‘Perfect’ health system? No such thing

The NHS is under massive pressure and government is developing a 10-year plan for reform. But we’re not the only health system under strain. Across Europe, health systems are struggling to cope with staff gaps, populations ageing in poor health and wide inequalities. Other health systems are reforming in response too – for instance, to strengthen primary care and better integrate services.

Comparing health system performance between countries has a long history. Is the NHS cheaper than health care in Germany or France? Are patients in England waiting longer for care in hospitals than elsewhere? International comparisons are popular among policymakers and widely used in the media. But making meaningful comparisons between health systems in different contexts is complex. And unless we know why some countries do better or worse, opportunities for learning are limited.

Comparing policies and performance

We commissioned the OECD to analyse potential links between how country health systems are designed and perform. Put simply: do some types of health systems – for instance, countries with more or less of a role for the private sector, or with different kinds of primary care systems – perform better than others? The work built on previous OECD analysis and involved four broad steps.

First was to survey policymakers across OECD countries to develop an up-to-date picture of the characteristics of their health systems – including how health care services are funded, organised and delivered, and how resources are allocated. For example, how far do GPs act as gatekeepers to other parts of the health system, like specialists in hospital? And how much choice do patients have over the level of coverage they receive and who provides their health care? This is the fourth round of a survey that has been run since 2012, allowing us to compare changes in health system policies over time. 

Second was to group health systems based on these overarching characteristics. The approach involved using data from the survey to cluster health systems with similar features – focusing on indicators from the survey that seemed to most differentiate the health systems included in the analysis. These covered the degree of user choice in basic health coverage, role of the private sector in delivering care, extent of gatekeeping in primary care and several other measures. The analysis divided OECD countries into eight broad clusters depending on their design, with the UK sitting alongside other heavily regulated public systems, like Denmark, Sweden, New Zealand and Italy.

Third was to compare the overall performance of OECD health systems between and within these clusters. The researchers compared countries using a measure of health system efficiency – looking at the relationship between health care inputs (using health spending as a share of a GDP) and outputs (using age-standardised mortality rates to account for differences in population size and structure between countries). They found that no type of health system consistently outperformed others. More and less efficient health systems could be found within each cluster.

Last was to explore other ways of comparing health systems in more targeted policy areas that might be linked to better or worse performance. If the broad clusters don’t tell us much about which type of health systems do better, might looking more closely at one policy characteristic – say, the role of GPs in the health system – give us more to go on? The researchers looked at two policy areas: the strength of primary care services and use of financial incentives to improve quality. They found that countries with more primary care-oriented systems – for example, with a stronger role for GPs as gatekeepers and better continuity of care – may be linked with lower avoidable hospitalisations. They also found that greater use of incentives for improving quality may be associated with lower treatable mortality. 

The study has a mix of limitations. For example, the survey only provides a snapshot of each country’s health system, relies on the judgement of officials filling out the survey, and – inevitably – can’t capture the nuance and complexity of health policy in each country. The overall performance of health systems is shaped by a mix of factors that are hard to control for when making comparisons, including social and economic context. And the analysis can only tell us about potential links between health policies and performance – not if one causes the other. Even then, there is lots of uncertainty in the results, so they need to be treated with caution. Despite these limitations, the analysis provides helpful lessons for policymakers in the UK and elsewhere seeking to learn from other countries.

Implications for improving policy

The analysis reminds us that anybody searching for the perfect health system should stop. Politicians and the media in England often suggest that fundamental reform of the NHS model is needed – for instance, switching to European-style social health insurance. This argument is bad for a mix of reasons – not least because there is no clear evidence that one model performs systematically better than another. But the OECD’s analysis helps illustrate that even when you group health systems based on a broader mix of factors, there is no obvious ‘type’ of health system that comes out on top. Policymakers should focus on how they can improve their own system instead. 

International comparisons can help policymakers do this – but only if we think about them differently. Health system comparisons often start from some measure of overall performance (for example, which country has the most efficient system?) or the high-level design of the systems being compared (like do Beveridge or Bismarck-style systems do better?). These kinds of comparisons have a place – for example, for low- or middle-income countries considering how to reform health financing to achieve universal health coverage (where evidence indicates that social health insurance would not be the magic bullet commentators often suggest). But too often these broad comparisons stop short of providing useful enough data to inform policy. Health care costs more in country X than Y. So what? 

Another approach might be to start from more targeted policy questions instead. For example, the UK Labour government has pledged to shift NHS resources from hospitals to the community and reform general practice to ‘bring back the family doctor’. Which other countries have strong primary care systems with good continuity of care? How does their performance differ? What policies helped them do it? The OECD’s exploratory analyses on primary care and financial incentives need to be interpreted with a good dose of caution, context and alongside wider evidence. But they illustrate how international comparisons can be more deliberately designed to provide practical pointers for policy. Done well, these comparisons can act as a ‘tin opener’ for more in-depth exploration of policy differences between countries – and, ultimately, tangible lessons that could improve our own system.