the United Kingdom and Sweden were the least likely to report having these cost related access concerns (4% and 6%, respectively),” the report noted.

Timeliness of care varied, depending on the type of services patients were seeking. US patients, for example, reported difficulty in obtaining rapid access to some primary care services, but access to specialty care was relatively rapid.

Although it is common to associate universal coverage with long waiting times for specialty care, the report found that this was not necessarily true. “The UK has short waiting times for basic medical care and nonemergency access to services after hours. The UK also has improved waiting times to see a specialist and now rates fourth on this dimension with the US ranking third,” the report said.

In terms of efficiency the US scored last, spending 17.7% of its gross domestic product (GDP) on healthcare, with 7.1% of that spending going on administrative costs. By comparison, the UK spent 9.4% of its GDP on healthcare, with 3.4% of the spending going on administration.

The US did poorly on all measures of equity, scoring last overall, the report found. “Americans with below average incomes were much more likely than their counterparts in other countries to report not visiting a physician when sick; not getting a recommended test, treatment, or follow-up care; or not filling a prescription or skipping doses when needed because of costs. On each of these indicators, one third or more of lower income adults in the US said they went without needed care because of costs in the past year.”

In the final measure, healthy lives, France was ranked highest overall, scoring among the top three countries on each of the three indicators—mortality amenable to healthcare, infant mortality, and healthy life expectancy at age 60. The US was lowest overall, ranking last on mortality amenable to healthcare, last on infant mortality, and second to last on healthy life expectancy at age 60.

Although the UK ranked near or at the top of most measures of health system performance, it ranked second to last for healthy lives. The fact that France—which ranked near the bottom overall—was ranked the highest in healthy lives while the UK came near the bottom, may reflect a lack of comparable cross national health outcomes data, the report noted. “However, the indicators that are available demonstrate the healthcare system to be just one of many factors, including social and economic wellbeing, that influence the health of a nation,” it added.

The report concluded that its findings showed “a consistent relationship between how a country performs in terms of equity and how patients rate other dimensions of performance: the lower the performance score for equity, the lower the performance on other measures. This suggests that, when a country fails to meet the needs of the most vulnerable, it also fails to meet needs for the average citizen.”


Cite this as: BMJ 2014;348:g4080


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