UKC

Let’s try and keep this politically neutral, but on the 70th Birthday if he NHS I wanted to give some praise to the NHS, the principles behind it and the staff that make it happen.

It saved my Dad’s life 25 years ago and has helped my elderly relatives in there later years (my Gran and her sister both lived to be 104), but it has perhaps been in the last few years that I have appreciated it most. My step-daughter was born with a serious heart defect, which would have killed her if she had been born only a few years earlier. She had groundbreaking surgery at Birmingham Children’s Hospital as a baby and further major operations before she was 3. Last year aged 16 she had 7 hours of open heart surgery and was able to start college only three weeks later. Even as someone with a good income, under alternative systems we would be crippled by either direct or insurance costs relating to her condition.

Its not perfect and it needs more resources, but I am very glad we have it.

Me too, I owe it my life.

Happy Birthday NHS!

My Mum once once told me that when she was ill as a child they had to pay three shillings to the doctor.

Works out about £60 in today's money. 

Difficult to imagine a time when you had to make those sort of decisions in UK. I'm certainly grateful we don't. 

There was an interesting piece in the Economist about the NHS and it's 70 years making 3 points.

Prior to 1948 there were not people dying on the streets through there not being an NHS. There was throughout the country a network of hospices and charitable hospitals supporting the ill. Labours model brought these all under one roof successfully.

There are better resourced/different insurance based systems in other countries out there and the NHS/public/government  seemed to be blinded by the alternatives always thinking the NHS way was the best.The view that the NHS can do no wrong leads to situations like North Staffs, Gosport etc etc

And the most contentious. Despite publicity to the contrary it is only a few conservative MPs who want the private sector involved. They are outliers to main stream conservative thinking.Most conservative MPs are not in favour of privatisation seeing it as a vote loser.

  With respect, I am happy to hear of the happy outcomes for your relatives but this is not down to the NHS. It is down to doctors, nurses and modern medical technology which would have been available and not at great, if any, cost in many Western European countries.

Actually it wasn’t available in Western Europe at the time, just offered in one US hospital and in Birmingham.

To me “free at the point of delivery” is very, very important. 

Ok, but no doubt there were and are other things available elsewhere but not in the UK. Nothing to do with the NHS.

  There are other free at the point of service systems which are not the NHS. And others which require small copayments from those who can afford them which don’t seem to provoke much controversy. 

This thread is about the NHS, if you want to praise other systems you are free to. Access to healthcare is one of a number of areas where the NHS leads the world, that is why free at the point of delivery is so important.

  No, the NHS cannot be "celebrated" as some sort of triumph if it isn't. It is obviously better than what preceded it but so is pretty much every healthcare system in the developed world.There are very few things it leads the world in and many that it lags badly in. Given the difficulty in getting a GP appointment and the waiting times for basic tests and treatments it seems very unlikely that is "leads the world" in access. Pretending otherwise dooms it to further decline.

This is worth a listen for a balanced view https://www.bbc.co.uk/programmes/b0b6p8fy

It can and should be celebrated, it has achieved a great deal. We very much need to think about the challenges of the future, including some very significant threats. 

   Not, as much, it would appear, as most of its peers. That must be the reasonable way to judge it.

You obviously know better than the King’s Fund and Commonwealth Fund. I’m judging it based on their analysis.

I think the commonwealth fund tends to concentrate on value for money when it puts the NHS at or near the top.

When evaluating healthcare and outcomes; healthcare systems in countries like Switzerland, Sweden, Germany, Belgium, France are consistently rated higher than the NHS. All of them receive higher government funding than the NHS.

The US system also receives higher government funding than the NHS but despite the fact that private funding more than doubles total funding, outcomes for the population as a whole are worse.

The Commonweath fund is really just an opinion poll and an outlier in terms of analysis of the NHS.

The report the Nuffield Trust, the Health Foundation, the Institute for Fiscal Studies and The King’s Fund ("How good it the NHS?") found that "The UK is in the middle of the pack when it comes to the length of time people wait for treatment: people requiring a hip replacement waited around 97 days in the UK in 2015, compared to 150 days in Spain and 42 days in the Netherlands. A&E waits are also average, according to survey data.

  Another key finding (one shared by the Commonwealth fund) is that "Its main weakness is health care outcomes. The UK appears to perform less well than similar countries on the overall rate at which people die when successful medical care could have saved their lives."

