health systems

In 1948 Aneurin Bevan predicted that the NHS would soon be the envy of the world, a promise which was echoed by Tony Blair 49 years later. Joan Higgins examines the evidence behind those predictions

For many years UK commentators described the NHS as the 'envy of the world', with its comprehensive services available to all, free at the point of use.However, critical tabloid headlines, opposition taunts and the publication of international league tables have called into question this comfortable assumption. But was it ever true to say that the NHS was so highly regarded? And how does the service compare now with similar healthcare systems in other countries?

It was the then health minister, Aneurin Bevan himself, who first made this ambitious claim for the NHS in 1948. In a House of Commons speech, he said that 'before long' the NHS would become the 'envy of the world'. The incoming Labour government repeated this aspiration 49 years later. Prime minister Tony Blair declared that he wanted the NHS to 'take a big step forward and become a modern and dependable service' that was 'once more the envy of the world'.

So what was distinctive about the NHS in the 1940s - and why does the present government feel that the service compares so favourably with other 'mature' healthcare systems?

The NHS was introduced in 1948 to enormous popular acclaim. People contrasted it with a disorganised set of health services, unevenly distributed across the country and of questionable quality. From the 1930s onwards, growing numbers of the population were entitled to free or low-cost care, but services were often provided in workhouse hospitals or overcrowded consulting rooms. Recent studies have shown that the age group which was young in the 1930s and 1940s still compares present-day provision with pre-war services. This group is largely satisfied with the NHS. It is younger service users, who compare the NHS with other service industries, with overseas healthcare systems or with private sector healthcare, who feel that the NHS could do better.

Whether or not the NHS was the 'envy of the world', it was certainly different from all other healthcare systems when it was established in the 1940s. It was distinctive in that it was funded largely through a system of progressive national taxation.A small amount of funding was raised through national insurance (what many people called 'the stamp') and direct charging was minimal.All other countries that set up national health systems around that time opted for an insurance-funded system of some type. But in the NHS, the coverage of services was to be comprehensive (that is, it included a full range of preventive as well as curative services) and it was to be free to citizens at the point of use.Many other countries favoured co-payments, reimbursement systems or user charges as a way of limiting demand and encouraging the responsible use of services (as they saw it).

Perhaps the most important feature of the NHS, which other countries did not share (and perhaps envied), was the universal availability of primary care services to all citizens. Over 90 per cent of the population was registered with a family doctor who, with their practice staff, provided a formidable range of services from maternity care to preventive services, rehabilitation and the treatment of chronic conditions. Though primary care services have rarely achieved the seamlessness which other countries assume when they look at the NHS, they nevertheless provided a local and accessible service to all citizens at no (direct) cost.

In recent years, other countries have looked enviously at the capacity of UK general practice to guard the entry gate to the expensive secondary care system and have tried to emulate some aspects of primary care's gatekeeping role.

When we talk about the NHS being the 'envy of the world', however, we are often dealing with images rather than reality.What was the inheritance of the 1940s, and how does the NHS measure up to other healthcare systems today?

The truth is that the NHS was, for many years, a disorganised shambles of poor quality services. It may have been better than the system it replaced, but it was distinctly inadequate to meet contemporary needs.

The Nuffield survey of pre-war hospitals showed that many of them were bankrupt and in poor physical condition. Their average size was just 68 beds and they ranged in quality from excellent to dire.

There were enormous geographical inequalities in access to care. Lincolnshire, for example, had no radiologist and only one gynaecologist. London had a dense concentration of acute services and specialist care.Quality differences were also stark, and GP services, which were to be the foundation of the new NHS, varied markedly. Some had been decimated by the war, while others were a model of their kind.

If other countries admired the standards of clinical care in the NHS, they can hardly have been envious of the squalid physical conditions in which many health professionals practised their skills. Two-thirds of the newly nationalised hospitals had been built before 1891 and 21 per cent before 1861. Despite a recognition that the location and poor state of many hospitals did not meet 20th century needs, it was not until 1962 that the government (by then Conservativeled) published the Hospital Plan. This set out, for the first time, a blueprint for replacing much of the hospital stock in the NHS. It was later still before the rebuilding programme actually began. Even today, the NHS is providing care in accommodation built in the 1800s. Some mixedsex wards remain and privacy is severely restricted.

Toilet facilities are poor and standards of cleanliness notoriously bad.

Though the recent government directive to address these issues was greeted with derision, NHS chief executive Nigel Crisp was surely right that it should not have taken ministerial instructions to make hospital staff give cleanliness a priority.

The deteriorating fabric of many NHS hospitals compares unfavourably with conditions in European and North American hospitals. These countries have more spare capacity and there is less pressure on the physical fabric. Though the NHS now has its state-of-the-art hospitals, there are fewer modern facilities than elsewhere.

A number of controversial studies of health system performance were published by the World Heath Organisation in 2000. The main study by WHO ranks the UK ninth (out of 191 countries) in terms of overall health system performance, with France ranked first.

1Blendon et al have recently compared 'citizen satisfaction'with WHO's assessment of healthcare systems and per capita expenditure.

These figures show that the UK comes in the middle of the rankings in terms of citizen satisfaction with health services, even though it spends less than any other country in the study apart from Portugal and Greece.

