11-country Commonwealth Fund: The sting in the tail for number 1

The US-based Commonwealth Fund has released a new 11-country comparative ranking of health systems. See the diagram. commonwealth fund table

Before the UK pops the champagne corks, let’s decode this ranking a little bit. Oh yes, before we also get too excited, rankings like this are useful only as a discusion tool. What does it say say operationally, if you had to choose a system to be ill in?

In effect the UK is tops and the US bottom, overall. But there are some disturbing issues with the data that necessitate a reflective pause.

If the UK is 1 for Quality of Care, and 1 or 3 for Access, and 1 for Efficiency, why doesn’t that translate into Healthy Lives? If the US is middling for these, which it appears to be, are we surprised that they have poor efficiency, equity and healthy lives?

What strikes me is that the UK despite having scored 1, that all this effective care, etc. is really ineffective as it doesn’t translate into better results. Efficiency, too, seems a technical measure, and one which also seems to fail to translate. So two quite different systems on the ground, and which are poles apart on the ranking, are competing with each other for impact on people’s healthy lives.

If we look at the other countries through that same lens, we’re struck by how much better they are at driving improved results (in the jargon of the Fund: mortality amenable to medical care, infant mortality, and healthy life expectancy at age 60. It seems to me on this basis, that while France has poor access (really!), it produces the highest ranking for Healthy Lives. Now isn’t that the point of having a healthcare system in the first place? Something else is going on that this ranking is illustrating but which isn’t being drawn out from any commentary,

So, my summary:

  1. The reason the US is last on Healthy Lives is mainly ideological and not for a lack of trying to things better, but regretfully, only for those who have insurance cover, with eye-watering variances from state to state. I do find this surprising to some extent as the US is very well served by a research community that analyses costs and treatment flows and the ability of payers to drive incentives into the system. Perhaps the distributional inequity of access will pass the reform, while the relative inefficiency may be a measure of the tolerance of a wealthy country has for ensuring people who can afford the care do in fact get it. Hmmmm.
  2. The failure of the UK to translate all those 1’s into Healthy Lives is evidence of the dysfunctional nature of the design of the health care system to actually deliver care itself and a fetish with structural reform, rather than organisational reforms which would enable other models of care to emerge. This focus on driving out variance actually drives out innovation rather than enables it: the UK’s public health system eats its young and fails to bury its dead, so the system goes round and round, in some massive holding pattern and people wonder why things don’t change. The system is efficient once you get the care and access, at least defined in terms of general practice is great, but waiting times for tests and access to the hospital based specialists doesn’t really translate well into timeliness. I question the 3 for the UK as countries with direct access to specialists enjoy much quicker access to care and this indeed does translate into the higher Healthy Lives rankings we see.
  3. I’m not sure how you can have a healthcare system that scores 10 for effective care and 2 for Healthy Lives. If you’re getting ineffective care, wouldn’t that translate into poorer results like in Sweden? Hmmmm, again.
  4. It is interesting to see how poorly performing very wealthy Norway is, but then it has a state-run monoply health system. But again, how can you square all those 11’s?  Are the poor results evidence that a state-run bureaucracy is not working? Probably.
  5. Canada’s system is a fragmented mess at the best of times, and affected by a powerful mythology about its performance, premissed mainly on it not being like the US. Restrictions on patient access to care are systemic, and designed in by the slavish belief in the Canada Health Act prohibiting alternatives. A real policy straitjacket, I think.
  6. Finally, the one’s that in the middle, so to speak, Australia, Netherlands, Switzerland may be more worthy of further consideration.

 

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