Frankly, you could have the best and most equitable access in the world but if the outcomes are substandard then so what?

Fund it properly then, your fellow travellers are underfunding it to try and justify replacing it with a system that is a catastrophe. Think how good the outcomes would be if we had EU-14 average levels of funding, that is ignoring the areas where our outcomes are better than average, such as CHD hospital admissions.

Got to admire an organisation that survives despite Jeremy Hunt.

Isn't it funding that it lags badly in, compared to other systems with better outcomes?

From the report:

"Figures compiled by the OECD show that the UK spent around 9.7% of the total value produced in its  GDP) on health care in 2016. The UK’s expenditure is just below an average of 10.2% for our comparison group.UK expenditure is well below France and Germany, with11.0% and 11.3% respectively, but above Ireland (7.8%) and several southern Europeancountries like Spain (9%).The United States spends much more than any other country in the group (17.2%).Excluding the US brings the average down to 9.8%, so that the UK remains below average, but only very slightly.

Reflecting the NHS’s principles of being funded from taxation and free at the point of use, health care spending from taxation and compulsory insurance is slightly above average in the UK, at 7.7% of GDP compared with an average of 7.5%. But spending from charging patients and from private insurance is below average, at 2%, comparedwith 2.7% across the comparison countries."

  So the UK government health spending is above average (of the 18 coutires covered) and a bit below in overall spending. There is definitely a funding issue but not an enormous one.

  As Niemitz (see BBC moral Maze link) says "It is mostly the result of crude rationing: innovative medicines and therapies that are routinely available in other high-income countries are often hard to come by in the UK. Any country could keep healthcare spending in check by simply refusing to adopt medical innovation. In more sophisticated estimates of health system efficiency, the NHS ranks, once again, in the bottom third."

   The NHS is simply a middling performer in terms of cost and performance, and we should see it that rather celebrating it as some sort of unique game changer in terms of global healthcare and be looking overseas to examine ways of doing things that might enhance it.

Best analogy is with the English football team, until we stop believing that the NHS is the best and greatest, then things will really never improve.

Until the UK tax payer accepts that we are going to have to put our hands in our pockets, then funding will be an issue.And we are not talking about a couple of pennies on the tax rate.The same applies for paying for Dr's visits- just look at how France, Sweden etc operate - its a farcical situation in the UK.

So what you are saying is the USA model is a system that we should stay as far away from as possible but otherwise you get more or less what you pay for with the UK performing pretty well against the best in the business? Seems like there's plenty to celebrate there and also a pretty resounding case being made that further privatisation is not some panecea. 

I guess one thing not shown by the figures is the baseline health of the nation in the first place. I know the Mediterranean diet thing has been discredited but I would be surprised if UK is not in the bottom half for general health given our diet, attitude to sport participation, drinking, urban based population etc.   

You are still just making the case that the only way for the NHS to improve is to increase funding of it. You and Nick just differ on where that funding should come from. Personally I think that for a country of our relative wealth increased funding can and should be covered by tax take. The Tory govt seems to be adopting a position that improvements can come without increasing funding which is dishonest.  

   We don't see the Germans, French and the Dutch etc etc "celebrating" a decentish health service. No, "privatisation" (whatever people mean by that) is not a panacea, but neither is it to be avoided for ideological grounds. Whatever works, do it.

  The problem with simply thinking that increased (tax based or maybe other) funding will "do it" is that the ever increasing costs of healthcare will ultimately make such a system unaffordable so we have to look at radical alternative forms of provision,question the methods of funding , the point of healthcare itself (do we really want to keep very sick 92 year olds alive until they are 93) etc etc . The evidence of Brown's spending splurge was that although it improved outcomes it also lowered productivity. We have to improve both.

I'm not quite clear what you mean by "want the private sector involved"? By any reasonable definition, the private sector are involved and have been for years. Lots of NHS services are delivered by private sector companies. According to the Independent, which isn't without agenda on the issue but probably isn't lying about the basic stats, private companies won 70% of available contracts in 2016-17.

Worth reading the IFS reports on the funding gap and financing.

I personally doubt charging a few £ for appointments will make any difference.But it might improve appointment attendance rates. The fact that we just will not try out these things ( which work well in other countrys) because the NHS mantra has to be free at the point of delivery illustrates some of the issues neatly.

Improvements can come without funding, look at the way that A & E's are having to be rethought because there is no money.But that is only part of the solution.

