How does the NHS compare internationally? big election questions

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Ahead of the general election on 8 June, we examine the big issues around health and care.

What’s the issue?

Although comparing different countries’ health systems is fraught with difficulties (such as differences in how data is collected and in the local context) and should not be over-interpreted, comparisons do provide an important perspective on what the NHS does well and where it should seek to improve.

International league tables have been used to support arguments that our health service is one of the best in the world – and also that it is a failing system.

As there is little internationally comparable data available for the four nations separately, we focus here on the UK, rather than England. Our analysis is not comprehensive; it provides a sample of comparative performance on selected indicators.

What’s behind this?

How the NHS performs relative to other countries depends on what you measure and how.

The UK performs well on several efficiency measures. For example, the NHS has made significant savings on its pharmaceutical spend and is a leader in Europe on the proportion of drugs that are prescribed in their (cheaper) generic form instead of the (more expensive) branded version. Length of stay in hospital, which some see as a key indicator of efficiency throughout the health system, is around a day shorter in the UK than the EU average and lower than in France and Germany, for example. However, there is still room for improvement – length of stay is shorter in Denmark, Sweden and the Netherlands. And despite these areas of efficient practice, reviews in the English NHS have identified significant opportunities for the health service to become more productive, particularly by tackling variations in clinical practice.

Comparative data on capacity in the health system highlight some of the difficulties in making international comparisons between systems– the optimum number of hospital beds and staff vary depending on local context, the model of care delivery in place and the skill mix in clinical teams. The UK, for example, has 2.7 hospital beds per 1000 population compared to an EU average of 5.2 – far lower than Germany (8.2) and France (6.2) but similar to Ireland (2.6) and Sweden (2.5). Although this might be seen as a sign of efficiency (indeed the declining number of hospital beds in the UK has been partly due to medical advances that have shortened length of stay in hospital and a shift in the model of care that means people with learning disabilities, mental illness and the longer-term care of older people occurs in community settings) there are significant concerns about high levels of bed occupancy in hospitals and the problems this causes. International comparisons on numbers of hospital beds also need to be treated with caution as countries can differ over important definitional issues.

The UK also has one of the lowest numbers of practising doctors per population (including GPs and hospital doctors) in the EU and although the number of nurses is around the EU average, it is lower than comparable countries like France, Germany and The Netherlands. The UK also has fewer CT scanners (8 per million population compared to an EU average of 21.4) and MRI scanners (6.1 per million compared to an EU average of 15.4) than most other European countries. However, this data does not include diagnostic scanners based in non-NHS providers that are used by the NHS.

International surveys show that people in the UK have good access to care (particularly primary care). For example, an EU survey found that 2.1 per cent of respondents had gone without a necessary medical examination in the past year because it was too expensive, too far to travel or too long to wait, which is below the EU average of 3.6 per cent (lower than in France, but higher than in Germany). Unlike most other countries in the survey, in the UK there was very little difference in the experiences of people with high and low incomes. A survey by the Commonwealth Fund found the UK has the lowest level of cost-related problems accessing health care among the 11 countries surveyed. In line with this, out-of-pocket spending on health care is also relatively low among EU countries, with only France and Luxembourg spending a lower proportion of household income out-of-pocket on health.

Waiting times for treatment in the UK appear similar to or shorter than those in other countries based on the limited data available. The OECD found that in 2014, UK waiting times for cataract, knee and hip replacement were below the average among the 14 countries for which they have data. The Commonwealth Fund’s survey of adults’ own experiences in 11 countries shows that the UK has middling performance on rapid access to primary care: 41 per cent of people in the UK said they did not get a same-day or next-day appointment the last time they needed care, compared to 19 per cent in the Netherlands and 53 per cent in Canada.

Although the UK has been at the forefront of the development of measures of health care quality (like the national patient survey programme) and the use of quality improvement techniques (like evidence-based clinical guidelines), performance on some indicators of health care quality remains ‘average or disappointing’ compared to international benchmarks according to the OECD. For example, although there is a comprehensive screening programme for breast and cervical cancer, survival rates are below the EU average (despite improvements in recent years). Rates of hospital admissions for asthma and chronic obstructive pulmonary disease (COPD) (combined) have improved at a faster rate than many other countries in recent years, but also remain well above the EU average. The UK has also slipped down international league tables for infant mortality and is now 15th out of 19 comparable countries. In a recent study that compared access to and quality of health care in 195 countries by analysing ‘health care-amenable mortality’ – ie, mortality rates from causes that should not be fatal if effective health care is in place – the UK is ranked 30th out of 195 countries – its overall score was similar to Portugal and Malta but lower than comparable countries like Germany, The Netherlands, Spain and Sweden.

There are, of course, other areas where the UK is a world leader on quality of care. For example, admission rates for congestive heart failure are around a third of the EU average, suggesting that patients with chronic heart failure are managed effectively in primary care.

Although the UK’s performance against international benchmarks of health care quality is variable, British people rate the quality of their health care highly, and most are satisfied with the NHS overall. However, in a global online survey of public opinion, 47 per cent of British respondents thought quality would get worse over the next few years, making them the most pessimistic of the 23 countries surveyed.

The King’s Fund view

While we should not rely too much on international comparisons for the reasons set out above, they do emphasise one of the unique features of the NHS – that access to care does not depend on how much money you earn. The key building blocks of our health system – its public funding base and the comprehensive range of services provided (mostly) free at the point of use – have made the UK a world leader on equitable access to care.

They also shine a spotlight on the quality improvement challenge in the NHS. The UK’s focus on monitoring and improving quality is impressive, as is our performance in areas like chronic heart failure and elective waiting times. However, while recent improvements on some key outcome indicators like cancer survival rates are encouraging, there is further to go to bring some important measures of quality and outcomes in line with those of the best in the world. The King’s Fund’s work has shown that engaging clinicians in the task of understanding and tackling the wide variations in clinical practice that persist across the country will be key to improving quality in the UK.