‘NHS is the world’s best healthcare system’ was a headline last week in The Guardian newspaper.  However, six paragraphs into the article, the authors observed that  ‘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 by the US based Commonwealth Fund of  health provision in eleven advanced countries. –  seven European states, the US and Canada, Australia and New Zealand,.  The findings use measures of service quality, mainly derived from judgements by patients.  The effectiveness of care is judged by the intensity of preventive activity – are necessary tests carried out, do doctors advise on a healthy lifestyle – and on 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 do test results reach medical professionals.

Britain’s NHS 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 (only New Zealand spends less).  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, Britain is tenth out of eleven – only the United States is worse.  If your objective is to live a healthy life, go to France. (On Friday, I plan to).  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 health care’ is the incidence of death attributable to causes that can be substantially reduced or eliminated by medical intervention, the adoption of a healthy life style, or by a combination of the two.  The World Health Organisation 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 around the world, not just in advanced societies – basic hygiene makes a huge difference.  But the UK does not come out well here and the US has the poorest record among advanced countries.  There has been a good deal of discussion of the reasons.  Births before term are much more common in the US than elsewhere. This difference 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 preserve the lives of infants born extremely prematurely.

Most people in France will have entered retrait by the time they are sixty, and they will enjoy it for longer than in any country except Switzerland, whose elderly people live longest.  Britain is towards the bottom of the rankings for the longevity of old people, along with the United States and – surprisingly – Norway.  (Neighbouring Sweden does much better).   But the differences between countries are not large – the French benefit from little more than an extra year of steak frites  with red wine.

The obvious message of the survey is that the US spends a much larger 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% or more of the country’s national income.  But everyone, except perhaps a majority of Americans, already knew that.  

       Other lessons are less obvious, but perhaps more significant.  Despite the appearances of excess bureaucracy, there appear to be real benefits from the centralisation and standardisation imposed by a National Health Service; there is value in imposing routines of testing and record keeping on otherwise independently minded professionals.  Medical expenditures above a base level attained in all rich countries seem 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 health care system that patients value may have little to do with clinical outcomes.