You are making a strawman, read my OP. It’s not perfect. Wouldn’t it be great if it had German levels of funding, or the number of doctors they have in pretty much every other European healthcare system. Wouldnt it be great if changes were made for clinical, not political reasons.

   There was work done by Journard in 2010 trying to measure efficiency net of the "baseline effect". The main conclusion was that some high spenders like the Switzerland  and Japan are also very efficient and that the UK was moderately inefficient. It's obviously a complex thing to analyse but it seems counterintuitive to think that we shouldn't shouldn't look at more efficient models to see how they achieve better results rather than just throw money at it.

Despite what we disagree on, did you miss the bit where I wrote “the staff that make it happen” those 1m or so people are the NHS.

You may doubt charging will make much difference, but I’ll go with the research rather than your hunches.

Yes. Most of the staff work very hard and do very well within a very frustrating system. I'm very happy to congratulate them on that, just as I would their equivalents in other countries.

It's pretty interesting. One can provide lots of independent evidence to suggest that the NHS might benefit from exploring alternative practices and one gets numerous dislikes but very little evidence or rational argument to the contrary. It kind of reflects the ludicrous "envy of the world" mantra that people are supposed to believe.

People might suspect that you hold an ideological position that leads you to cherry pick and make biased unsubstantiated claims. I wouldn’t know how your dislikers think, but I have certainly noticed some claims you are making which seems to contradict the research that I have seen.

I think you may be the only person on this thread to use the phrase “envy of the world” that said I have American friends who are envious, but of course they are envious of any functioning healthcare system.

  Well, if one regards the simple idea that one should be pragmatic and open minded about how the system might be improved and explore the evidence accordingly as an "ideology" than I happily plead guilty

It would be helpful if you had your facts correct.....I think you probably meant to say Mid Staffs not North Staffs which are completely separate organisations. There is certainly no view within the NHS that it can do no wrong.....the systems of clinical governance and quality are extensive and reportable to the dept of Health.

The private and third sector are already hugely involved in providing care within the NHS, with many services required to competitively tender to be the providers.

I've been on both sides of the NHS down the years. I had a daughter who was born prematurely. Sadly she died shortly afterwards. I can never forget the incredible kindness and compassion shown by the staff on the neonatal unit. Two members of staff came came to her funeral.

Inspired by the skill and professional of the medical and nursing I trained as childrens nursed. In the decades since I have the privilege to have nursed some of the sickest and most dependent babies. I like to think I've given something back and more than repaid the cost of my training pre and post qualification. Nursing is more than a job!

Incredibly prode to have been part of the NHS.

I've learned some interesting facts about the NHS today which I didn't know before.

It's the UK's biggest employer and the NHS Budget is 3 times greater than the Defence Budget.

It's a fantastic organisation and concept, and rightly the envy of much of the rest of the world.

When you start telling people that groundbreaking treatment for a person's relatives' undisclosed medical condition was freely and cheaply available elsewhere throughout the Western Europe when it wasn't you reveal your ideological bias. 

I'm not sure why we have to agree that the NHS is shit to want to improve it. Why don't you blow us away with your pragmatic and open-minded ideas on how to improve the system instead?

Being pragmatic and open minded also requires being suspicious of the siren voices of those who understand there are huge amounts of money to be made from healthcare.

Heard this today, I'm glad I don't live in America ...

from about 1:13:00 https://www.bbc.co.uk/programmes/p069xssq

Straight up: I'm a huge NHS supporter  but the NL system I found to be far better all in(I paid Zilveren Kruis for almost 6 years). However, I do not think it is an approach that would translate seamlessly to the UK. Mainly because of cultural issues.

Well it seems to work in other country’s with slightly different models. France, Sweden etc etc .

Poorer access, higher hospital admissions. It works in that sort of way!

  No I don't. I reveal the fact that I don't believe, that the NHS is any more at the cutting edge of provision of treatment than other European health systems. In some cases it may be, but so might other countries. Nor, for that matter, would that be a key metric in judging a healthcare system. We are not terribly good at adopting innovations:

https://www.nuffieldtrust.org.uk/research/falling-short-why-the-nhs-is-stil...

  And, as for ideas, we could start by looking and learning from our peers.

Of course we have quite a bit of co-payment in the NHS, dentistry is a good example, also a complete disaster for dental health.

That article makes some very good points, but ultimately it identifies two problems; underfunding and government interference. We could of course learn from our peers in Europe and put another 2% of our GDP into healthcare and give the service the breathing space to innovate, rather than just constantly fire fight.

