The ‘best’ health care is not always the one that keeps us alive


“NHS is the world’s best healthcare system” was a headline last week in The Guardian newspaper. However, six paragraphs in, the authors observed: “The only serious black mark against the NHS was its poor record on keeping people alive.” Further investigation was clearly required.

The newspaper was reporting a survey of health provision by the US-based Commonwealth Fund in 11 advanced countries: seven European states, the US and Canada, Australia and New Zealand.

The findings use measures of service quality, mainly derived from judgments by patients. The effectiveness of care is judged by the intensity of preventive activity – whether necessary tests are carried out, whether doctors advise on a healthy lifestyle – and the reliability of management of chronic conditions.

The safety of care is judged by the frequency of medical mistakes, and the incidence of hospital-induced infection. Good care is patient-centred and timely, with necessary treatment easily accessible. The survey also reports measures of efficiency, or more often inefficiency – how great is the burden of medical administration, how much unnecessary use is made of emergency services, how reliably test results reach medical professionals.

The UK’s National Health Service is at or close to the top on almost all these indicators, and its health spending per head is the second lowest in the survey. The US system scores badly on everything except preventive care, and US medical costs are off the scale when compared with other countries.

The problem, however, is that when it comes to keeping you alive, the World Health Organisation puts Britain tenth out of 11; only the US is worse. If your objective is to live a healthy life, go to France. Medical outcomes are judged by reference to three measures: avoidable mortality, infant mortality, and healthy life expectancy at age 60. And the NHS does not do well on these metrics.

“Mortality amenable to healthcare” is the incidence of death attributable to causes that can be substantially reduced or eliminated by medical intervention, the adoption of a healthy lifestyle or a combination of the two. The WHO measures excess deaths attributable to smoking, drinking, obesity, hypertension, preventable diabetes and similar causes. And the US and UK are much worse than other countries in these respects.

Infant mortality has fallen dramatically worldwide, not just in advanced societies. Basic hygiene makes a huge difference. But the UK does not come out well, and the US has the poorest record of advanced countries.

There has been much discussion of the reasons. Births before term are much more common in the US than elsewhere. This may be the result of worse prenatal care or of lifestyle factors such as obesity. But it may also be the product of a more determined, but not always successful, attempt to save infants born extremely prematurely.

Most people in France will have entered retraite by the age of 60, and they will enjoy it for longer than in any country except Switzerland, whose elderly live longest. Britain is near the bottom of longevity rankings along with the US, and, surprisingly, Norway. But the differences are not large.

The obvious message of the survey is that the US spends a much greater proportion of its national income than other developed countries, without any clear impact on the overall quality of its medical care. Excess medical costs represent a “tax” amounting to 5 per cent or more of the country’s national income. But everyone, except perhaps a majority who oppose US President Barack Obama’s healthcare reforms, already knew that.

Other lessons are less obvious but perhaps more significant. Despite the appearance of excess bureaucracy, there seem to be real benefits from the centralisation and standardisation imposed by Britain’s NHS; there is value in imposing routines of testing and record-keeping on independently minded professionals. Spending above a base level attained in rich nations seems to have little effect on mortality and morbidity; lifestyle and environment matter far more.

But the Commonwealth Fund assessment was based mainly on patient opinions, and the aspects of a healthcare system that patients value may have little to do with clinical outcomes.

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