The NHS and USA’s Efficiency and Effectiveness in reducing mortality

During the last US presidential campaign I was amazed at the misinterpretation of the NHS, which led to Mark Wallace and I considering the question `just how effective and efficient is the NHS’ compared to the USA and other Western countries health care systems (Comparing the USA, UK and 17 Western countries’ efficiency and effectiveness in reducing mortality Pritchard & Wallace, 2011, Journal of Royal Society of Medicine)?

We decided that the ultimate outcome measure of any health care system is to reduce adult deaths between 15-74 years and drew upon WHO mortality data. Of course a major issue is how much countries spend on health i.e. Total health expenditure as percentage of Gross Domestic Product  (GDPHE) and drew upon an impeccable source, the US Bureau of Statistics, for the latest comparable international figures 1980-2005. We calculated the average percent of GDPHE over the period and despite media assertions of how expensive is the NHS, we showed that the UK gets the NHS on the relative cheap compared to most other Western countries!

Our assessment model was quite simple, examining financial input, annual and average GDPHE to health care set against the clinical output, of reduced Death Rates (DR) to calculate a cost-effective ratio of how many deaths were saved per 1% of GDPHE.

GDPHE 1980-2005. In 1980 only Spain spent less than the UK’s 5.6% compared with the USA’s 8.8% but to be fair over the last decade the UK had the second proportional biggest increase in GDPHE, the USA was highest, and the current UK HDPHE of 9.3% is its highest ever but still below the Western average of 9.7% and way behind the USA 15.3%. Over the period the USA easily had the highest average GDPHE at 12.2% to the UK’s 7.1%, and only Japan and Spain spent less.

Adult Death Rates: The `good news’ is that during that period most countries average (15-74) DR fell more than 24%, the UK by 43%  and only two other countries DR fell more.

In the 1980’s the UK had the third highest Death Rate at 9,682 per million (pm) now it is 5th highest at 5,471pm, a reduction of 3,951pm compared with the USA reduction of 2,498pm. Moreover when we compared the UK DR for older people aged 55-74, whilst four countries did better than the UK the UK reductions fell significantly more than 12 other countries, including the USA.

Cost-Effectiveness ratio:  Based upon 1% GDPHE to reduced DR, the USA cost-effective ratio was 1: 515 pm deaths, whereas the UK had the second highest ratio at 1: 1490pm, almost three times more cost-effective than the USA, where `private health care’ is the dominant model.

Another Perspective- Cancer Mortality Rates: A key argument for the Governments changes of the NHS is that the UK did not achieve as well as most other countries in respect to cancer `survival rates’. We repeated the above methodology to examine Cancer Mortality Rates (CMR), rather than `survival rates’ in the ten major Western countries (1980-2006) in an admittedly more complex paper. (Pritchard & Hickish British Journal of Cancer, 2011).

By 2006 the UK GDPHE averaged 7.3%, equal with Japan, again Spain only Spain spending less.. This low `financial input’ was reflected in the fact that the proportion of GDPHE going specifically to cancer care, the UK was equal 5th out of the six biggest European countries and also had the lowest spend on cancer drugs in Europe.

Nonetheless, when calculating a cost-effectiveness ratio for cancer deaths, UK had the largest cost-effective ratio, 1% GDPHE to 120pm reduced CMR, compared to the USA’s 1: 39pm!

Professor Souhami’s paper (see British Journal of General Practice, 2010) highlights the flaws in preferring `cancer survival rates’ rather than Cancer Mortality Rates, exemplified in my own surgical treatment for cancer. If I had been assessed in the USA my survival rate would have been 9 years but only 8 years (in March 2012) in UK, as cancer survival rates are not as firm a measure as mortality rates.

Conclusion: Based upon these two recent papers we can celebrate the NHS and suggest that UK citizens, especially the middle-classes, get a relatively cheap but effective and efficient health care service, whilst the US middle-classes are virtually being ripped off because they have the least effective and efficient health care system in the West, despite Fox News’ horror at `socialised’ British medicine.

What these results show is that the NHS achieves more with proportionally less. The only way to judge the NHS is to compare it with other health care systems. This should be a boost to patients, their families and front-line NHS staff. But sadly it seems that the media denigrates the NHS at every opportunity, and this effects patient morale. My co-author, consultant oncologist Professor Tamas Hickish, meets new cancer patients almost daily and many have said to him “should I go abroad for treatment?” His reply used to be “no, we have a great team here at the Royal Bournemouth, but now I can give them our paper to see for themselves”, which is why there are good ground for celebrating the NHS.

Professor Colin Pritchard, School of Health & Social Care, Bournemouth University.