  Well, the UK State spends more than Switzerland and only 60bps less than the Netherlands on healthcare as a % of GDP, more than Australia,New Zealand,Canada  and more than Belgium. Only Germany, the Scandies and France seem to be more than a percentage point higher of comparable peers (OECD 2015).

  Overall UK healthcare spending is abpve the EU average.

  And yet UK outcomes are easily mistaken for Slovenia and the Czech Republic which spend a lot less. A lack of government spending does not fully explain the discrepancy in outcomes properly.

Healthcare spending in Switzerland is nearly twice per capita what it is in the U.K., Australia, Canada and Belgium are all substantially higher; of the examples you give only New Zealand is lower.

It is significantly lower than EU-14 average, which is what anyone not being a bit Esther McVey would measure it against.

Outcomes on some measures are similar to Slovenia. Slovenia spends a similar percentage of its GDP on healthcare.

  Only Switzerland's State healthcare spending per capita (PPP, current prices)  is substantially higher (47%). Belgium's is 10% higher. Canada is about the same. Oz and NZ are lower and Slovenia and The Czech Republic are much lower (the latter two even including private expenditure)

  (Overall) Spending as a percentage of GDP is just above the EU average. Per capita it is very marginally below.

http://healthmedicinet.com/i/uk-nhs-spending-now-matches-that-in-other-eu-n...

No it doesn't. The UK 9.8%. Slovenia spends 8.5% (2015 OECD) and per capita about 28% less.

Whilst I still disagree with your figures (based on checking the numbers) you have disagreed with yourself.

Still going down the McVey route.

UK is 8.5%.

  How? I was responding to the comments you made on specific countries.

How?

Not according to the OECD 2015 figs I noted as the source.

What is your source?

Kings Fund, I appreciate that you are going off the Nuffield figures, but I really don’t think that they are comparing like for like. 

You said U.K. funding was higher than Switzerland and Belgium, then you conceded that it was 47% and 10% lower.

I'm using the OECD data base, as I've said. It's not impossible I've misread them but I'm pretty sure not. All I've then done is reply to your specific points on specific countries and on per capita comparisons.

 It's very tricky to make very accurate comparisons across countries, hence the Appleby/Nuffield link which actually makes the UK look better than previously thought because it tries to compare like with like.

One of the obvious conclusions is that  significant part of some of the overall spending disparities is accounted for by the UK's lower proportion of non-State spending. One would think that this might at least provide some food for thought above and beyond the fact that our outcomes don't appear to match  overall spending.

I said "the UK State spends more than Switzerland and only 60bps less than the Netherlands on healthcare as a % of GDP, more than Australia,New Zealand,Canada  and more than Belgium"

In 2015 UK State spending on healthcare was 7.8% of GDP, Switzerland's 7.5%, Australia 6.4%, Canada 7.3%. I think I misread Belgium for Austria (7.7%) but actually Belgium was 7.9% so pretty much the same so the point remains valid.

You were referring to total healthcare per capita which is a different metric. So I acknowledged that alternative metric and corrected your figures on the basis of the OECD numbers.

"  Overall UK healthcare spending is abpve the EU average."

This isn't a meaningful statement by itself. What do you mean by overall? Private and public combined? Are you talking about gross spending? Or spending per head, or in relation to GDP? 

It appears A&E's are being rethought by removing targets as they are not being met. They are not doing more with less they are doing less with less. 

You seriously expect us to trust that article written by a Mail journalist over more sensible independant sources?

The source article that the journalist spins is here: 

https://www.nuffieldtrust.org.uk/news-item/spending-on-health-how-does-the-...

Which if you read it includes accounting changes in OECD data which means including much more of the spending on social care which most people won't regard as health spending. From the same article:

"Understanding how much or little we spend in comparison to other countries is important information, but it’s not the only piece of information. Providers are still in deficit, services are still being rationed, and staff are still short on numbers and pay."

Some more sensible comparisons of health costs (often including the new OECD stats which now include more social care expenditure in health spending):

https://data.oecd.org/healthres/health-spending.htm

https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/hea...

https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-co...

https://en.m.wikipedia.org/wiki/List_of_countries_by_total_health_expenditu...

Combined as percentage of GDP. It’s a (probably the most)commonly used metric.

