Healthcare outcomes and quality in the NHS: how do we compare and how might the NHS improve?

Life expectancy

One important measure of population health, which is less prone to bias than some other measures, is the average life expectancy in a country. For men, current average life expectancy in the UK (79.2 years) is around the average for countries in the Organisation for Economic Cooperation and Development (OECD). For women, the average life expectancy—although higher than for men—is below the average for the OECD (82.8 for the UK versus 83.9 for the OECD).4

Child health

Improvements in child mortality in the UK have lagged behind those seen in many other European countries. For example, the average infant mortality in the 28 current members of the European Union (EU28) in 1961 was 36.2 per 1000 births, substantially above the level in the UK in that year (22.1); but by 2015, infant mortality in the EU28 had fallen to 3.6 per 1000, below the level in the UK (3.9) in the same year (fig 1). The absolute differences in childhood mortality are now though quite small and may be better tackled through social measures—such as reducing poverty—than through health service interventions.

Fig 1

Infant mortality (deaths/1000 live births) in EU28. UK and Sweden, 1960-2015

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The UK also lags behind many other EU countries in childhood mortality from potentially preventable causes such as meningococcal disease, pneumonia, and asthma. Although death rates in children from these conditions are low, the higher death rates in the UK suggest that there may be problems with their recognition and management and the way in which health and social support for children is organised in the UK (for example, a lack of integration between primary care and specialist child health services); austerity in the public sector is another contributor to poor child health.5 The UK also lags on some of the important wider socially determined aspects of child health. For example, it has low breastfeeding rates and high rates of childhood overweight and obesity.6

Management of long term conditions

The NHS generally performs well on measures of the management of long term conditions in adults. The UK Quality and Outcomes Framework is the largest primary care based pay for performance programme in Europe and has helped to improve prescribing in key areas, such as diabetes and coronary heart disease.7 For example, the UK has the highest per capita use of statins in Europe, important for the primary and secondary prevention of cardiovascular disease. It also has among the lowest rates for amputation of the distal leg in Europe (table 1). A 2014 study comparing 30 European countries ranked the UK fourth for the quality of diabetes care, behind only Sweden, the Netherlands, and Denmark.8

Cancer survival

The UK has long lagged behind comparator countries in cancer survival, and this difference has persisted in recent years despite the introduction of the “two week rule” requiring patients with suspected cancer to be seen by a specialist within 14 days of their referral by a general practitioner. In the CONCORD study of global trends, five year cancer survival in the UK was below that of many other European countries (table 2 shows figures for colon cancer).9

The underlying reasons for the poorer cancer outcomes in the UK are complex. The explanations will include factors such as delayed presentation by patients; delays in recognising cancer symptoms in primary care and referring patients to specialists; delays in completing specialist initiated investigations; and regional variations in the uptake of the most evidence based treatments for cancer.1011

Integration of services

When the NHS was first established, general practitioners remained independent contractors. Although they provided publicly funded primary care, they were not employed by the NHS. This resulted in a split between the provision of primary care and specialist services, which still remains. Despite decades of speaking about the importance of the integration of services, it is difficult to see how the NHS can achieve this objective when hospitals and general practices remain separate organisations.15 For patients, this split can be hard to understand as they generally see the NHS as one organisation and do not understand why the different parts of the NHS are not more connected (box 1).

Bringing general practices and specialist services into one organisation will not be politically straightforward; nor will it be cheap.16 Investment in integrated services will, however, ensure that people can obtain appropriate care promptly. This is particularly important for patients with long term conditions such as heart failure or chronic airways disease, for which complications and unplanned hospital admissions are common if exacerbations are not identified and treated quickly.

Another important target for integration is urgent care. Currently, patients with acute problems are faced with a range of services to choose from. In England this includes, for example, NHS 111, out-of-hours primary care services, urgent care centres, emergency departments, pharmacies, community nursing services, and the ambulance service. Patients are often confused about which service is most appropriate for their needs, which in turn leads to inappropriate use of some services (such as emergency departments and ambulance services). Integrating these services and having one single point of contact would benefit both the NHS and patients.17

Specialist services

Specialist services also need increased investment if the NHS is to continue to improve the population’s health status and health outcomes. On many important structural indicators—such as the number of hospital beds and diagnostic equipment—the UK lags behind most other European countries. The effect of this under-investment is now being seen, for example, in fewer patients meeting targets for cancer treatment, increased pressures on emergency departments, and lower public satisfaction with the NHS.18

Tackle shortages of health professionals

The UK has shortages in key medical specialties such as general practice, paediatrics, and emergency medicine as well as in other health professionals such as nurses and therapists. The UK has around 2.8 doctors per 1000 population, which is below the European average. The UK also has fewer nurses per 1000 population (7.9) than countries such as Germany (13.3 per 1000) or Switzerland (18 per 1000).18 Although the government has promised to tackle the shortages, little progress has been made; in the past few years, for example, the number of general practitioners working in the NHS in England has declined further.19 Given that these shortages will present for some years to come, the NHS needs to look at ways in which the skills of health professionals are used appropriately, such as by reducing the low value administrative work they undertake.

Improved use of digital technology

The rapid advances we are seeing in information technology present an opportunity for the NHS. Through the internet and websites such as NHS Choices, patients in the UK now have easy access to medical information for self care. Developments in artificial intelligence (AI) are also leading to new routes for accessing medical and health promotion advice. In the longer term AI may be used to support the work of doctors and other health professionals in areas such as radiology and dermatology and to provide tools to support the further integration of health services—for example, better sharing of medical records between health services and with patients.

One caveat about digital health is the gap between the postulated and empirically demonstrated benefits of these technologies. There are few well designed studies on the risks of implementing these technologies or on their cost effectiveness.20

Reduce health inequalities

Many of the poorer health outcomes in the UK can be explained by the wider determinants of health such as housing, employment, poverty, and social support.21 These factors will be particularly important for groups such as children and elderly people, for whom NHS based initiatives by themselves will not be enough to improve UK health indicators.