The Unreported NHS The NHS is one of the most popular, equitable and effective health systems in the world, but it often only gains media attention when it is said to be underperforming or overspending. Clearly the NHS isn’t perfect, but these largely negative snapshots can erroneously distort the image of our health service. Worse still, they can be used to misguidedly inform or justify policy – just as they have done with the government’s recent Health and Social Care Bill. This is concerning because there is a genuine danger that by not appreciating the strengths of our health system, we will allow its essential qualities to be lost. So this report attempts to redress the balance a little. It is a brief summary of recent research and analysis that you may not have heard about. It tells a different story to the one we hear most often in the mainstream news media,, and it challenges some of the more negative myths about the NHS - particularly when compared to health systems in other developed nations. The report doesn’t suggest that the NHS can’t be improved, but the evidence gathered here sheds better light on how it should be improved, and what we might lose if this evidence is ignored.
I don’t think we should put up with second best. David Cameron, January 2011 Photo: Armin Kübelbeck
The Unreported NHS
The research The impetus for this report were the findings of two large-scale comparative studies of national health systems carried out by the Commonwealth Fund in 2010 - studies that were largely ignored by the mainstream news media in this country. The first study (denoted in graphs as 2010a) was a patient survey of eleven developed health systems looking at a range of criteria to assess performance.1 To illustrate these results concisely we have included the performance of the NHS only against the three countries that, economically and/or culturally, serve the most relevant comparisons: Germany, France and the US. The second study (denoted 2010b) - was an assessment of seven developed health systems, using surveys of patients and primary care physicians and other secondary data.2 The findings of this study were ranked and in each illustrated example we have shown the top four ranked countries. To supplement these studies we have also included data and analysis from several other sources (which are indicated) and full references can be found at the end.
NHS performance â€˜kills thousandsâ€™ BBC, 2008
The NHS is failing in basic aspects of care The Daily Telegraph, 2009
Half NHS hospitals are failing patients The Sun, 2009
The unreported NHS
Is the NHS underperforming? The belief that the NHS is underperforming is perpetuated and reinforced by two types of news story. The first type is the human interest story that highlights an incident of negligence, misdiagnosis or error within the NHS – which then is then used to implicitly suggest that the whole service is underperforming or unsafe. However, the Commonwealth Fund’s patient survey tells a different story, showing that the NHS is actually one of the safest healthcare systems in the world (figure 1). Furthermore, in the Commonwealth Fund’s second study, the NHS is also ranked first for effective care (figure 2) and first for cost-related access - an important criteria of performance often overlooked by critics of the NHS. This study does suggest that patient-centred care, timeliness of care and lifestyle are all issues that need to be addressed, but in overall ratings the NHS is ranked above all but one of the seven health systems - second only to the Netherlands, a country with a population one quarter of the UK’s. Interestingly, although this study suggests that patient-centred care is a key area for improvement, patient confidence is also higher among NHS patients than in other countries (figure 3), suggesting the high level of trust that NHS patients have in NHS staff: that they are being treated purely on the basis of clinical need - and indeed by ‘patient-centred’ staff. The second type of news story about NHS performance is usually generated from wider scale research into national health outcomes. In particular, it is the apparently poor outcomes for heart attacks and cancer (using data from several sources) which have most often been used to criticise NHS performance. However, recent analysis by John Appleby, chief economist of the King’s Fund, suggests that these figures are usually not interpreted in their 3 full context. Rather than simply comparing data for a single year (which is the basis of most news stories) Appleby compares the death rates from
1: Reported medical errors 2008-2010 (%) Commonwealth Fund 2010a
18 14 10 8
2: Effective care: top four ranking Commonwealth Fund 2010b
3: Patient confidence in treatment (%) Commonwealth Fund 2010a
The Unreported NHS
