10 June 2005
... we just have to find it. Much of the anguished debate about the NHS involves biased comparisons with other countries. But the UK does not have to adopt another system lock, stock and barrel, argues Simon Stevens. It can just take the best bits from each
Let's start by acknowledging that no country has got health care right. And then let's get beyond the sloganising. Clearly Britain is not going to learn about cost containment from France, or about universal coverage from the US, nor are those countries going to learn much from us about short waits for surgery at least not yet.
Nor, while we're on the subject, is the NHS the biggest employer in the world next to the Chinese army and the Indian railways (as I was taught on entering NHS management in the 1980s). Wal-Mart is far bigger. Most major oil companies have larger turnovers. And Medicare in the US has a much greater tax-funded budget than the NHS. So, no, the NHS is not uniquely complex by virtue of size.
What about its relative performance? What do the international comparisons tell us? The answer is: not that much. The World Health Organisation's infamous attempt at a global ranking in 2000 made the French feel good until thousands of pensioners expired in a summer heat wave.
We do know that until recently we've been spending less than our European partners (in fact, £220bn less during the final quarter of the twentieth century), and that in turn has meant we have relatively few doctors and relatively old infrastructure.
And we also know that in some respects NHS incentive structures have been skewed away from what the international evidence suggests will work best. A recent report from the Organisation for Economic Co-operation and Development showed that countries with low waiting times tended to pay hospitals according to activity volumes and surgeons according to their output. This is one reason why the NHS is moving to pay hospitals on a tariff, and paying surgeons fee-for-service bonuses rather than sessional overtime.
But what we don't know is how our clinical outcomes compare. Most of the data are out of date by the time we get them. For example, cancer survival rates a favourite of the Daily Mail typically measure survival five years after people have been diagnosed and treated, so at best reflect the state of cancer care before the NHS Plan and its related investment came on stream in 2000.
Part of the problem lies in the way that international health comparisons are used and abused. Think about any recent newspaper article on the subject and you'll see that these comparisons are mostly used for one of three conflicting purposes.
- to confirm the innate superiority of the NHS by emphasising the manifold defects in every other country's systems
- to prove the wholesale inferiority of the NHS, to justify why it should be scrapped lock, stock and barrel in favour of employer-based social insurance or some such scheme
- genuinely to learn from other countries' failures and selectively copy their successes.
Sadly, most debate falls into the first two categories when it should be the third, particularly as most health reform consists of incremental adjustment to an existing system rather than a Year Zero big bang upheaval.
Of course, other countries can be just as solipsistic as us, despite the fact that we are tackling similar health issues. It's worth remembering that 50% of deaths globally are caused by four chronic conditions (cardiovascular disease, diabetes, lung disease and some cancers), which in turn are driven by three preventable risk factors (tobacco, diet and lack of exercise). These are problems for all of us.
And learning shouldn't be one-way traffic. We should feel confident as we've got lots to teach the world, such as motivating GPs in the world's biggest 'pay for performance' experiment, and computerising health records, in what is apparently the world's biggest civil IT procurement. There's also the European Union to consider. In the aftermath of the collapse of the new European constitution, it's easy to be sceptical about the union. Clearly, it will continue to affect the NHS on issues as diverse as the free movement of health professionals, junior doctors' hours of work, the single market for pharmaceuticals and the cross-border flows of patients. But I believe that, for some time to come, some of the most powerful European influences on UK health policy will come directly from other member countries, rather than from legal direction emerging from the EU itself. Apart from anything else, with 25 member states, it is hard to see how one-size-fits-all policies can fit health care systems as diverse as those of, say, Germany and Slovakia.
So, rather than expect any form of EU- or European Court of Justice-led convergence in the way our systems work, we should adopt a magpie-like approach, taking the parts we like and passing over the rest. Indeed, recent controversial NHS reforms have explicitly borrowed ideas from other European countries, including patient choice of surgical provider (almost everywhere else), cross-charging local authorities for blocked hospital beds (Scandinavia), and foundation trusts (a hybrid of continental models).
And it has been obvious from most of Europe that it's entirely possible to combine equitable health care funding with more public and private providers. It's worth remembering too that the bedrock of the NHS namely the GPs are almost all for-profit private contractors, and have been since 1911.
But perhaps the strongest of our health policy love-hate relationships is with the US. Clearly, there are lots of things we don't want to copy but equally there are plenty we should. Here are four reasons why.
First, the US excels at health services policy research, so it is relatively easy to find out about successes and failures of particular innovations. If UK health policy is the triumph of implementation over analysis, in the US it's the opposite. But, precisely because proposed reforms in the US are subject to so much scrutiny, it is easier for vested interests to mobilise opposition to them.
Second, the technological developments that push up health care spending such as new drugs and equipment largely originate in the US but their consequences spill over to the rest of the industrialised world. So what happens domestically in the US 'medical-industrial complex' is what will eventually percolate here.
Third, the patchwork of health care subsystems makes the US a valuable laboratory, with a multitude of natural experiments from which to learn. In fact, it probably makes no more sense to talk of 'the US health care system' than it does 'the Western European health care system'. The mixed and overlapping responsibilities of US federal and state governments, large and small employers and individuals make national (macro level) comparisons of little use for practical learning though they work brilliantly for ideological slapstick. Transferable learning is more likely to be found at the organisational (meso) and clinical process (micro) level.
Fourth, the fragmented US system has of necessity stimulated highly sophisticated techniques including provider performance profiling and patient risk stratification for chronic disease management which are adaptable and valuable even in allegedly more integrated delivery systems such as the NHS. Considerable investment has gone into their development over many years. If the NHS is open minded and smart, it can access these state-of-the-art tools without having to reinvent the wheel and duplicate development costs.
So the truth is out there. While no country has the perfect answer, each might have something the NHS can learn from. It just has to look objectively for it.
Simon Stevens is president of UnitedHealth Europe and visiting professor of health policy at the London School of Economics, and was previously the prime minister's health adviser. He will be speaking at the CIPFA conference on Thursday, June 16 on 'Reforming the NHS: is the medicine working?' Simon_L_Stevens@uhc.com