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Performance of UK National Health Service compared with other high income countries: observational study

BMJ 2019; 367 doi: (Published 27 November 2019) Cite this as: BMJ 2019;367:l6326
  1. Irene Papanicolas, associate professor of health economics1 2 3,
  2. Elias Mossialos, Brian Abel-Smith professor of health policy1,
  3. Anders Gundersen, senior research project coordinator3,
  4. Liana Woskie, PhD candidate and research fellow1 2 3,
  5. Ashish K Jha, K T Li professor of global health, director23
  1. 1Department of Health Policy, London School of Economics and Political Science, London, UK
  2. 2Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA, USA
  3. 3Harvard Global Health Institute, Cambridge, MA, USA
  1. Correspondence to: I Papanicolas I.N.Papanicolas{at}
  • Accepted 25 October 2019


Objective To determine how the UK National Health Service (NHS) is performing relative to health systems of other high income countries, given that it is facing sustained financial pressure, increasing levels of demand, and cuts to social care.

Design Observational study using secondary data from key international organisations such as Eurostat and the Organization for Economic Cooperation and Development.

Setting Healthcare systems of the UK and nine high income comparator countries: Australia, Canada, Denmark, France, Germany, the Netherlands, Sweden, Switzerland, and the US.

Main outcome measures 79 indicators across seven domains: population and healthcare coverage, healthcare and social spending, structural capacity, utilisation, access to care, quality of care, and population health.

Results The UK spent the least per capita on healthcare in 2017 compared with all other countries studied (UK $3825 (£2972; €3392); mean $5700), and spending was growing at slightly lower levels (0.02% of gross domestic product in the previous four years, compared with a mean of 0.07%). The UK had the lowest rates of unmet need and among the lowest numbers of doctors and nurses per capita, despite having average levels of utilisation (number of hospital admissions). The UK had slightly below average life expectancy (81.3 years compared with a mean of 81.7) and cancer survival, including breast, cervical, colon, and rectal cancer. Although several health service outcomes were poor, such as postoperative sepsis after abdominal surgery (UK 2454 per 100 000 discharges; mean 2058 per 100 000 discharges), 30 day mortality for acute myocardial infarction (UK 7.1%; mean 5.5%), and ischaemic stroke (UK 9.6%; mean 6.6%), the UK achieved lower than average rates of postoperative deep venous thrombosis after joint surgery and fewer healthcare associated infections.

Conclusions The NHS showed pockets of good performance, including in health service outcomes, but spending, patient safety, and population health were all below average to average at best. Taken together, these results suggest that if the NHS wants to achieve comparable health outcomes at a time of growing demographic pressure, it may need to spend more to increase the supply of labour and long term care and reduce the declining trend in social spending to match levels of comparator countries.


  • Contributors: IP led the design of the study, guided the data collection and creation of tables and figures, and drafted the manuscript. EM provided critical guidance on the project to make it as relevant to a UK audience as possible and contributed to the drafting of manuscript. AG contributed to data collection, table and figure creation, and drafting of the manuscript. LW participated in data collection and drafting of the manuscript. AKJ supervised the data collection and drafting of the manuscript. The corresponding author attests that all listed authors meet the criteria for authorship and that no others meeting the criteria have been omitted. All authors have read and approved the final draft. IP is the guarantor.

  • Funding: None.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Not needed, as the study relied solely on secondary, aggregated data and involved no human participants.

  • Transparency: The lead author (the manuscript’s guarantor) affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

  • Data sharing: No additional data available.

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