myocardial infarction (heart attacks) in the UK and France (which reports the lowest rates in Europe), but does so over the last 30 years; and, in doing so, finds a more revealing and positive picture of trends . Statistics from the Organisation for Economic Cooperation and Development 4 confirm that in 2006, the age standardised death rate for heart attacks (acute myocardial infarction) was 19 per 100,000 in France and 41 per 100,000 in the UK. However, a look at long term trends (figure 4) reveals that the UK had the largest fall in death rates between 1980 and 2006 of any European country and, Appleby argues that, if the trends of the past 30 years continue, then the UK could have a lower death rate than France by 2012. The story is similar for cancer mortality too. Death rates for breast cancer, for example, have fallen by 40% in the UK to virtually close the gap with France, where they have fallen by just 10% (figure 5). Death rates for lung cancer in men peaked in 1979 in the UK, but since then they have steadily fallen and are now lower than for French men. As Appleby points out, the causes of death are often linked to changes in lifestyle behaviours, rather than healthcare spending or policy, but the role of the NHS in helping to inform and guide the public to change unhealthy lifestyles should not be underestimated. A more precise indicator of health system performance might be survival rates, and it is the ongoing Eurocare study of cancer survival 5 across Europe that typically lead to headlines that the UK - and, by implication, the NHS - is the ‘sick man of Europe’. However, both Appleby and Cancer Research UK argue that this data is also misinterpreted. Firstly - again - trends show that survival rates in the UK are improving and the survival gap is narrowing. But the Eurocare data also lacks consistently reliable reporting and coverage varies dramatically across countries. The French data covers around 10-15% of cancer patients for example, while the UK covers 100%. The ‘latest’ data is also fairly old, and included diagnoses only up to
4: Myocardial infarction: standardised death rate (per 100,000) OECD
5: Breast cancer: standardised death rate (per 100,000) OECD
The Unreported NHS
2002. This was in the early stages of, or before, reforms like the NHS Cancer Plan were implemented. Both these factors are likely to distort the UK data more negatively. The Office of National Statistics confirmed an improvement in survival rates for most cancers 6 over the 1999-2004 period - an improvement also recorded by Cancer Research UK (figure 6 four most common cancers shown).7 Interestingly, these findings donâ€™t make headlines in the same way that the problematic Eurocare studies and other stories have done. Also ignored by much of the mainstream news media were the results of a revealing analysis of ten major health systems by Pritchard and Hickish, published in the British Journal of Cancer in September 2011. Comparing cancer mortality rates with health expenditure between 1979 and 2006, they found that the NHS achieved significantly higher reductions in deaths on proportionally less expenditure than all the other nine countries â€“ including France, Germany and, perhaps less suprisingly, the United States.8 Which leads us neatly onto the next widely reported news story: that the NHS is inefficient and overspends.
6: UK cancer survival rates (%) Cancer Research UK
40 30 20 10
The NHS is a lumbering state bureaucracy Daily Mail, 2008
NHS bureaucracy spending doubles BBC, 2008
The NHS is an ever more inefficient behemoth Mail on Sunday, 2009
The Unreported NHS
Does the NHS overspend? The NHS budget is typically reported to be a huge burden on the UK economy, often likened to a ‘black hole’ of government spending. It is a health system that some commentators, critics and headline writers say encourages bureaucracy and overspending. So perhaps the recent improvements in performance are the least we should expect - especially given the ‘record’ levels of investment spent on the NHS by the previous government. But again, this negative and pervasive view is often taken without meaningful comparisons. Firstly, the recent levels of NHS spending are only new ‘records’ in relation to previous levels of NHS spending. They are not records at all when compared to other major developed countries. Figure 7 shows the most recent figures on UK healthcare spending compared 4 to the US, Germany and France. Even after recent increases in investment, the NHS still costs less than most comparable EU and OECD countries. It suggests that the NHS is a lot more efficient than some commentators would have us believe. The myth that the NHS is wasteful, costly and inefficient is also challenged by the Commonwealth Fund which ranks the NHS as the most efficient in its comparison of seven national health systems (figure 8).2 These findings are supported by a McKinsey report which showed that NHS management costs accounted for just 1.5 per cent of the NHS’s total costs in 2009, placing the UK 18th lowest in a list of 23 global health systems. By contrast, the US’s were 7 per cent and France’s were 6.8 per cent.9
7: Healthcare spending as % of GDP OECD 2010
8: Most efficient system: top four ranking Commonwealth Fund 2010b
The newsworthy story here then, is not that the NHS overspends, but that in many key areas it manages to outperform far more costly systems.
