Damage caused by PFI, pay rows and the 2012 reorganisation needs reversing, says Martin McKee of the London School of Hygiene and Tropical Medicine

The NHS has been the envy of the world for its fairness, good outcomes and value for money, but it needs more funds and the dismantling of recent changes if it is to be so again, according to a leading expert on international health systems.

Healthcare in the UK still takes first place in the rankings of 11 wealthy nations put together by the Commonwealth Fund in the US. But Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine, says the real glory days of the NHS were in the 1980s. Other countries, such as Spain, Italy and Portugal, modelled their own systems on it.

“The NHS was envied because it was very effective, low cost and delivered good outcomes,” he said. But it was always under-funded. “It needs more money and it needs to dismantle some of the more recent changes,” he said.

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PFI – the private finance initiative, which was used to raise money to build new hospitals – has left a huge legacy of debt. The financial troubles of the Barts trust in London, heading for a £135m deficit, the largest in NHS history, are largely a result of PFI, said McKee. That, together with the reorganisation imposed by the Health and Social Care Act and issues around the pay and performance of the workforce including junior doctors, had created “a perfect storm”, he said.

In its latest report comparing healthcare in 11 countries, published in 2014, the Commonwealth Fund ranks the UK’s healthcare top, based on outcomes and patients and doctors’ surveys, as well as value for money. The UK comes first for access (tax-funded care free at the point of delivery) and for quality of care, while the US trails in 11th place. The other countries in the study are Canada, Australia, New Zealand, France, Germany, the Netherlands, Norway, Sweden and Switzerland.

“The UK continues to demonstrate strong performance and ranked first overall, though lagging notably on health outcomes,” said the report. It found the UK had a higher rate of “amenable mortality” – deaths that could have been prevented by healthier lifestyles or medical intervention – than other countries. France, Sweden and Switzerland did the best.

However, McKee takes issue with a regular survey of European nations, which ranks the UK’s healthcare as only middle of the pack. A 2015 survey produced by the Health Consumer Powerhouse, founded by a Swedish entrepreneur, puts the UK in 14th place out of 35 countries, with the Netherlands first.

The Euro Health Consumer Index [pdf] survey says the UK falls down because of “accessibility”, ie waiting times. “A 2014 survey to the public of the UK, asking about ‘What is the essence of being British?’ got the most common response ‘Having access to the NHS’. Nevertheless, the UK healthcare system has never made it into the top 10 of the EHCI, mainly due to poor accessibility (together with Poland and Sweden the worst among European healthcare systems) and an autocratic top-down management culture,” says the report.

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But according to McKee, although the Index is influential and often used to criticise the NHS, it is also market-oriented and flawed. In a critique published on Tuesday in the British Medical Journal, he argues that “while many other health systems rankings … have been widely criticised, such as the 2000 World Health Report, these are far more transparent, methodologically, than the Euro Health Consumer Index”.

The Index awards points on a “seemingly indiscriminate” basis, he says. So abortion rates and cancer survival are given the same weighting, and both count less than waiting times.

“Although the report accepts that its results are not ‘dissertation quality’ and must be treated ‘with caution’, it draws inappropriate conclusions about the superiority of one system versus another one, leading to uninformed recommendations and assertions that display limited understanding of health systems. This is patently irresponsible,” write McKee and colleagues, who are all members of the European Observatory on Health Systems and Policies, a partnership of governments and academics, in Brussels and London.

McKee believes there are areas where the NHS is recognised not to do as well as some of its neighbours, for instance in paediatric care. “Our child health outcomes are not as good as they should be,” he said. GPs do not receive enough paediatric training and miss things that ought to be picked up early on. There is also a problem with fragmentation of care, because the discipline includes, for instance, premature babies, teenage mental health and genetic disorders.

Our child health outcomes are not as good as they should be

Cancer outcomes in the UK are known to lag behind those of many European countries, which is thought to be partly a problem of late diagnosis – patients do not go to the doctor early enough with symptoms and GPs do not spot some of the less common cancers that they rarely see.

The US has very good outcomes, including for cancer – for older people. But many miss out. According to the Centers for Disease Control last year, 35.7 million people did not have health insurance in the US, which is 13.3% of the population, although this is a significant improvement since the introduction of the Obama reforms.



Medicaid provides basic healthcare for the poorest people. Those not entitled to it who also do not have insurance can get emergency care. But the really good results from the US system are in people aged over 65, when everybody is entitled to Medicare, a scheme that is similar to the NHS, though better funded.