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Author: Stuart Rock
Written on: 05 January 2018
Last updated: 14 February 2018

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Healthcare, NHS
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Ranking the NHS


Is the NHS the best healthcare system in the world? This article, published by Full Fact in the summer of 2016, caught our eye.

It was prompted by Prime Minister Theresa May's remarks during a PM Question Time that the NHS is the number one health system in the world, citing a study carried out by the Commonwealth Fund, a US private foundation, which looked at 11 rich countries and compared their healthcare systems on a number of criteria. In the spirit of evidence-based positive journalism, World Class Britain likes the work of the independent fact-checking charity Full Fact. (Incidentally, which other countries have similar organisations? Must check with them.) As Full Fact note, the question as to whether the NHS is the best healthcare system in the world is not an easy question to answer, and the Commonwealth Fund research doesn’t answer it.

Here's what Full Fact has to say:

"The authors told us the analysis didn’t distinguish between NHS and private healthcare in the UK, or between countries within the UK (each of which has a separate system). Studies like these also need to make a lot of judgement calls about what to consider in forming the rankings: how valuable is equal access, for example, compared to timely care? What you consider to be a good healthcare system might not be the same as what this research takes as its starting point.

None of these points mean the research itself is bad: the problems start when the ranking is passed off as the final word on how the NHS is doing compared to other countries. The Commonwealth Fund report covered Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States.

The UK was ranked first overall, though its performance varied across the five areas. It was ranked first for ‘Care Process’ and ‘Equity’, third for ‘Access’ and ‘Administrative Efficiency’, but second-to-last for ‘Health Care Outcomes’. The previous Commonwealth Fund report in 2014 also placed the UK first overall. The study wasn’t actually focused on the NHS—which is different depending on which UK country you’re in—but on the UK healthcare system as a whole. The authors told us the surveys were weighted to take account the size of each country in the UK and so the bulk of the UK results would reflect the performance of NHS England. 80% of spending on UK healthcare in 2015 was by the government, largely on NHS services.

The five main areas were broken down and assessed using surveys of patients and doctors plus official statistics from the OECD, WHO and European Observatory on Health Systems and Policies. The existence of comparable data between countries influenced which measures were chosen, so things like mental health and long-term care services are not well covered.

The Nuffield Trust health think tank noted in response to the Fund’s previous report that: “These results provide only a partial view of health care quality and how patients and physicians answer the questions may be affected by their own experiences and expectations; which are likely to differ across countries, cultures and population groups. For example, if the British are generally positive about their health care system and have lower expectations than say the Norwegians, the UK system will score better.”Each of the five main areas assessed by the Commonwealth Fund was weighted equally. So, for example, a service being affordable and timely (access) was as important as the difference in care reported by people with higher and lower incomes (equity).

A lot rests on choices like these, according to the King’s Fund and Nuffield Trust health think tanks. The King’s Fund weighed in on a previous version of this study: “The Commonwealth Fund’s study is primarily designed to highlight poor performance in the US system. As we’re good at lots of things that the US isn’t – like access to care—we come out particularly well”

It went on to stress that this didn’t mean comparative rankings like the Commonwealth Fund’s are misleading or unhelpful—they can raise questions and highlight areas that need attention.

The Nuffield Trust, meanwhile, also commented on the latest study, saying that “While the NHS does well on a number of measures including efficiency, affordability, equity and some aspects of the process of care, it performs poorly in terms of outcomes.” It says that because the five themes examined by the Commonwealth Fund are given equal weight, the fact the UK does well in some “swamps the effect of its disappointing outcomes on its overall score.” It concludes “One thing is clear though: just because a ranking system produces a result we like does not mean that it is the final word.”Different international comparisons look at different countries and measure healthcare performance in different ways.

The Euro Health Consumer Index ranked the UK 15th out of 35 European countries at the start of this year (although the authors point out that precise rankings aren’t that important). This was based on 48 measures across six areas, chosen to reflect patients’ experiences.

A 2015 study by the Nuffield Trust and Health Foundation compared the healthcare systems of 15 countries (Australia, Belgium, Canada, France, Germany, Greece, Ireland, Italy, the Netherlands, New Zealand, Portugal, Spain, Sweden, the United States and the UK). It found that for 14 out of 27 measures the UK performed worse than other countries, although it did note that the UK’s performance was “stable or improving” in 25 of the areas.

There really can be no such thing as a "best" system, particularly one as large and complex as national healthcare. What is important is that we keep monitoring the performance of the NHS against other healthcare systems - and reporting clearly and fairly on how well it is doing.

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