How is the NHS doing in 2010? How do we measure up against Nye Bevan’s yardstick of wanting people to feel “serene” about their health care system?
Those of us into comparing the NHS with other health care systems know that in November every year we are going to be looking at an international league table.
The survey is carried out by the misleadingly named Commonwealth Fund. Misleading because in the UK we think of the Commonwealth as the collection of ex dominions and colonies that used to make up the British Empire. In fact this Commonwealth Fund is from the US and relates to an older meaning of “Commonwealth” as a part of US politics. It literally means what we have in common, and how do we utilise that wealth for all.
The Commonwealth Fund is an US trust fund that carries out and publishes health care research and, once a year in conjunction with national organisations (In the UK the Health Foundation), that research draws from a large sample of the public in each of 11 nations. These are the UK, Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland and the US.
So all of the data below is based on what members of the public think about their health care systems. It is their experience rather than a series of abstract facts. That is why as a ‘league table’ it is of particular interest to those that are interested in the interaction between national politics and national health services.
Two caveats. Of course since it is based in the US the particular sets of questions will have more meaning there than in the UK. Thus for example this year’s questions contain a lot about members of the public not getting access to health care because of costs. (In the US this year 33% of the public either did not get a prescription, or did not visit the doctor, or skipped a test or a follow up because they could not afford it. In the UK that was 5%) The cost of access tends not to be a problem at all in those health systems that are mainly free at the point of need.
The second warning is that the Commonwealth Fund is highly critical of the US health care non-system. One of the aims of the survey is to shame the US as the world’s richest country into doing something about its chaotic non-system. In most of the answers to the questions US members of the public report their health care system as worse than the other 10 systems. (Even though the US pays a lot more for it). It is almost inevitable that we in the UK use this system to compare ourselves to the US. And that we therefore almost inevitably come out of it feeling good.
The report containing the data is available here. If you wish you can make comparisons with the country of your choice.
For the rest of this post I am however not going to compare the UK with the US, but will compare the UK and Canada, a system which has similarities to ours and a nation that is proud of its state health care system. But, to make a political point, a nation that has not reformed its health care system.
Starting with GDP per person spent on health (and this is not patient experience but financial fact) The UK spends about US$3000 per head and Canada US$4000. The most important point about this chart is not the comparison but the sharp growth in all health care expenditure between 1980 and now. The chart shouts out the unsustainability of current health care systems all over the world. They cannot go on growing their resources at this pace.
In answers to the question about not getting some health care because of affordability (referred to above) 15% of Canadians – 3 times the UK figure – felt that they had been prevented from accessing some form of health care by its cost during the last year. This is in a ‘free’ system. (The UK system is not completely free because some people in England have to pay prescriptions and most people have to transport themselves to their health care providers). Continuing on this theme, in the UK 1% of people had out of pocket medical expenses of over US$1000 in the last year compared to 12% in Canada. It’s difficult to think what that means in the UK although if someone did feel they had to use private health care they could have spent that much. But in the Canadian free health care system a much higher number had to spend that amount.
The public were asked, “If they were seriously ill would they be confident/very confident that they would get the most effective treatment?” This for me is the Nye Bevan question. He wanted to create a health care system where the individuals were not just secure but were “serene” in their expectations of their health care system. This is a strong word and is based upon his experience of the 1930s where people not only worried about becoming ill (being seriously ill in itself is awful) but also knew that, if they did, they could not afford the treatment and therefore worried about that for all of their lives.
In 2010 92% of people in the UK were either confident or very confident that they would get the most effective treatment. This was the highest in the world and for me says that the NHS in this year generally passes the Nye Bevan test. (76% in Canada and 70% in the US).
Alongside this 90% of people in the UK are confident that they will be able to afford care if they become seriously ill compared to 68% in Canada. We are starting to see the difference between a nation whose people have confidence in its publicly funded health care system and one that does not.
Access is still a problem in the UK – although diminishing over time. So 8% of people waited 6 or more days to see their doctor or nurse in the UK while in Canada it was the highest of all the countries at 33%.
There are failings that we still know are there in our urgent care service and these are reported by the public. “Did you have difficulty getting an after hours service outside of A and E?” 38% in the UK and 65% in Canada. OK we are doing better than Canada but that still means that more than 1 in 3 people in the UK do NOT have Nye Bevan’s serenity at weekends and in the evenings. That is a sizeable problem.
Waiting to see a specialist or to have an operation is still a problem in the UK. 19% had to wait 2 months or more to see a specialist and 21% waited 4 months or more for an operation. But these numbers were 41% and 25% respectively in Canada. Waiting is still an issue for too many in the UK, but much less than it used to be – and less than Canada.
There is then a new and very interesting set of questions about the experience of the health care system of people in each of these countries with below average income, compared to those with above average income. They have created a sort of income inequality health experience index. In effect – how much easier is it for the “better off”?
Returning to the question “Are you confident that you will receive the most effective treatment?” 92% of less well off, and 95% of better off, UK citizens are. This is politically interesting for a number of reasons. Better off people have as much confidence in the NHS as poorer people, there is little difference between them. We have created a system where rich and poor feel that if they become seriously ill they are safe. In Canada the difference is 9 points – and in the US 17.
The worst results for the UK in the whole survey are the answer to the question of getting non A and E outside care split by income. Whilst 31% of better off people experienced a problem of getting urgent care nearly half – 47% – of poorer people experienced a problem. Again, using Nye Bevan’s yardstick, nearly 50% of the poorer half of the country feels that the out of hours system is difficult to get into. This is not good. Whilst more people in Canada experience this (64% and 72%) the gap between better and worse off is lower.
So overall my analysis of this data is that country by country, it is patients in the UK who feel they have a better system. Better both in comparison with data in the past (go on the web site and compare with other years) and in comparison with members of the public in other countries.
There is still more to do in health care delivery for the poorer half of the country and we need to improve the access to non A and E services that are out of hours.
It was interesting that when these results were published in the press that the English Government were, to say the least, lukewarm about it. They didn’t say “the public think we have the best health service in the world yippee!”. Well of course they wouldn’t because the data does not reflect on their stewardship but is a reflection of the recent past. I expect next year they will give two cheers for good data and the year after three.
BUT – and this is the biggest problem for the Government in all the data – the public were asked that if they looked at the health system as a whole, do they think it needs minor changes in the system; fundamental changes; or do you think it should be rebuilt completely.
3% in the UK think the system needs to be rebuilt completely (the lowest in the world). 34% think there needs to be fundamental changes, and 62% think that only minor changes are needed. The UK public think their health care system needs changing less than any of the other countries surveyed.
If I were a Government about to embark on the biggest change in the health care system since the war this would give me pause for thought.
Of course in itself this won’t change what the current Secretary of State is proposing. But if it might mean that the narrative around his reforms moves from revolutionary to merely a few small changes.
At the moment the public don’t think their system needs big changes.
I am not saying whether they are right or they are wrong, but their opinion could politically be very important.
Because if you start a revolution the public think isn’t necessary – and mess it up – they are likely to be pretty angry with you.