How good is the NHS?

That’s a question many have asked and few have answered convincingly. But one Swedish think tank has produced an index of healthcare performance in Europe and its 2013 results were published last month. Compiling such an index is a daunting task because the public information on health services in different countries is often incomplete or inconsistent. So it is necessary to gather not just official government data, but surveys of patients and practitioners across Europe, and in each country talk directly to health professionals to get an inside view of the service.

This year the index includes thirty-five countries, and for the first time it splits out Scotland from the rest of the UK. Over the last few years Scotland has pursued health polices which are radically different from England. At the same time it spends a lot more on healthcare per head than England. In such a big and complex industry, change happens slowly. But now is the time to start seeing if real differences in performance are starting to emerge north and south of the border.

As for the results, the clear champion of European healthcare is the Netherlands. The Dutch perform well across the board in all the categories of healthcare performance measured: medical outcomes, waiting times, patient rights, the range of health services provided, prevention and access to medicines. In Holland healthcare is good, safe, efficient, clean, convenient, and as comfortable as can be expected.

Next in line in the 2013 league table are Switzerland, Iceland, Norway, Belgium and Germany.

And the NHS?

Well, it has to be said that both the Scottish and English NHS are rather ordinary performers, tied nearly together in 13th and 14th places. This might not sound too bad in a field of 35. But when you look at who is below them, it is mainly the formerly communist countries of Eastern Europe, plus a few in the Mediterranean region such as Greece and Spain.

What is the reason for this mediocrity? Well, one thing we can say for sure is that it’s not the money.

Debate on healthcare in Britain usually revolves around spending. Politicians argue about how much they are ‘putting in’ to the NHS, how many nurses they’re hiring, how many new hospitals they’re building and so on.

But the evidence does not show that such ‘inputs’ make much difference.

To be sure, there is a correlation between wealth and good health. Rich countries can afford more advanced medicines and equipment than poor ones. But among countries with roughly the same overall resources there is a huge variety of healthcare performance.

The Dutch, for example, do spend a lot on healthcare. But the most expensive elements of their system, such as psychiatric treatment and care for elderly patients, are not the main contributors to their success.

And if you look at key performance indictors such as waiting times, the link with spending is almost non-existent.

The Scottish – English comparison is another case in point. The study throws up some modest differences in performance between the two countries in areas such as waiting times (where the Scots edge it) and the range of available services (where England has the advantage). But overall the scores are almost identical.

This is despite that fact that Scotland spends about 11 per cent more per head on healthcare. This can’t wholly be explained by demographic factors. Instead we have to conclude that Scotland throws a lot of money at healthcare with no clear impact.

To put it another way, if the Scottish NHS was as ‘productive’ as its counterpart in England, the Scottish Government would have an extra £1billion plus to spend on its other priorities – roads, schools or even tax cuts.

So if money isn’t the key to good healthcare, what is?

Well, the healthcare index has shown one trend that is remarkably consistent over the years, and that is to do with how health services are organised. On the whole, those with decentralised ‘Bismarckian’ systems – after the 19th-Century German Chancellor who built Europe’s original social insurance system – perform better than centralised ‘Beveridge’ systems like those in the UK and most of former Communist Eastern Europe.

When they are not talking about money, British politicians tend to talk about health policy in black and white terms – with white being the government-run NHS and black being a privatised American style ‘free-for-all’.

But the norm in Western Europe is neither of these two extremes. Instead, patients in ‘Bismarckian’ countries like Holland, Germany, Belgium and France benefit from the best of both worlds. As in Britain, healthcare is financed by taxation (usually via employers), and so is affordable for everyone.

But that is where the similarity ends.

Citizens typically choose an insurer which then buys their healthcare from competing independent doctors, hospitals and other healthcare providers. The quality of care is usually better (and more efficient) because there is more autonomy for professionals, less government interference and, in the last analysis, healthcare providers know they have to do a good job or else their patients will go elsewhere. In other words, ‘Bismarckian’ systems use market mechanisms while at the same time ensuring equal access for rich and poor alike.

It is true that some small Scandinavian ‘Beveridge’ countries also do well, such as Denmark and Iceland. But these countries enjoy a long tradition of highly decentralised decision making and professional accountability that has not been matched elsewhere.

What are the implications of this for the NHS? Well clearly the system needs reform to encourage patient empowerment and competition among providers (and preferably between insurers too).

It is as well, then, that the NHS in England has started to follow this route. Reform began as early as the 1990s, and continued slowly under the Blair government and now a bit more rapidly under the Coalition. The aim has been to copy elements of the ‘Bismarckian’ social democratic model, and patients can now choose between a range of providers – sometimes NHS trusts, some independent – just like they can in Holland, Switzerland and Germany.

It is still too early to tell if these English reforms are bearing fruit. It will be important to get the incentive structures right, particularly for purchasers, so that competition is really effective. But at least the principle behind these reforms is clearly correct.

Sadly, Scotland has so far turned its back on more successful European models of healthcare. But one piece of good news is that Scots patients should find it increasingly easy to access treatment elsewhere in Europe.

For once the European Union may be doing something useful for ordinary citizens in this regard. A recent directive, implemented in October this year, gives EU citizens the right to healthcare in any member state, with their local health service picking up the bill.  In a sense, the ‘Bismarckian’ model is coming to Scotland whether we like it or not. That won’t just help Scots looking for first class treatment. It might focus minds in the Scottish Government too.

These issues are analysed in more detail in Patient Power – Lessons from the best healthcare systems in Europe by Arne Björnberg, published by New Direction: The Foundation for European Reform.

1 thought on “How good is the NHS?”

  1. Posted 14/12/2013 at 17:05 | Permalink

    The ECHI index is not new – it has been producing results like this for years.
    Additionally, the OECD has produced its own comparisons of quality and efficiency ( . In summary, the UK spends about the average, but we get much less medical care and and a lower quality of medical care for our money. Our system is one of the least efficient (in European OECD members, only Greece and Ireland have less efficient systems)

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