A fair performance? Findings from the 2016 international health policy survey

The NHS occupies a unique place among our national institutions, regularly topping polls of what makes people most proud to be British. But what is it about the NHS we’re so attached to?

Our work on public attitudes found distinctly mixed views on care quality, patient experience and waste, with opinion split on who should provide NHS-funded care. However, there was overwhelming support for the founding principles of the health service: nearly 90% of people agreed the government should support a tax-funded national health system that’s free at the point of use, and that provides comprehensive care for everyone. In other words: fairness.

It’s easy to overlook the importance of fairness – sometimes referred to as equity – but it’s the ‘for all’ bit in NHS England’s mission statement. Thankfully, last week offered a timely reminder via the US-based Commonwealth Fund’s 2016 international health policy survey of adults (covering Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the UK and the US).

Equity of experience was part of the survey, but a wide range of other areas are also covered. The UK performs well overall on hospital discharge and care coordination, with respectable showings in several areas relating to people’s discussions with their regular doctor. Quick access to specialist appointments was a weak point, though direct access to specialists in several of the better performing countries arguably skews the results somewhat.

For easy and fast primary care access, the Netherlands stood out with just 19% of respondents reporting problems getting a same or next-day appointment and only a quarter having difficulties with out-of-hours care. The UK didn’t do as well, scoring 41% and 49% respectively on the same questions, though that’s still better than the median score.

And that may not be surprising. The Netherlands spends relatively more than the UK on health, with a greater proportion of spend in the private sector – both factors tentatively linked with improved health system responsiveness. But the same is true of the US and Switzerland, which scored worse than the UK.

In fact, according to the OECD, most of the countries in the survey spend more on health than the UK. In 2015, only Australia and New Zealand spent less as a proportion of GDP than the UK, and only New Zealand had a lower cost-adjusted spend per head.

But the section on equity is where the survey gets really interesting: examining differences in responses between people with household incomes of less than half the national median, and everyone else.

More low income adults in the UK (32%) reported having multiple long-term conditions, for example, compared to only 12% for all other adults – the second biggest gap after New Zealand. The additional complexity of meeting the needs of people with multiple long-term conditions may help explain why low income adults in the UK were also substantially more likely to report problems with care coordination (37% vs 20%).

Less explicable is the income gap for long waits to see a GP: 27% of low income UK adults – more of whom reported having multiple long-term conditions, remember – said they had waited six or more days, compared to 16% of all other adults. This is broadly on the median score, though, and doesn’t seem to translate into extra A&E usage.

However, the UK did particularly well on cost-related barriers to accessing health care – both overall and in terms of income differences. Only 7% of people (joint best with Germany) reported not seeing a doctor when they needed to; missing tests, treatment or follow-ups; and/or not taking up prescribed medications on cost grounds. By contrast, 33% of US residents – 43% of people on a low income – reported affordability issues. The picture on dentistry is similar.

Across all of the countries surveyed, a higher percentage of people on low incomes reported that cost had stopped them accessing care when they needed it. However, the gap between the poorest and the rest in the UK was by far the smallest at only a single percentage point – admittedly the UK sample size here was particularly small, being a subset of the 1,000 people surveyed. In contrast, over 5,000 were surveyed in Australia and more than 7,000 in Sweden.

There are other limitations. The survey is based heavily on people’s recollection, and some aspects of care may be more memorable then others. For example, I have no idea how long I waited for my last specialist appointment but have vivid memories of almost everything else. Also, there are probably differences between countries in terms of what people expect from their health system and it’s hard to account for these.

Overall, the UK – and, by extension, the NHS – performs very well, though there’s no room for complacency. Terms like equity, financial risk protection and social solidarity may not immediately spring to mind when looking at the latest quarterly results. But we mustn’t ignore the gaps we can see – however small – between how the system treats people with equal needs but different means.

Tim Gardner (@TimGardnerTHF) is a Senior Policy Fellow at the Health Foundation