Jewel in the crown or rough diamond?

What do you want first: the good news or the bad news?

The good news is that we are one of the best of 11 developed nations at coordination in primary care. The bad news is that we are one of the worst of 11 developed nations at coordination in primary care. The mixed news is that more important than where we come in a league table is the amount of variation in the data underlying it, and what we can learn from the data.

Let’s take a step back.

19 June 2015. Jeremy Hunt is speaking to a collection of GPs in London. It’s his first speech after the General Election. He refers, as many do, to the fact that the UK came top in the Commonwealth Fund’s ranking of health systems. Many of the UK’s marks were from the quality of general practice.

‘In other words a respected, independent US think tank has made it official: general practice is the jewel in the crown of our NHS.’

This was based on the ‘coordinated care’ section of the Commonwealth Fund’s Mirror, Mirror report (which draws on their 2012 international survey of primary care practitioners), where the UK ranked first outright.

We at the Health Foundation have part-funded the latest Commonwealth Fund survey of GPs, as well as shaping the questions. So we can now have an in-depth look at updated data from that section of Mirror, Mirror and see how the experience of UK GPs in coordinating care compares with that of primary care doctors internationally.

How did we do?

So, do we win again? Well, no. But we do pretty well, only being outranked by New Zealand.

We’ve crept up the rankings for doctors receiving alerts about test results and GPs getting good information within two days of patients being discharged from hospitals. But these improvements have been cancelled out by falls in the rankings for GPs being told that patients have been discharged and GPs receiving timely information from specialists.

While it’s never nice to be dethroned, and there’s some cause for concern, it’s worth putting things in perspective. The UK’s performance across these metrics deteriorated but so did that of most countries, and only two of these drops were statistically significant. Most of it is just basic churn: we did have the gold medal, now the silver. Still pretty good.

But maybe this league table language isn’t the right way to think about things.

Something as complex as the interaction between millions of different people, across thousands of organisations, across different countries (and time periods), can’t be summed up in a few numbers. And aggregating across all these things makes the numbers so abstract that all pretence that they’re useful to those working in the NHS (except as a source of pride) goes out the window. The danger is that you hide variation between different themes, different questions, different areas of the country, different GPs, and everywhere else for that matter.

But international comparisons can be useful: they shed light on areas for improvement as well as best practice, are a rough guide to health system performance, and can be used to inspire pride. But to say they’re more of an art than a science is like saying that Einstein was more of a physicist than a patent office assistant. The Commonwealth’s International Health Policy Surveys in particular allow us to look at trends over time across a number of developed health systems. And once you dig deeper into the numbers, you see some interesting things.

The impact on patients

Looking beyond Mirror, Mirror our new report Under Pressure, which analyses the Commonwealth Fund’s 2015 International Health Policy Survey of Primary Care Doctors, looks in more depth at UK GPs’ views on care coordination. And it surfaces another scuff on the jewel in the NHS’s crown: UK GPs feel poor coordination is affecting patients, much more than GPs in any other country.

Part of this can be explained by UK GPs seeing many more patients in need of this kind of coordination. But this still doesn’t explain why we perform poorly compared to New Zealand (16 percentage points more GPs reporting patients experiencing problems), Sweden (26 percentage points), or the Netherlands (33 percentage points), all of which have similar levels of ‘need’.

Add on to that the fact that 70% of GPs find it difficult to coordinate care with social services or community providers (more than any other country), and 48% of GPs having to repeat tests as results were unavailable (more than any other country), and there are some clear signs that patients are dealing with the consequences of poor coordination.

So where does that leave us?

Looked at in the round, while the processes for GPs to communicate with (in particular, acute) providers are pretty good relative to those in the other countries surveyed, there is clear room for improvement when it comes to the quality of coordination, and the difficulty GPs are having in trying to coordinate care is impacting on patients.

It’s worrying that four in five GPs have had a patient experience a problem in the past month due to poor coordination, and this is not made ok by our strong performance on simple communication measures.

In fact, most of us would probably rather the NHS did well on outcome measures (patients not being impacted by poor coordination) than process measures (doctors’ systems communicating with each other well). And there’s no reason we can’t have both.

While it’s nice to do well in league tables, a simple ranking isn’t the be-all and end-all. Under Pressure tries to look at the rich data underlying these league tables and it’s through this that we can strive to improve. So let’s not use our rankings to gloat or chastise: let’s try and understand what’s going on and learn where we can improve and develop.

Ben is a Policy and Economics Analyst at the Health Foundation, www.twitter.com/BenGershlick.