• Burying the lede when talking about the NHS

    Austin alerted me to a piece in BMJ News discussing a presentation on the NHS, the health care system in the UK. You know – the one that’s totally run by the government. Here’s the title: “NHS scores well on access, out of hours care, and patient engagement but not on outcomes, conference hears.”

    Now I was surprised when I read that. After all, one of the knocks against a system like the UK’s is that access is limited. The wait times! Surely you’ve heard of them? Turns out, not so much:

    On almost every slide Osborn showed (except the one on outcomes) the NHS came out best or nearly best in an international comparison of 11 advanced countries: on access, out of hours care, patient engagement, shared care plans, electronic medical records, and patients’ and doctors’ opinions.

    She ended her presentation by expressing the hope that healthcare in the United States would change dramatically in the next 10 years, “inspired by the example the NHS sets.”

    All of these are areas where our health care system doesn’t do so well. I’ve shown these slides many times. So none of these things were a surprise. Still, for a system that gets so maligned in our press, it was nice to hear about data on actual access metrics where the UK outperforms the opinions of VSP in the mainstream media.

    But even at the BMJ, there’s a push to tell “both” sides of the story. So here’s the flip side:

    However, on the measure of mortality amenable to healthcare the United Kingdom performed worst in 1997-8 and second worst in 2006-07 of the seven countries Osborn compared for this (France, Australia, the Netherlands, Germany, New Zealand, the UK, and the US).

    So the UK enjoys a great health service but not great health, a puzzle that the conference participants never fully tackled. One who tried was Liam Donaldson, the former chief medical officer. “I think it strains credibility to say we have a world class service,” he said in response to Osborn’s presentation. “I don’t think it is.”

    When I first read that, I thought that the NHS must be making tradeoffs. The system is dirt cheap. They’re kicking butt in access. It’s not surprising that quality might suffer. But then I got to thinking. They’re “second worst” now in terms of amenable mortality? Who’s the worst?


    NHS story

    This kind of stuff drives me a little crazy. I have no idea if anyone in the US will cover this story. If they do, however, I bet it will be along the lines of the title. Sure, the UK does well in terms of access, but their outcomes are terrible. Do you want that to happen here? 

    What will be missed is the fact that the outcomes are, perhaps, terrible, but they are worse here. So “would I want that to happen here”? If you mean that we could spend less than half of what we do on health care, see access improve massively, and see our outcomes go from worst to second worst? I could live with that.

    For the record, using 2010 data, the UK would have moved up a spot. The US would still be last.


    UPDATE: Yes, I used PYLL instead of amenable mortality. They’re not exactly the same, but it’s what I could get easily from the OECD to make a chart of just the mentioned countries. But fine. Here’s amenable mortality, but with a lot more. For the seven that are listed above, the story is the same:


    • The measure “mortality amenable to healthcare” and “potential years of life lost, all causes” are two entirely different metrics. The latter goes up in the case of the U.S. tremendously b/c of gun violence (which is an entirely separate issue from the health system).

      Also on access: http://www.oecd-ilibrary.org/sites/health_glance-2011-en/06/08/index.html;jsessionid=as008die826bn.delta?contentType=&itemId=/content/chapter/health_glance-2011-59-en&containerItemId=/content/serial/19991312&accessItemIds=/content/book/health_glance-2011-en&mimeType=text/html

      Waiting times are pretty bad in the UK; that being said, they improved quite a bit in 2010.

      • I know, but that’s what I had to make a chart. You’re not the only one who complained, so I updated. 🙂

        • Understandable. That last chart is pretty interesting (I think I’ve seen it before).

          Check out pages 33 and 34 from that report. Looks like the US does worst in circulatory system diseases and (surprisingly) infectious diseases. Could the latter be influenced by AIDS prevalence?

      • It would be be nice if we could adequately separate socio economic causes for differences in survival from the healthcare system causes. It would also be nice if we didn’t have so many cross national reporting differences.

        Too many times we see confusing charts that are measuring effects due to things other than the healthcare systems. As mentioned above gun violence is not the only factor that skews the results. Add improper infant mortality comparisons, drugs, AIDS, automobile accidents, genetics, politics, etc. These problems make many of the charts near meaningless in comparing healthcare systems.