No, but the FT article I was reading is behind a firewall. https://www.ft.com/content/4a009b68-7cf1-11e7-9108-edda0bcbc928

Actually I'd looked at several different versions and the original, hadn't noticed this version was orginally from the DM but it summed up the points reasonably well.

Poorer access, in sweden I can ring now and see a doctor today in normal hours. Out of hours I can see a doctor in town and then if urgent there is A&E. For elements that are out sourced like skin care, such as suspect moles, you book direct no doctor referral and can easily go from first phone call to biopsy result in under 2 weeks. 

Perhaps the UK is better but I'd say I have good access. It cost me £15 for docs and £30 for a&e or specialist. There is an annual CAP of £200ish so the very ill don't pay a fortunate and kids, very low income, refugees etc don't pay at all. 

High admissions. Not in my experience, but I'm sure everyone is different. 

Good access for you, but those costs are a barrier for many and the research shows that. There is also a very strong argument that the added cost of administration means that charging actually costs money rather than saving.

Your personal additions rate isn't going to add much to the debate here, for example UK CHD hospital admissions are much, much lower than EU average, this is considered to be a result of easier access to primary care.

It's really very lazy just to cut and paste links without even summarising what you conclude for them or highlighting the relevant data.

The FT link above (based on the Nuffield report I have already referred to) highlights the change in how the figure look when elements for social care are included:
Ben Gershlick, economics analyst at the Health Foundation — found that a new definition of health spending adopted by the OECD suggests that the UK actually spent above both the EU-15 and the OECD averages, as a percentage of GDP, in 2014.  The reappraisal reflects a new definition of what constitutes “health” spending. It now includes much more of what in Britain has traditionally been thought of as “social care”, as well as spending on the NHS and preventive care. The definition excludes capital spending.

And the OECD dataset I was using looks suspiciously like the ONS one you present and I suspect is based on it. The ONS link  has comparisons with 7 OECD States and , as I have said, is behind France and Germany but within a smidgeon of Begium, Canada and Austria.

So what am I supposed to be looking for in your links?

Not from what I know, see and hear. As I said the vulnerable groups don't pay at all, so there is no disincentive to attend. 

I think it is cheap to administer. Because sweden has a personal number/ID card driven system, you simply pay as you ID yourself at the doctors reception. A&E you are invoiced after as treatment is the priority and I think £30 will cover the letter costs. 

Are admissions as sign of better or worse care, better care in the community, or perhaps a generally healthier society.. I don't see the correlation with charging for healthcare.  

I should add that I don't think the Swedish system of paying a modest fee per visit is better. The UK system is currently flawed because the tax rates are too low to adequately fund it upfront. Both could work equally well if the end result is sufficient funds. 

What you are doing is taking an ideological position - the NHS is BAD, I have no idea why  - then researching all you can to justify that position. All your talk of impartiality and rationality, measuring outcomes etc  is so much b*llocks. E.g. comparing outcomes between countries like Switzerland, Sweden and the UK without taking into account factors like poverty, lifestyle, ethnic backgrounds and culture is just pseudo science. 

There are a number of reasons why a centrally funded, free at the point of need service is the best system in the best of all possible worlds. 1) Insurance is ridiculous. You either factor in lifestyle factors, hereditary etc, in which case it becomes unaffordable to those who need it; or you don't, in which case everyone pays into a common fund. A  bit like the NHS really.... 2) Paying service providers on 'procedures performed' is equally daft. Most morbidity has complex aetiology; the NHS isn't perfect in this respect (I've worked in hospitals where the stats where for all intents and purposes were made up) but a charging model that ISN'T based on the reality of illness - as in the US - is just building in inefficiency on top of inefficiency. Not only does it consume vast resources by way of administration, it distorts what physicians do and distorts rational analysis of what is and what isn't effective.  3) Healthcare isn't something like bread, or consumer goods, that we want to consume - most of us DON'T want healthcare, we want to be healthy. 4) The free market has only a limited place in healthcare. Most of us don't want to die, so will snatch at any snake oil to keep us alive, without being able to evaluate the effectiveness of interventions; and private providers have a built-in incentive to generate demand for their services. Hence Bupa and others offering ludicrous screening programmes that turn the middle aged into the worried well, consuming unnecessary healthcare resources.

Given the ignorance, incompetence and ideology of most health ministers of the last few years it is a wonder that it has survived at all; but it has, and that, for once, is down to the common sense of the electorate. I think what we should be exploring is removing the NHS from direct government control, a bit like the BBC, with a charter, agreed funding but a board pretty much independent of the government of the day, able to make long term and difficult decisions without being swayed by the next by-election. Do you know what? It wouldn't be 100% efficient. But it would be making a great institution even better.

