Join me, if you will, in a thought experiment. Imagine you love burgers. I mean, you really love them. You love them with the zealous passion of the religious convert and it is your greatest ambition in life to share their joy with the world around you. To this end, you devise an idea. You will find the world’s greatest burger. Now, you’re no fool. You’ve been to university. You remember well the best kebab you ever had. It was three in the morning, you were so drunk you couldn’t feel your face and you stumbled into a tiny chippie down a hidden side street that you never found ever again. You went to great lengths to try. You recreated the exact circumstances that led to its discovery. You went out with the same people, drank the same drinks, begged the DJ to play the Piña Colada song, and left the club at the exact same time, but… Nothing. Years later, reflecting on your failure, you realise that experience is subjective. It was just the right culmination of circumstance that made that one kebab the best kebab you’d ever had. With the benefit of hindsight it is clear to you that, in your quest to find the best burger in the world, you will have to be more objective.
How do you even choose the best burger? There are whole aspects to consider: the bun; the patty; the burger sauce; the environment. You’re gonna need a system, a team and dedication. Still, there are worse quests. Just say you find it. Say, for arguments sake, that you find that the best burger in the world is served in a little pub on East 18th street, not far from the Flat Iron building. Good for you. But you rapidly realise your quest hasn’t helped anyone. After all, you’re an evangelist. You want the largest number of people possible to enjoy the very best burger possible. Sure, when you make your announcement New Yorkers might flood the place for a week or two until the next big thing. But most people aren’t going to be able to fly to the city that never sleeps just for a beef patty in a bun. Would that they could.
Dejected, you do what any sensible individual would. You go the pub. Therein, you meet up with your friend who happens to work at a think tank. He’s got a degree in mathematics. He analyses stuff for a living. He buys you a pint, commiserates on your failed quest and it’s not too long before he’s offering some helpful insights. It sounds, he says, like you just got your question wrong. You weren’t ever looking for the best burger in the world. You were looking for the best burger in the world that most people could try. Dude, you need to add whole new categories! You need to consider availability, you need to consider cost and you need to consider ease of access. Your friend is a genius. You meet with your burger-quest team the very next day, scour the data using his new qualifications and announce to the waiting world media that the world’s best burger, using your new selection criteria is… Well, it’s a major global chain, isn’t it?
Disappointed, you retire from the public spotlight to consider how you tried to rank that which is impossible to quantify.
This week, the Commonwealth Fund think tank announced, after three years of analysis, that the NHS provides the best healthcare system of the eleven comparably wealthy countries it studied. It topped the table in four of its eleven categories: it was the most affordable, it provided the most equity, it had the best coordinated health ‘processes’ and it was the safest. Cool. Those are resounding successes and should be applauded. With crushing inevitability, however, those on either side of the political spectrum queued up to use the results for their own ends. Jeremy Hunt will no doubt take the figures to heart – turns out you can deliver the biggest real terms cut in funding in NHS history and still come tops in this survey. Those on the left will point to the enduring success of the last socialist Labour government’s legacy. And on, and on it goes, ad infinitum.
What if I suggested to you that problems of health access and equity are, essentially, socio-political? That’s not to deny that such issues are public health issues, but they are public health issues with social and political solutions. What if I suggested that safety and processes are, by and large, systems problems, incumbent on any organisation, performing any given task. What if I asked you, bluntly, why you interact with a health service in the first place?
If I’m a patient, or a friend, or a brother, or a son, hell, if I’m a doctor, I’m not desperate to know how equitable care is. I care, of course, but it’s not the thing that worries me most, in the moment, when I have to give someone a diagnosis, or when I have to see a loved one go through their therapy. Ultimately, the thing I and everyone else cares about, above all, is how successful any treatment will be. How do patients do?
In the Commonwealth Fund analysis the UK ranks second to last in terms of health outcomes. It has one of the highest rates of avoidable death in the Western world. Despite being the safest, despite being the cheapest, despite having great processes, it’s not the best.
Frustratingly, any conversation about the nature of how care is delivered in the UK rapidly descends into comparisons with the American system, as though commentators are only aware of two countries in the world that have doctors, clinics and hospitals. In terms of size and sheer complexity, the two nations afford an unhelpful comparison. If only there were similarly sized rich European nations, on their doorstep, that the UK could compare itself to.
I’ve been away from the NHS for a little while now. Whilst I’m proud of what it achieves and the incredible work put in by everyone I’ve ever worked with, using this data to announce that the NHS is the best healthcare system in the world is like saying that the best burger in the world comes from the globally ubiquitous chain with the plastic seating and the cheap meals. It’s successful, sure. It’s available, without doubt. It probably has a pretty good health and safety record. It is not the best. Demand better.