Just how well are we?

The EUROCARE-4 study into cancer survival released this summer in the Lancet Oncology once again threw the NHS’ apparently inferior performance in terms of health outcomes into the limelight. The UK is depicted as out on a limb, with survival rates remaining ‘stubbornly low’ and the exception - with Denmark - to the general rule that countries spending the most on health care do better.

Much of the blame for this sub-standard performance has

predictably been placed at the door of the NHS. But is this

really fair?

One concept that can help us answer this question is that of

avoidable mortality. Avoidable mortality is based on the notion that deaths from certain conditions should not occur in the presence of timely and effective health care. In essence, even after the condition has developed and even if a person leads a pretty unhealthy lifestyle, death should still be preventable with the best medical care and treatment.

Focusing on these conditions gives us a much better idea of how good a health system is at tackling disease than if we looked at all conditions regardless of how amenable they are to health care. It helps to separate the effectiveness of a health system from the multitude of factors aside from medical failure, such as diet and lifestyle, that may lead to the natural end of someone’s life.

Looking specifically at the ‘biggest killers’, circulatory disease and cancer, there is fairly robust evidence that avoidable mortality in England & Wales has improved quite markedly between 1999 and 2005. Avoidable mortality from cancer fell by 15.0% and from circulatory disease by 34.0%. The most significant decreases were registered in deaths from ischaemic heart disease (-35.4%) and – perhaps surprisingly given the long-standing vilification of stroke care in the NHS – cerebrovascular disease (-31.4%).

The performance also looks fairly impressive in the international context. Improvements in avoidable mortality from both cancer and circulatory disease in England & Wales are above the eleven country average of Austria, Czech Republic, Finland, France, Germany, Hungary, the Netherlands, Norway, Spain, Sweden and England & Wales over the period 1999-2004, the latest year for which international data is available. Avoidable mortality from cancer decreased by 13.5% in England & Wales, compared with an average decrease of 9.9%, and avoidable mortality from circulatory disease fell by 29.4%, compared with an average decrease of 26.2%. This has to be good news.

What’s more, it’s also clear the NHS has been playing its part. While it’s incredibly difficult, if not impossible, to determine exactly how much improvements in avoidable mortality can be attributed to a health system – avoidable mortality, as much as non-avoidable mortality, may still be falling due to external factors such as a decrease in the number of people who smoke – we can be pretty sure betterhealth care has helped. Avoidable mortality, far more likely to be influenced by medical care, has fallen faster than non-avoidable mortality between 1999 and 2005; at 15.0% compared with 10.1% for cancer, and 32.9% compared with 28.1% for circulatory disease. That this has also happened at the same time the incidence of disease has increased strongly suggests the NHS has not just been riding on a ‘healthier’ environment. The health care it provides does save lives and evidence suggests its impact has increased over time as new medical technologies, such as thrombolysis and i ntensity modulated radiotherapy (IMRT), have been introduced.

Still, not all is rosy. For one, despite all the improvement that has been registered, avoidable mortality still remains extremely high in England & Wales compared with other countries. This is particularly true with regard to circulatory disease. In 2004, at 72.6 deaths per 100,000 of the population, avoidable mortality was over 100% higher in England & Wales than the best performing country, France, which had a rate of 31.7. This means around 18,400 more people died in England & Wales from circulatory disease, where death is considered avoidable, than in France, despite the population being some 10 million less.

Of course, a part of this is surely down to the fact the incidence of circulatory disease in England & Wales is higher than most places; we’re an unhealthy lot and we’re probably getting unhealthier still. The Health Profile of England in 2007, just published by the DH, showed that the rate of obesity in British adults is not only the worst in Europe, but in some areas is now worse than in the US.

Then again, while the task of catching up with the best performers on avoidable mortality will certainly be difficult – purely because the NHS will no doubt have to treat many more patients with circulatory conditions – it shouldn’t be impossible. Crucially, we are dealing here with those circulatory conditions that are considered amenable to health care, which means that with the best medical care and secondary prevention, death should be preventable. Austria has proved this. Since 1999, they have blazed the way with a 14.1% fall in avoidable cancer mortality and a 38.3% fall in avoidable circulatory mortality, despite having a similar ‘starting position’ to England & Wales.

For this reason, when a closer look is taken at domestic developments in avoidable mortality from cancer, alarm bells must be ringing. On the face of it a 15.0% fall looks impressive – and it’s true that it still compares quite favourably with other European countries – but it masks a worrying trend. In every year between 1999 and 2005 – and in direct contrast to circulatory disease – the rate of improvement in avoidable mortality from cancer has slowed. In 1999 avoidable mortality fell by 3.6%; in 2005 it only fell by 1.7% (Table 2). What’s more, this bucks the long-term trend. The five-year period 1999-2004 is the only period since 1979 in which the rate of decrease in avoidable cancer mortality has been less than in the previous one, which can be ill-afforded. Avoidable mortality rates from cancer in England & Wales are still higher – at 25.5 per 100,000 population in 2004 – than countries at a similar level of economic development, e.g. France (24.5), Austria (24.6), Sweden (22.0) and Finland (18.9) .

This trend would be disquieting enough on its own, but is particularly so because the slowing rate of improvement has apparently coincided with the introduction of the NHS Cancer Plan in 2000. This was supposed to revolutionise cancer care in the NHS and provided for an injection of some £2.0 billion in extra funding for cancer services. On the face of the avoidable mortality statistics presented here, its impact appears negligible. Performance has retreated from the long-term trend, not improved on it. With a possible lag between implementation and results, perhaps we need to wait a bit longer to properly test its impact, but perhaps it is also time to consider alternatives to the traditional top-down structure the Plan has worked through. Would a move to greater pluralism in provision and greater degrees of choice be more effective? Urgent investigation is needed.

James Gubb is director of Civitas Health Unit