        • No, they don’t, and it’s getting tiresome that you keep saying that. These things would be concerning if they all, always, were stacked against us.

          The complaint was about PYYL, not amenable mortality. I already addressed that, but you keep ignoring whatever doesn’t fit into your meme.

          • I didn’t comment on any chart in particular, but made a generalized comment that many charts and statistics include data that has a lot to do with socio economic problems, genetics etc.

            That could work either for or against me so I don’t know why you made the statement you did. If you find something in particular that I stated that was wrong why don’t you quote that portion of my statement and tell me why you think it is wrong.

            Let me give you one citation regarding many of the numbers we see in particular infant mortality where in Switzerland “an infant must be at least 30 centimeters long at birth to be counted as living.”

            Nicholas Eberstadt, The Tyranny of Numbers: Measurement and Misrule, (Washington: The AEI Press, 1995), p. 50.

            • My frustration is that I have addressed the specific thing you cite (infant mortality) before.

              I’ve also shown evidence that even after standardizing to overcome this issue, the poor showing of the US remains.

              I’ve done whole posts on how any one metric and any one country is cherry picking.

              But you ignore everything I write and come in de novo every time as if you’ve just “discovered” something we missed. No matter how many times I point you to a refutation of your point, you ignore me and keep repeating it. It’s incredibly frustrating.

            • “My frustration is …”

              I feel sorry that I cause you such frustration, but you shouldn’t be frustrated. Instead you should engage or accept that not every viewpoint will mimic yours. You have shown evidence about a lot of things and I frequently can show contrary evidence so I don’t think you should feel I ignore everything you say. I don’t. I am merely providing contrary evidence or opinion much of it that has been very well documented and proven.

              You might have addressed infant mortality before, but that demonstrates just one of the many metrics known and *unknown* that affect the statistics and graphs you cite. There is more to infant mortality than the fact that data selection is inexact causing many countries to count a lower number of dead infants sometimes calling them miscarriages and sometimes simply forgetting to add them to the statistical data base. There is also the fact that we have a high rate of low birthweight deliveries partly due to drugs and low birthweight correlates very closely to infant mortality that you know better than I since you are a pediatrician. When broken up into quintiles based upon birth weights suddenly the US looks excellent. We are the best at LBW deliveries. We even deliver anencephalic infants that are doomed to die and be counted against us when we are rated for infant mortality or longevity.

              You are in a university setting where debate is supposedly a desirable thing so I hope you take my future postings in a better light and either prove me wrong or let the posting stand as it is for others to agree or disagree with as they see fit.

            • You are hilarious. There’s no way I believe that every viewpoint will mimic mine. That’s not what frustrates me. I already said what does, so feel free to check again.

              Do I not keep approving these posts? I’m sorry I don’t just “let them stand”, but that’s not the point.

              I love debate. Should you come up with a new debate point that hasn’t already been addressed on this blog, I’d be less frustrated. But I don’t have the time nor inclination to repeat myself over and over because you refuse to acknowledge that I have already covered what you cite. I’ve already done the “proving”.

          • @Aaron.

            Have you ever made a post where you go beyond the statistical aggregates and attempt to uncover precisely what it is that is driving excess infant mortality in the US, and of that excess what percentage of that differential is specifically due to differences in the quality of care delivered in American hospitals and clinics by American physicians and nurses?

            If more infants are dying here because the quality of care delivered by American doctors and nurses is deficient relative to international norms, please be specific and forthright and tell your peers *precisely* how their clinical practice is deficient, and present your evidence to support your indictment.

            If it’s not a matter of clinical efficacy, and it’s all a matter of access, then why not be more precise in your language when you address the topic and say that in your view access to health care is the reason why you believe that we have excess infant mortality in the US rather than arguing that the entire system in the US (access + efficacy) is deficient relative to the rest of the OECD?

    • Really that is an amazing statistic-just the fact that we have a higher mortality then . . . Greece? But God forbid we do any major overhauls because it’s all *working*so well.

