Intended for healthcare professionals

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 (Sheilaleatherman{at}, research professor,
  2. Kim Sutherland (k.sutherland{at}, 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.

    • In 2001-2002, the budget for health and personal social services in England was £60.2 billion (≈ $100 billion; Her Majesty's Treasury, 2003). In contrast, the US spends $1.4 trillion annually on health care for its population of 270 million (of whom over 40 million lack insurance).Health spending per capita in the UK is $1992, compared to $4887 in the US.13In 2002, the UK Labour Government committed to increase investment by 7.5% a year, compared to a historical annual increase of 3.7%. This will result in a rise in the share of GDP spent on health care from 7.7% in 2002 to 9.4% in 2007.


    The quality agenda comprises a multitude of new organizations and initiatives concerned with such diverse functions as regulation, inspection, standard setting, change management, patient advocacy, assessment of clinician competency, “pay for performance” contracts, and routine performance monitoring. Broadly speaking, the quality agenda represents a coherent and comprehensive set of policies that have built organizational capacity and conditioned the system to enable the NHS to realize the benefits of increased investment. It has been driven centrally by the government in a largely top-down fashion, inciting concerns by some constituencies, particularly, the professions.

    Admittedly, the NHS is not often looked to by the US for lessons on how to improve performance in health care systems, but there are indeed lessons to be learned…. In the US, we have relied excessively on… what is often called a consumer-oriented system.

    In our study, we applied internationally accepted domains of quality to evaluate impact: access, effectiveness, system capacity, patient centeredness, and disparities. Many of the early efforts in England have focused on access, reflecting widespread public concern about waiting times. In 1999-2000, some 50 000 patients were waiting more than 12 months for admission to hospital; by the last quarter of 2002-2003, this figure had fallen to 73. Similar success has been achieved in reducing the longest waits (> 26 weeks) for outpatient appointments. These fell from almost 150 000 patients who were waiting in the fourth quarter of 1999-2000 to 9655 at the end of 2002-2003. Access issues play a role in outcomes of care, such as for breast cancer survival rates. In 1985-1989, these were well below those in other comparable countries,1 explained in part by the lag between suspected diagnosis and specialist consultation. At the end of 2002-2003, 98% of patients with suspected cancer were seen by a specialist within 14 days (of referrals received by NHS Trusts within 48 hours). Access problems remain, however; for example, around 20% of patients continue to wait over six months for surgery.

    Capacity measures must be part of a quality evaluation in the NHS; this contrasts with the United States, where structural measures are infrequently used. Critical workforce shortages continue to plague the NHS despite some increases. Compared with 1997, there are 13% more nurses, 15% more doctors, and 4% more general practitioners. Publicly acknowledged resource problems have been tackled in critical care beds (increased 30% since 2000), specialized stroke units (audit data show a 50% increase since 1998), and scanning technology (over 200 new CT and MRI scanners purchased since 2000).

    Beyond access and capacity, there have been notable successes in the last five years in increased appropriateness. For example, the use of thrombolytic drugs and secondary prevention of myocardial infarction have increased markedly in a short period. Patient outcomes show improvement: Mortality rates from circulatory disease have fallen by 19%, and those from cancer have decreased by 9% since 1995-1997. Gains in treating these diseases are attributed in part to additional resources as well as to National Service Frameworks (NSFs), which set national standards and define critical interventions in key clinical areas (eg, diabetes, cancer, coronary heart disease).


    Overall, our midterm evaluation of England's quality agenda is a positive one. The data we collected suggest that the NHS, as a system, shows the capacity to improve predictably. We emphasize that these are early results; the arduous work of embedding systemic improvement in the NHS is still to be done. Additionally, we must temper our conclusions with a concern about the deficiency of validated, standardized, and longitudinal data. Such data sets are essential for authoritative, credible, and actionable analyses of system performance and clinical quality.

    What lessons can be learned by the US from these midterm observations of the NHS? It is likely that four factors explain progress to date. The first is political leadership—the will and courage to admit problems with quality. Second, careful design and development of a policy environment and requisite national organizational capacity. Third, commitment of necessary resources which, in the case of England, constituted significantly increased expenditures. And finally, explicit articulation of priorities and the promulgation of NSFs, which define the evidence base, identify deficiencies of care, and allocate resources to actualize national policy objectives through clinical services.

    Admittedly, the NHS is not often looked to by the US for lessons on how to improve performance in health care systems, but there are indeed lessons to be learned. A recent publication summarizing the results of patient surveys performed in 2001-2002 in five countries (US, UK, New Zealand, Australia, Canada) shows the UK performing better than the US. This is not unsurprising in the domain of equitable access to care (unimpeded by cost), but it is in patient-reported perceptions of safety (medication errors), care coordination, and overall satisfaction with the health system.5

    The US is often viewed as leading internationally in the state of the art of clinical medicine as well as in the field of quality measurement and improvement. Why, then, does the US not consistently excel across objective and comparative measures of quality—in access, safety, effectiveness, and efficiency? In part, because the US lacks a cohesive policy environment—a particularly devastating gap in a fragmented health care system driven by a host of disparate and competing interests and still wrestling with growing numbers of uninsured.

    Three models of accountability in and improvement of health systems have been described: professional, economic, and governmental.6 In the first, it is professional conduct and ethics that drive improvements in performance. This is operative to a varying extent in all countries, but it is increasingly supplemented by the market or government models. In the US, we have relied excessively on the market, or what is often called a consumer-oriented system. Despite efforts by some employers and health care organizations, deficiencies in quality remain serious and widespread.7 The Quality Agenda implemented in England demonstrates the potential for government to play a constructive and cogent role, one that is also applicable in the US, with modifications. The role of the US government is dramatically weaker than that of the UK, not only for the obvious reason of our private sector-based health system but also because American attitudes are equivocal with respect to government having a hand in health care, outside of well-delineated programs such as Medicare.

    Professional ethos and market dynamics are proving to be necessary but insufficient in driving predictable and sustained improvements in quality in the US. Routine conduct by the professions of quality improvement practices is uneven and unpredictable. Efforts by purchasers exercising economic clout coupled with individual health care organizations voluntarily adopting quality improvement methods have led to demonstrable improvements8—but more is needed. It is time to revisit the findings and recommendations of the national bipartisan Advisory Commission on Consumer Protection and Quality in the Health Care Industry appointed by President Clinton.9 After more than a year of study, the final report in 1998 urged that the expansion of voluntary actions by the private sector be augmented by increased leadership by the government. Some steps have been taken, such as the recently published reports on national quality and disparities in health care.10,11 Additional actions should include the identification of specific priorities (clinical conditions and populations) to improve quality of care,12 the establishment of a national quality council, and the implementation of incentives to encourage improved quality. These and other actions by the US government are needed to catalyze systemic capacity building for quality improvement, in the same manner as is proving effective in England.


    • Conflict of interest None declared.


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