Following his recent report assessing the UK health system in an international context, Tim Knox writes that the UK's declining health isn't any one person's fault, it is simply that the NHS is no longer providing the best possible care.  

In my recent report for Civitas, I showed that, sadly, the UK does badly in terms of our health care outcomes. In comparison to 18 other well-off countries (the countries were chosen not by me but by a group of specialist health think tanks and the IFS), the results were shocking: we are bouncing along the bottom of the league tables. We have the worst results for treating many cancers, for heart attacks and for strokes; and are in the bottom three for life expectancy and treatable mortality. An important note: this is all about numbers – and all the figures that follow, and all the figures in my report, come from the highly regarded OECD international health database which provides the data to enable cross-country comparisons to be made.

My conclusion – that our health care system for treating major diseases is really poor – has provoked two main lines of counter-argument: firstly, that it is all a question of money, that the government has seriously underfunded the NHS, that it is therefore the fault not of the NHS but of government. However, according to the OECD, our spending on health care was 10.2 per cent of GDP in 2019* – exactly matching that of the average of the other countries studied.

The other way of measuring health spending is the average spend per person on health care: here, we do not do quite so well, coming 14th out of the 19 countries with spending of $4,500 (in $ppp in 2019, according to the OCED) compared to the comparator country average of $5,101. Is this average, or slightly-lower-than-average, spending an excuse for coming bottom of the league tables in terms of outcomes? I think not.

The second line of attack is that it is all our fault: that we eat the wrong food, that we smoke too much, that we drink too much, that we are too fat; and that the poor old NHS has to deal with the results of our own self-indulgence. This was the argument made by Trevor Phillips in a radio debate on the pamphlet with Melanie Phillips (see here at 3.20:00) when he accused me of making a "basic category error"; and also on a twitter thread from the King's Fund and a blog by the Health Foundation. It is certainly true that we could, overall, do better in looking after our own health but again we should look at how well we do in comparison to our list of similarly well-off countries. The results?

  • Smoking: UK ranks 11th out of 17 countries with 15.8 per cent of the 15+ population who are daily smokers. Comparator country average is 15.7 per cent (2019)
  • Drinking: UK ranks 13th out of 19 countries with average annual alcohol per capita consumption by the 15+ population of 9.7 litres. Comparator country average is 9.2 litres (2019)
  • Obesity: UK ranks 6th out of 9 countries with 28 per cent of the total population being obese (measured, not self-reporting). Comparator country average is 25.8 per cent (2019)
  • Fat Intake: UK ranks 5th out of 19 countries with average daily fat consumption of 138.3 grams per day. Comparator country average is 145.2 grams (2018)

So we are not that bad, in international terms. Not great. But average. Our rankings for how we treat ourselves are certainly not as low as the outcomes we endure for major diseases.

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There are a couple of other points to bear in mind: first, that the OECD approach is far more sophisticated than my critics allow. So the OECD does not measure deaths from cancer, which could obviously be highly influenced by lifestyle and environmental factors (smoking too much, eating the wrong food, not enough exercise and so on). Instead it measures the five year survival rates of patients from first diagnosis: in other words, how well the health service does, once a patient is unfortunate enough to be diagnosed with cancer. Here the results are striking: compare our outcomes for lung cancer with those of Japan, a country with a higher prevalence of smoking. In Japan, 60 per cent of patients live for five years or more from the point of diagnosis. In the UK, it is just 21 per cent.

Second, there is the question of the euphemistically named "Treatable Mortality". This is where patients unfortunately die when they would have survived if they had received appropriate medical treatment. This clearly has little to do with our behaviour. And sadly, again, we do not do that well here, coming one but last of our 18 comparable countries. This means too many people die unnecessarily: over 6,600 people in the UK would have lived if we had achieved the average of our comparator countries in the latest year for which the OECD publishes data. It is worth stressing again: this cannot be blamed on lifestyles. What possible excuse can there be for this appalling ranking?

Finally I should make it clear that I personally have no grudge against any doctor, nurse or health sector worker. I and my close family have often, if not always, had the most amazing treatment from concerned, dedicated and caring individuals working extremely hard in difficult circumstances in the NHS.

So if it is not the politicians fault, if it is not our fault and if it is not the medical profession's fault, then whose fault is it?

Might it just be the NHS? And can we please talk calmly about the possibility that we no longer have a health system that provides us with the best possible care?

*The cut-off for all data was 2019 to avoid any pandemic influences. Future iterations of the report will include an analysis of how well we did, comparatively, in terms of our pandemic health outcomes.

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