In a few days the NHS will reach the milestone of being 70 years old. As with all major birthdays this has prompted introspection and comparisons with others. No wonder we’re being deluged with a range of statistics and league tables which present a mixed and somewhat contradictory picture of the NHS, in which some commentators have focused on areas of the NHS’s performance that seem below average, whether to stimulate debate or to promote alternative healthcare models. But too often forgotten in the ensuing exchanges is a key question: how can we measure how good a healthcare system is unless we define what ‘goodness’ means?
The values and social objectives of a healthcare system
Unlike many other areas of public policy, healthcare is deeply personal. We all rely on health services in various ways and these experiences profoundly affect the quality of our lives and those of our families. This means that we tend to have strong opinions about what a health system should provide, and who should provide it.
When the NHS was established after WW2 it expressed a strong moral preference for universalism – i.e. fair and equitable access to healthcare for everyone in the country, based on residency and not ability to pay. To achieve this a progressive system of financing was needed, with the wealthier members of society contributing more than the less wealthy. It also implied a system of risk-pooling, with the cost of being ill or injured shared across society.
But there are competing social values and trade-offs inherent in debates about how healthcare systems should be financed and organised. For example, a universal system of financing and provision based on taxes that everyone must pay, and the nation-wide sharing of risk, can be seen as restricting individual liberty. The principles on which a healthcare system are founded thus reflect views about the role of government, the responsibilities of individuals, and the boundaries set around individual freedom. In turn they can influence how a healthcare system is viewed in economic terms some may see it as a drag on the economy while others may see it as a contributor to economic growth and wellbeing.
Aside from values which govern views on who can access healthcare and how it is paid for, there are also different opinions about what organisations should provide healthcare, and who should regulate them. The resulting variations make each system unique and hinder the comparability of one ‘type’ of health system with another. Most healthcare systems incorporate some elements of universalism, equity, and risk-pooling: for example, insurance-based systems incorporate subsidies or free basic healthcare packages for those on low incomes and the indigent.
Clearly, different values will produce different measurements and rankings. For example, the US-based Commonwealth Fund publishes a league table of performance of a number of healthcare systems in which the NHS scores very highly. However, it’s important to note that their approach to measuring performance places a strong emphasis on equity, universalism, risk-pooling and prevention, and less on outcomes.((E. C. Schneider, D. O. Sarnak, D. Squires, A. Shah, and M. M. Doty. (2017). Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care, The Commonwealth Fund, July 2017.)) Other comparisons come up with different rankings , resulting from the use of different methodologies or data, and from prioritising different values.
What can be said about the performance of the health system in the UK?
In general, the UK compares favourably with other countries in such rankings in terms of access to healthcare, equity of treatment, and protection against the cost of falling ill or having an accident, and it does all of this with far fewer resources than our peers. However, the UK does worse than average in respect to some health outcomes, such as cancer survival rates.
What should we make of these positive and negative comparisons?
The first thing to say is that all such comparisons, positive as well as negative, are difficult to make. Comparisons which do not mention the social and economic functions of healthcare systems, or the values prioritised by those making the comparisons, or which push alternative models, should be treated with scepticism.
When it comes to the comparison of outcomes apparent differences in performance can be complicated by:
- differences in underlying population health (e.g. higher obesity rates) which affect responses to treatments;
- the cumulative effects of years of relative underfunding, which do not show up in annual statistics;
- inconsistencies in data measurement and collection between the systems compared;
- internal variation within a health system, such as differential outcomes depending on coverage levels or administrative such as in England, Wales, Northern Ireland and Scotland; and
- different priorities that different healthcare systems are designed to serve.
For example, with cancer survival rates, the UK’s relatively weaker performance is influenced by diagnosing cancer later (resources), a greater reluctance to speak to a GP about early symptoms (cultural), and GPs being less likely to refer a patient for diagnosis in the early stages (priorities).((Walters S, Maringe C, Coleman MP, et al (2013). Lung cancer survival and stage at diagnosis in Australia, Canada, Denmark, Norway, Sweden and the UK: a population-based study, 2004–2007, Thorax 2013;68:551-564. Available at: http://thorax.bmj.com/content/68/6/551.info)) ((Forbes LJ, Simon AE, Warbuton F, et al (2013). Differences in cancer awareness and beliefs between Australi, Canada, Denmark, Norway, Sweden and the UK (the International Cancer Benchmarking Partnership): do they contribute to differences in cancer survival?, British Jounral of Cancer 2013;108:292-300. Available at: https://www.ncbi.nlm.nih.gov/pubmed/23370208)) ((Rose RW, Rubin G, Perera-Salazar R, et al (2015). Explaining variation in cancer survival between 11 jurisdictions in the International Cancer Benchmarking Partnership: a primary care vignette survey, BMJ Open 2015;5:e007212. Available at: https://bmjopen.bmj.com/content/5/5/e007212.info)) This combination of factors is being addressed by cancer strategies across the UK and the NHS is closing the gap. What’s clear is that a change in health system is not needed, or desirable, to make up for this relatively weaker performance. When this is proposed one should ask: does fixing the difference in performance really require a radical change in the financing, organisation, or regulation of the NHS? Most often improvements can be made within an existing system through changes to where resources are invested, cultural factors, and priorities. It’s also important to ask about the inherent trade-offs i.e. what priorities, values, and resource allocation does an alternative system undervalue in order to do better in other areas?
We should also bear in mind that good access to healthcare contributes as little as 10% to the health outcomes of a population((McGovern L, Miller G, Hughes-Cromwick P. (2014). Health Policy Brief: The Relative Contribution of Multiple Determinants to Health Outcomes, Health Affairs, 21st August 2014.)), spending more money doesn’t necessarily improve outcomes (what it’s spent on matters a lot); while ‘social’ factors such as housing, education, and environment have a large impact on population health.
Second, the NHS in England today is very different from the NHS in England of thirty years ago, above all in terms of the extent to which the system has been reorganised on market lines. Any measures of current performance must accommodate the fact that while most of the NHS is financed out of taxes, there is a much greater level of private involvement in infrastructure development, as well many changes to the organisation and provision of healthcare. In fact there has been a state of constant change and flux, which in itself makes it difficult to attribute indicators of performance to particular features of the healthcare system.
A third thing to say is that if we want a healthcare system that prioritises equity and social solidarity, as well as general cost-effectiveness, we should stick to the principle of funding it by means of a progressive tax system. There is some evidence to suggest that the introduction of an insurance-based system of healthcare financing would result in increased costs, and possibly greater inequity.
If one values both equity and efficiency, there are good reasons to conclude that the principles that underpinned the founding of the NHS remain relevant for the future. These include the principles of a universal system of progressive financing (most efficiently done through tax) and maximum risk-pooling, as well as the public provision of healthcare. The latter need not imply a rigid and inefficient bureaucracy; there are many ways to ensure that efficiency and innovation flourish without competition.
The NHS will still have to face up to the challenges of a growth in healthcare need due to demographic changes, and an increase in cost pressures due to technological advancements. But there is no evidence that a shift towards an insurance-based system, or competition between providers would better enable us to tackle these challenges fairly, effectively or efficiently. If anything, a healthcare system based on public financing and public provision will help contain some of these future cost pressures better than otherwise, as can be seen from the NHS’s impressive record of cost containment to date.
Finally, it should go without saying that health and wellbeing can be improved far more cost effectively through better public health measures and disease prevention, as well as by reducing the harmful health effects of social inequalities. Going forwards, healthcare system comparisons will need to increasingly emphasise public health and social care as integral parts of an effective system.