NHS performance: are we really getting it right?

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According to The Commonwealth Fund, in the UK we’re getting it (mostly) right – or, at least, we’re getting it more right than our international counterparts. In their comparative study of health system performance in 11 countries, the UK ranks first across a range of measures covering quality, access and efficiency of care, while the US comes in last place.

While it’s nice to be told that the NHS is performing well, there are limits to how much we can learn from comparative rankings.

First, different rankings by different people can tell us different things. The UK moves up and down in various international scorecards depending on which indicators have been included and how different dimensions of performance have been weighted. Second, The Commonwealth Fund’s study is primarily designed to highlight poor performance in the US system. As we’re good at lots of things that the US isn’t – like access to care – we come out particularly well.

It’s also worth noting the variations that exist between the UK’s four health systems – whose differing policy paths mean we can’t really talk about a UK health system.

This isn’t to say that comparative rankings like The Commonwealth Fund’s are misleading or can’t be useful. They give us a broad indication of how we are doing and raise important questions about how and where we can do better.

What’s really striking is the variation that exists within health systems rather than between them. In the US, the focus of The Commonwealth Fund’s study, we know that the scale of unwarranted variations in outcomes and costs of care is dramatic – both across and within geographical areas. The story in England is no different

At one level, this variation can be seen in terms of the persistent and avoidable differences in health outcomes that exist across society. For example, we know that avoidable mortality rates vary significantly between geographical areas in England. People living in poorer parts of the country will typically die sooner than those living in the richest areas, and will spend more of their (shorter) lives living in poor health. Deprivation is a key factor in how healthy our lives will be and in our use of health services. While inequalities in health outcomes are inevitable, their scale in England isn’t. Yet in many cases these gaps are widening.

We also know that large unwarranted variations exist in the use of health services in England that can’t be explained by illness or the preferences of patients. These variations don’t just exist geographically but also within health care organisations.

Lessons from high-performing systems internationally show us that sustained efforts to reduce this unwarranted variation can improve quality of care while also reducing the costs of providing it. Brent James and others at Intermountain Healthcare – a high-performing system within the US, the lowest performer on The Commonwealth Fund scale – have done just that through a systematic approach to identifying, measuring and reducing variation. As we argued in our recent paper, Reforming the NHS from within, this type of systematic approach to improvement from within must be a priority for the NHS – particularly as pressures on the system continue to rise.

Rankings can only tell us so much, and necessarily look through the rear view mirror. The NHS today is rapidly heading towards crisis and struggling to hold on to the performance gains made over recent years. The challenge is how to maintain our position against other health systems while focusing on the unwarranted variations that exist within our own.

This blog is also featured on the British Medical Journal website.


Verite Reily Collins

Comment date
27 June 2014
Lovely to read sensible analysis - and also comments. I did wonder, as a patient who had had to go to France for up-to-date cancer treatment, when UK dismissed me with "it's just your age", why Commonwealth people hadn't looked at WHO figures. Having read that on average French cancer survivors live 4.6 years longer - I want some of those extra years please!

Bruce Gray

Heart of England NHS FT
Comment date
24 June 2014
Lots of valid caveats in the piece and the esrlier comment. One point of comparison ref. the usual suspects of Kaiser, Virginia Mason, Mayo etc. is that they have a focus on quality improvement through the consistent application of Improvement science methods. This consistency and focus is lacking in the NHS.

David Oliver

Visiting fellow,
King's Fund
Comment date
23 June 2014
Excellent blog Hugh

And of course, whilst as a proud NHS lifer I am very happy to read the Commonwealth Fund findings, I also realise that other rankings such as WHO use different rating systems and produce different rankings. I think you spot on in pointing out the story of major unwarranted variation in UK services - in terms of inputs/processes, activity, service utilisation and outcomes and the pressing need to address this and get "the rest as good as the best"

I am, however, always a tad wary of comparisons between outstanding US providers be they Kaiser, VA ,Virginia Mason, Mayo, Intermountain, etc and the English NHS and as a consequence the transferrable lessons for our systems taken with a health warning.


1. Our system is designed to deliver equitable access to a half decent service for the whole population and every "service line" free at the point of delivery based on need not ability to pay. Whereas US providers can selectively opt into or out of patient groups and services apples and oranges. And "any qualified provider" risks providers cherry picking profitable lines, using NHS-trained staff to provide them and destabilising local providers who have no choice but to continue delivering that universal service

2. Our system runs on full to bursting hospitals, full to bursting GP lists, rationed social care, with numerous vacancies for clinical posts (e.g. in general practice or emergency medicine or community nursing). There is little possibility to be competitively recruiting clinical staff for values and allowing them to leave if they don't perform to that organisation's standards.

3. Clinicians have been to an extend disempowered/deprofessionalised by the post Griffiths managerialism in the NHS so the idea of clinically led and owned organisations is less prevalent here. Moreover, the NHS is still run from "the centre" be it Whitehall/CQC/NHS England with constant fears about managing upwards and worries about financial constraints. It doesn't make for the kind of visionary quality focussed clinical leadership described in certain US organisations.

4. British Culture (across all sectors) is very different (and I speak as someone with a wife who is a US citizen) We don't have that same free market drive to outperform every other organisation or clinician in league tables. We don't graduate as doctors saddled with the gargantuan levels of debt that US colleagues do. We do have relative job and pension security. We don't have massive pay differentials between primary and secondary care or between various secondary care specialities - so we can actually attract high calibre people to general medicine, acute medicine, geriatrics, general medicine - reflecting population need rather than income earning potential or "prestige"

Ultimately, whilst we may have a "cultural cringe" to the better performing US providers, we do have a system of health care and one which is universal and that system by any metric outperforms the US - which has no system as such merely a collection of providers competing with each other for custom like hotel chains or airlines.

And no UK patient (nor most overseas visitors) - whether a vagrant or a peer need worry about a wallet biopsy on acute admission or financial ruin on the back of a long term condition or two.

Finally, two of the very best performers in the US - the VA and Kaiser are "socialised medicine" par excellence.

There might not be too much wrong with UK healthcare that an uplift to 11% of GDP in line with comparable countries mightn't fix. Ultimately, we are not American, don't have the same ethic around competition, do have more than 2 weeks paid vacation a year, do enjoy a welfare and pensions safety network.

A more valid comparison would be between us and France, Scandinavia, Holland, Germany, Australasia - culturally more similar countries with more social democratic traditions and healthcare seen as a public good. And dollar for dollar pound for pound, we do pretty well in comparison - certainly holding our own in terms of performance and beating most in terms of value for money and comprehensive coverage as the Commonwealth fund shows.


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