The Unreported NHS
Misdiagnosis Contrary to most news stories about the NHS, the research we have summarised here suggests that, while improvements need to continue, the NHS actually provides its patients with a first-rate service on several key performance criteria; its health outcomes are (or were) on course to equal the best in the world; and it costs less than most comparable health systems. In short: it cannot honestly be said to be underperforming or overspending. And yet the current reforms have been largely justified on a rather bleak assessment that the NHS is doing both of these things - aided and abetted by the widely circulated myths perpetuated by much of the mainstream media. In spite of all the bad NHS news, it is perhaps surprising that most people in this country do recognise the value of the NHS and its principles. Indeed, the Commonwealth Fund’s patient survey (figure 9) found that far fewer people in the UK believe our system requires fundamental changes (such as the current reforms) than people in the US, France or Germany believe of their health systems. Our own survey conducted in August of this year reiterated this view, with only 33% of the public believing that the government’s reforms should have been passed in their amended form and half wanting them to be dropped altogether. Unfortunately, the sheer weight of misinformation and misunderstanding circulated by the mainstream media means that judgements made on the basis of these myths are not able to be coherently or effectively challenged by the public. The power of media influence is even acknowledged by the Department of Health which has said that, “public satisfaction with the NHS remains high but is drifting downwards. Most of the fall is due to non-users becoming more critical – perhaps in response to media coverage, as they have no direct recent experience. In contrast, users of the service remain very positive (73% 10 satisfaction rating versus 61% of non-users).”
9: Health system requires fundamental change or complete rebuild(%) Commonwealth Fund 2010a
light shading = “fundamental changes” dark shading = “complete rebuild”
The NHS must keep improving, but most staff feel that greater integration and collaboration are the key to this - which are virtues that the current reforms do little to address. Instead - on the basis of the myths debunked in this report the reforms aim to further develop competition within the NHS. This doctrine not only lacks sufficient evidence in healthcare, but comparisons with more commercial health systems suggest that the reforms will in fact raise costs and make the NHS far less efficient. What’s more, by ignoring the first-rate strengths of the NHS - equity, access, trust and safety - the reforms could damage these strengths and the improving health outcomes. This misdiagnosis is therefore likely to end up making us all less healthy.
The Unreported NHS
References 1. The Commonwealth Fund 2010 International Health Policy Survey; http://www.commonwealthfund.org/Surveys/2010/Nov/2010 -International-Survey.aspx 2. Mirror, Mirror on the Wall: How the Performance of the US Health Care System Compares Internationally, 2010 Update; http://www.commonwealthfund.org/ Publications/Fund-Reports/2010/Jun/Mirror-Mirror-Update.as px?page=all 3. Appleby, J., Does Poor Health Justify NHS Reform?, British Medical Journal, January 21, 2011; http://www.bmj.com/content/342/ bmj.d566.full 4. Eurocare-4. EUROCARE-4 database on cancer survival in Europe. 2010; www.eurocare.it/Results/tabid/79/ Default.aspx#eu4dB 5. Organisation for Economic Cooperation and Development; http://www.oecd.org 6. Office of National Statistics; http://www.statistics.gov.uk= 7. Cancer Research UK. Cancer cure rates improving in Europe. Press release, 25 Mar 2009; http://info.cancerresearchuk.org/news/archive/cancernews/ 2009-03-25-cancer-cure-rates-improving-in-europe 8. Pritchard, C. and Hickish, T., Comparing cancer mortality and GDP health expenditure in England and Wales with other major developed countries from 1979 to 2006, British Journal of Cancer, 2011 (1-7) 9. Health Service Journal, 21 July 2011; http://www.hsj.co.uk/news/finance/lansleys-over-managed-n hs-claim-undermined-by-analysis/5032766.article 10. Department of Health; http://www.dh.gov.uk
Researched, written and designed by James Adams Front cover photo: Adrian Clark Back cover photo: Tom Varco
The NHS Support Federation is an independent organisation that works to protect and promote a comprehensive NHS, with equitable access and active public involvement. Our supporters and affiliated organisations are drawn equally from the health professions and the general public. If you require further information, visit our website or contact us directly. This report is part of our NHS Unlimited project, brought to you with the support of UNISON.
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A summary of health system research ignored or under-represented by the mainstream news media.