Professor Brian Jarman, the Imperial College statistician and former BMA president behind the Hospital Standardised Mortality Ratio (HSMR) figures that first raised the alarm about possible problems in Mid Staffordshire NHS Trust and at around a dozen other trusts, released new figures last week in an exclusive with Channel 4 News that show the UK performs worst out of seven developed countries on hospital mortality. Jarman’s methodology has been critiqued and for “confidentiality” reasons he was unfortunately unable to publicly name some of the countries, but he could reveal that the top-performing country was America.
This is not surprising. Though the overall US healthcare model is rightfully criticised throughout Europe for its high costs, fundamental lack of universalism and extreme inequities, it has long been known that at least for those with access, the quality of American health provision is second-to-none. An American journalist, Steve Silberman, once observed that “one renowned health-care expert who grew up in England recently explained the difference between British and American medicine to me by saying that if he was very rich and had cancer, he would rather live in the US. But if he was poor and had cancer, he’d rather live in the UK and be guaranteed at least B-minus care”.
A mix of factors underpin this world-class hospital care. One is probably spending – the US spends one-sixth of its entire GDP (17%) on healthcare, compared to a European average of around one-tenth (however, our spending is arguably slightly lower than some of our neighbours – we spend 9.4% of our GDP on health, compared to 11-12% in Denmark, France, Germany and the Netherlands). As a result, American hospitals tend to be well-staffed – Channel 4 explored the Mayo Clinic in Arizona as an example – and equipped with up-to-date technology and drugs. Furthermore, since America leads in medical research, most new technologies are invented there and come on-stream fairly quickly.
Another factor, and one that is perhaps easier to replicate in the UK, is competition and pluralism on the provision side of the system. Though America fails badly by allowing healthcare to be a laissez-faire voluntary market rather than a Dutch or German-style social market where healthcare is financed on a universal basis, as in these nations, American hospitals are under diverse ownership (60% non-profit, 20% public and 20% for-profit, approximately) and compete for patients. Some studies have suggested that hospital competition in the US reduces deaths from Acute Myocardial Infarction (heart attacks). What’s more, similar research into New Labour-era NHS competition has since yielded positive results, suggesting that more “US-style” competition, delivered within a European framework of universal access, could help break down the dichotomy Silberman noted and improve treatment in this country.
In response to Jarman’s findings, NHS medical director Bruce Keogh pledged that “I will be the first to bring this data to the attention of clinical leaders in this country to see how we can tackle this problem” – I hope they do.
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