Healthcare outcomes and quality in the NHS: how do we compare and how might the NHS improve?BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3036 (Published 13 July 2018) Cite this as: BMJ 2018;362:k3036
- Azeem Majeed, professor of primary care1,
- Dominique Allwood, assistant director of improvement2,
- Kim Foley, patient1,
- Andrew Bindman, professor of medicine, health policy, and epidemiology and biostatistics3
- 1Department of Primary Care and Public Health, Imperial College London, London, UK
- 2Health Foundation, London, UK
- 3UCSF School of Medicine, San Francisco, CA 94118, USA
- Correspondence to: A Majeed
Health outcomes in the United Kingdom have improved substantially since the NHS was established in 1948.1 For example, average life expectancy has increased by around 12 years from 68 to 80 years; and infant mortality has fallen nearly 90%, from 34/1000 live births to less than 4/1000.2 The NHS performs well in many international comparisons on measures such as efficiency, equity, and access.3 Despite these achievements, however, problems with health outcomes remain.34 Moreover, other European countries have also improved their health outcomes in recent decades, often at a faster rate than the UK. Consequently, the UK now lags behind many other European countries in key health outcomes in areas such as child health and cancer survival. Here, we review the quality of care and health outcomes in the NHS, focusing on areas that are important to patients, policy makers, and clinicians4 and for which there are comparative international data.
How does the NHS compare with other countries?
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
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.
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
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
Improving health outcomes—aiming above the European average
The NHS needs to focus its efforts on improving health outcomes so the UK is once again above the European average for key health indicators. The implementation of all new health policies should be viewed through this objective, and politically expedient schemes that are not cost effective and do not improve health outcomes—such as extended hours primary care services—should be jettisoned.
A lot of focus in the UK is on avoidable admissions. As these mainly occur among frail, elderly people, insufficient emphasis may be given to morbidity among children, in whom long term conditions, unplanned admissions, and deaths are all less common than in older people.12 Improving health outcomes also means reducing regional variations in the quality of care and health outcomes—for example, in mortality after hospital admission for hip fracture, which have persisted in the NHS ever since its foundation. Reducing these variations by improving outcomes in the worst performing areas would substantially improve the overall health outcomes achieved by the NHS.1314
What is needed to achieve better outcomes?
The NHS benefits from single payer status, with funding coming largely from taxation and only a small proportion raised through user fees (such as prescription charges). This has allowed the NHS to control costs better than health systems in many other countries. It therefore scores well on international comparisons of health system efficiency but has not always performed well on outcome measures.3 Its centralised structure means that innovations and changes in clinical services can take place relatively quickly. Nevertheless, the NHS does still have some structural problems that are relevant to its outcomes.
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).
Quality of NHS care—a patient perspective
As an NHS patient, I have been pleased at the prompt access to care when needed. I have had many positive interactions with healthcare professionals and staff at the surgeries and clinics and I have been grateful for the opportunity to be involved in decision making about my care and treatment plans.
Based on my personal experience, one area that I feel could use attention is the communication between specialists and my GP surgery. As a specific example, I was referred to a specialist for a suspicious mole. Although an appointment was made quickly for me and the mole removed, I did not hear anything about the results for a couple of months. My GP was unable to assist as they did not have access to that information, and the delays caused me some anxiety. I was unsure who to contact for the test results and eventually called the Patient Advice and Liaison Service to assist me in chasing the results. Perhaps my expectations for receiving the test results were unrealistic, but enhanced communication in this area (or between the specialist and my GP) would have improved my experience of the NHS.RETURN TO TEXT
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 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.
The NHS, despite its many achievements, lags behind health systems in similar countries in achieving good population health outcomes. Better performance will require a concerted focus on the quality of care, including a much greater emphasis on improving health outcomes when planning and implementing health services. Improved integration of primary and secondary care, investment in specialist services, and addressing the shortage of health professionals may help narrow the outcomes gap with our comparators.
The additional investment the government has recently promised for the NHS in England (along with investment for the NHS in the devolved nations) is welcome.22 However, we wait to see if this additional funding will be sufficient to meet the needs of the UK and whether lower rates of public spending in other areas—such as housing and education—lead to health outcomes in the UK falling further behind those in other European countries.
Important health outcomes such as life expectancy and infant mortality have improved substantially in the UK since 1948
In some key areas, such as child health outcomes and cancer survival, the UK has fallen behind other European countries
New health policies should help the NHS to focus on improving health outcomes
Continued progress is also needed on wider determinants of health such as poverty, housing, education, employment, and the environment
Contributors and sources: AM,DA, and ABM have experience of designing, implementing, and evaluating quality improvement initiatives in healthcare. To prepare this article, we used data from academic publications, reports from non-governmental organisations, and international health statistics from Eurostat. AM wrote the first draft and received comments from DA, KF, and AB. AM is the guarantor.
Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: AM is a GP principal in an NHS practice. DA is a consultant in public health medicine with the Imperial College Healthcare NHS Trust. Imperial College London receives support from the NIHR Collaboration for Leadership in Applied Health Research and Care programme.
Provenance and peer review: Commissioned; externally peer reviewed.