    • When I lived in the UK 10 years ago, the health metrics for Americans with good, company-provided insurance tended to better than in the UK. I think the comparison was the 4 most common cancers, and I don’t remember if it was survival rates, which I acknowledge aren’t the best metric.

      However, if you included all Americans, we did worse than the UK.

      To me, this is why the Republicans say we have the best healthcare in the world: the 47% doesn’t count. If all of the sick or unemployed takers just changed their attitude, they’d be healthy, employed workers with great, company-provided insurance. So their poor health outcomes are their choice and can be completely ignored.

      eOne of the problem with the US system is a huge inequality in health outcomes between people with good insurance and people without. If you have good insurance, the US system is better.

      • ” If you have good insurance, the US system is better.”

        This old canard has been repeatedly debunked. Consider all of the useless and dangerous procedures you are subject to as one benefit of health insurance. Also consider the lack of preventive care and lack of follow-up and lack of coordination of care.
        Wait times and access are worse here also.

        • People with generous preventative care coverage often have good preventative care and, with an active doctor, good coordination. I think the problem is that the average person with decent company health insurance doesn’t good enough coverage.

          On the other hand, these people are the one who, in the UK, would have NHS-gap insurance and also get better care than the standard NHS patient (ie no waiting lists for hip replacements or diagnoses of cancer), so any comparison is still polished, carefully selected perfect apples to an unsorted, random bushel.

      • I’d be happy to see a link to this. If it was survival rates, though, I’m not surprised we did better. I’ve discussed that before in much detail.


        I’m sure this won’t stop someone from claiming this as proof the UK is superior, or from accusing me of ignoring the “truth”, or from claiming they just have a “different opinion” of which is better.

      • “the comparison was the 4 most common cancers” … “However, if you included all Americans, we did worse than the UK.”

        I wonder if Dr. Carrol will be asking for proof with regard to this fact? It has already been pointed out that there is reason to believe differently. Do we have a bit of the selection process going on with regard to which posts will be criticized or withheld?

        • And there it is!

          • My question was if Dr Carroll would be asking for proof of the statement:

            “the comparison was the 4 most common cancers” … “However, if you included all Americans, we did worse than the UK.”

            Dr. Carroll responds to my statement “And there it is!” There is what? Like my other comment Dr. Carroll never responded to the substance.

            Instead Dr. Carroll referred me to a discussion regarding the problems of studies using survival rates and nothing about the particular study under discussion. Each study has to be looked at as a separate entity before deciding its value or lack of value.

            This is exactly what happened in an earlier posting that became personal.

            Al wrote: “It would be be nice if we could adequately separate socio economic causes for differences in survival from the healthcare system causes. It would also be nice if we didn’t have so many cross national reporting differences. …”

            Dr Carroll’s response was: “No, they don’t, and it’s getting tiresome …”

            With regard to low birthweight and infant mortality, LBW is the externality that likely contributes most greatly to our infant mortality. Much of our LBW has little to do with out health care system and a lot to do with socio economic problems, drugs etc. This might be one of the reasons that prenatal care has not demonstrated the effective results that were expected.

            See: http://www.nationalpartnership.org/site/News2?page=NewsArticle&id=29706&news_iv_ctrl=0&abbr=daily3_

            Groundbreaking Institute of Medicine Report Led To Increase in Prenatal Care, But No Decrease in Low Birthweight

            and see Nicholas Erbstadt’s Tyranny of Numbers.

    • I have no expertise in this area and have never been to Britain……

      but if you google “NHS horror stories” there a lot of posts with a lot of facts.

      I am sure that some of these posts are right wing propaganda, but I do not think all of them are.

      Aaron’s article seems to be in a different universe, and maybe that is correct. But I am a little uneasy.

      My gut feeling is that British unions do have an ugly history of laziness on the job, due to the whole class warfare environment for centuries. This can lead to patient neglect to a degree almost never found in the USA.

      In the USA the billing departments of hospitals are brutal, but nursing staff is almost always kind. In England there are no bills, which I love incidentally, bujt there is cruelty.

      Bob Hertz, The Health Care Crusade

    • Look at your chart, if it were about health care systems it would imply that health care in Italy is massively better than healthcare in Denmark, that is just not believable.