The last week has seen conflicting reports about the level of care offered by the NHS, which have been used by different sides of the debate on NHS reform to justify their positions. The Commonwealth Fund has once again found the NHS to offer well co-ordinated and safe care, combined with fast access, when compared to other countries, including France, Germany, the USA and Canada. The report also notes that the UK continues to spend relatively low levels on health services, something which politicians may wish to reflect on in the context of future spending plans. We have also seen research published arguing that the UK’s record on cancer is better than previously reported. More on that later.
Set against these reports, the Patients Association published a report detailing horrific examples of neglect in NHS care. Coming in the midst of the Mid Staffs inquiry and stories of abuse at Winterbourne View, these case studies are a salutary reminder of how care can go badly wrong.
So is the NHS good or bad? The truth, as ever, is somewhere in between. There are undoubted strengths to the NHS system. Reading the Commonwealth Fund findings on the impact of cost on patients seeking medical help in some countries, makes me realise how easy it is to take for granted the concept of universal healthcare. Likewise, we have greater continuity of care than in some other countries. Yet, even the Commonwealth Fund report makes clear that there is no room for complacency. No country has yet to get close to solving integration or care coordination, although our primary care model does offer some important advantages. There is more for us to do and the report should not be used as a justification for no change, rather it should be used as a basis for informing the right change.
On cancer, the study which hit the news is unfortunately an example of using one set of data to inform the wrong conclusions. It is true that our cancer mortality has dropped significantly in recent years, but mortality is a measure of prevention as much as anything else. The UK does indeed have a good record on reducing smoking over the past 40 years and this is now showing in cancer mortality (and mortality from heart disease etc). But mortality is not such a good measure of assessing service performance, as movements in mortality have been primarily driven by factors outside the provision of treatment services. Doing so is like assessing the performance of a car mechanic in fixing engines by the number of cars that break down in the first place. Of course ministers should probably not complain about this mis-comparison, as they did exactly the same thing (see page 44) during the general election.
Survival is a much better indicator for how effective NHS cancer services are proving to be as it is influenced by stage of diagnosis and the rate and quality of treatment. Here, unfortunately, we continue to lag behind the best-performing countries, as successive studies have shown. The NHS may have spent less per capita on cancer services – as the authors of last week’s report did show – but it also achieves poorer outcomes than are desirable.
So what do these studies tell us about the NHS and the direction of reform? Firstly, there is a benefit in comparing performance between countries as this approach can give an insight into what works, but there is also a danger of drawing stark conclusions from this approach. Health service performance is rarely black and white. Secondly, as well as looking at macro performance, there is also value in examining individual stories as they offer a window into the realities of care, and how it can go wrong. In this sense, studying the personal story can be every bit as valuable as examining the population trend. Getting population-level care right is important for improving outcomes, but this also means getting care right for the people who make up those populations.