Evans and colleagues have recently published another study, based on the WHO findings, which ranks countries according to aspects of health attainment.

3On this occasion, the UK comes 24th (out of 191) behind such countries as Oman (1), Malta (2), San Marino (5), Andorra (7) and Jamaica (8). The UK was ranked lower than Italy, France and Spain.

The main measure related levels of health attainment to expenditure on health and found that, while countries such as Oman were performing exceptionally well, other countries (including the UK) were performing below their potential. Evans and his colleagues concluded that although increasing expenditure on healthcare was essential in poor countries, developed countries could also improve the health of their population by using their resources more efficiently. The WHO studies have been criticised by writers who challenge the definitions used, the sources, validity and comparability of the data, and the assumptions on which the research is based. There are certainly some important methodological problems, but the overall picture nevertheless shows that the NHS is lagging behind comparable healthcare systems on a number of counts.

Another way to compare healthcare systems has been to examine the availability of health service facilities in different countries, and their use. A study by Anderson and Hussey shows that the UK has far fewer acute beds and doctors than other Organisation for Economic Co-operation and Development countries, but significantly more visits per doctor.

4Though expectation of life in the UK is at, or near, the OECD average, disability-adjusted life expectancy (an estimate of the number of years a person will live in full health) is lower than in most comparable countries, especially for men.

A further study by Blendon et al compared the views of doctors in Australia, Canada, New Zealand, the UK and US about the hospital in which they worked, the adequacy of nurse staffing and the likelihood that medical errors would be reported.

5The 500 doctors in the UK sample had less confidence than any of their colleagues that medical errors would be found and addressed. They had the greatest concerns about nurse staffing levels (45 per cent described them as poor, compared with between 12-23 per cent in other countries) and 18 per cent claimed that 'emergency room' facilities were poor (compared with 4-13 per cent in other countries). The UK doctors also came top of the poll in complaining that there were too few hospital beds, too few doctors, inadequate domiciliary care and long-term facilities, long waits for specialist referrals and 'not having enough time with patients'. It would be easy to dismiss these complaints as the views of 500 disgruntled doctors, but the study is persuasive and its findings are consistent with the objective evidence about availability of resources.

Finally, a study by Coulter and Cleary examined patients' experiences of hospital care in five countries (Germany, Sweden, Switzerland, the UK and US) and showed relatively low levels of satisfaction in the UK.

6The UK patients had the highest dissatisfaction ratings in terms of the information they were given and the co-ordination of their care. They were more dissatisfied than others with the levels of emotional support offered to them, the respect for their preferences and the involvement of their family and friends. They also had the highest level of complaints about the transition from home to hospital and vice versa.

More UK patients than any others felt their overall care was 'not good' and they would not recommend the hospital to family and friends.

Whatever perspective one adopts, no study describes the NHS as a world leader or even among the best-performing health systems in Europe. On many criteria, the UK falls well below the average (in terms of performance and satisfaction levels) of comparable countries in Europe and the OECD.

There are, perhaps, three conclusions to this analysis. The first is that - as in the early days of the NHS - the real problem of the healthcare system is the problem of the hospital. International comparisons show that the NHS lags well behind on the supply side (number of beds, number of nurses and doctors, availability of new technology and modern facilities) and in terms of the satisfaction levels of health professionals and patients.

Second, the prime minister's intention of increasing NHS spending to European levels will not automatically improve health status but, appropriately targeted, it could address some of the supply-side deficiencies of the NHS highlighted by international comparisons.

The third conclusion must be that the NHS is far from being the 'envy of the world' - in fact the claim is an embarrassment. The NHS is performing well in a number of areas (preserving a service which is free at the point of use, maintaining a comprehensive system of primary care and offering good value for the limited expenditure which goes on healthcare in the UK). The quality of clinical care and clinical research is, for the most part, highly regarded.However, the infrastructure compares unfavourably with many modern healthcare systems.

It is not a realistic expectation that the NHS will become the 'envy of the world' in the lifetime of this government, if ever.

It is more important, now, to identify and tackle the fundamental structural problems which international comparisons have thrown into relief, than to chase a chimera.

REFERENCES

1 World Health Organisation.World health report 2000.WHO.Geneva, 2000.

2 Blendon B et al. The public versus the WHO on health system performance. Health Affairs 2001; 20 (3): 10-20.

3 Evans D et al. Comparative efficiency of national health systems: a cross national econometric analysis. Br Med J 2001; 323: 307-310.

4 Anderson G, Sotir Hussey P. Comparing health system performance in OECD countries. Health Affairs 2001; 20 (3): 219-232.

5 Blendon R et al. Physicians' views on quality of care: a five country comparison. Health Affairs; 2001; 20 (3): 233-243.

6 Coulter A, Cleary PD. Patients' experiences with hospital care in five countries. Health Affairs, 2001; 20 (3): 244-252.

Key points

The NHS was introduced to enormous popular acclaim but services always varied markedly and the physical conditions were poor.

At the birth of the NHS, two-thirds of the hospitals had been built before 1891.

Even today, the NHS is providing care in accommodation built in the 1800s.

The NHS is now lagging behind comparable systems on several counts.

It is unrealistic to expect the NHS to become the 'envy of the world' in the lifetime of this government, if ever.

Joan Higgins is director and professor of health policy, Manchester centre for healthcare management, Manchester University.