   Except that I didn't say "it's bad". I said it is "middling" because that is what most of the evidence tells us. Its outcomes are arguably worse than middling. How can it be "ideological" to say something can be improved by looking pragmatically at ways of improving it?

  Quite obviously the ideological position is to assert, regardless of any evidence to the country, that something is fine and refuse on principle to look at alternatives, simply asserting an opinion that the current system is best, as you have done.

  Health care is free almost free at the point of service in most European countries and accessible to all. It is not the political/ideological hot potato that it is in the UK. Outcomes are often better. Yes, there are adjustments to be made for lifestyles etc. Can you link to some serious work on this? I have reffed one (Journard) above.

  Can you link to consistent evidence that private provision of healthcare is inferior to public-given that the Netherlands has very little public provision are we to assume that they are all morons? Or, as you imply, should we close are eyes and not even ask?

  Can you demonstrate that insurance based systems (quite common in Europe) are "ridiculous" despite plenty of evidence that they do many things very well?

  Finally, I repeat, "How can it be "ideological" to say something can be improved by looking pragmatically at ways of improving it?"

They've still got my tonsils, the bastards, so they can stick their 70th birthday up their arses.

Not really, we're losing it and we should all fight for the NHS.

They have still got me tonsils though.

Why can't you get back on the topic?

Alot of people strike me as ending up fighting against the NHS. Relatives of those at Gosport, North Staffs, Southern Healthcare etc etc may not hold the NHS in such hallowed status as worthy of celebration.

What your fight is for is nothing to do with the NHS it is to do with free at the point of delivery. " Free" is subjective anyway. We pay for dentists visits ( private firms owned by dentists), we pay for prescriptions generally etc etc. The list is quite long when you start totting it up.We even pay for car parking at hospitals.

This in no way detracts from what most of us experience with Nurses,Doctors, Consultants etc which is for the most part exemplary.

In 2016-17 the NHS carried out nearly 40,000,000 courses of treatment and had almost 1,500,000 employees on the books. With those sort of figures you're bound to get some bad outcomes especially if you're including (as you are) historic cases going back 30 years or more.

A major operation like a liver transplant will cost the NHS something like £200,000 while even a minor op like a knee replacement would cost about 10-15 grand if you went private. Taking figures like this into account it seems a little churlish to claim the NHS isn't free as you have to pay for parking etc.

More to the point the NHS may be "middling"* if you're minted but it's absolutely outstanding if you're skint.

* Your view, not my own.

Not "my view". It's what the evidence tells us.

If other European health services are also free or almost free at the point of service what logic tells you that the NHS is "outstanding" if you are skint ?

All my experience of the NHS (not enormous, but several long, serious occasions spread over six decades) has been that it's outstanding and not middling in any way. 

How much experience of alternative health services do you have? How much experience do you have of being a sick and poorly educated inarticulate person with no external support to help you through the system?

I saw a lot of elderly/dying patients in the Geriatric wing of the Lister Hospital (Stevenage) between October and December last year who would fall into that category. And the treatment they were getting was excellent. My only experiences of other health systems has been in Norway (equally good). My brother has lived for many years in USA and assures me that our system is infinitely better. 

  Everybody agrees the US system is dysfunctional but that is a massive outlier. How can one say anything is "outstanding" without anything to compare it with?

  Anecdotally my limited experience is that it is "OK", but requires somebody able to "co-ordinate and steer" it on behalf of the patient. But anyway, I'm not sure how valuable individual anecdote is.

You can certainly judge the competency and caring, selfless attitude of doctors and nurses compared with the same qualities in any other profession.

Comparing doctors and nurses to eg. City lawyers is not a valid comparison. They should be compared to medical professionals in other countries.

As you well know that 'evidence' is entirely subjective. What price, for instance, would you put on the fact that the NHS allows you access to healthcare 24/7 without you having to worry one jot about ID, money or whether you'd dotted all the I's and crossed all the T's on your social insurance payments?

In my family's, admittedly limited, experience of healthcare on the continent it is far from 'free or almost free' even with the relevant EU documentation (which you'd never be asked to produce for NHS treatment).

   No much, since for nationals most European countries provide care free or nearly free at the point of service and insurance is compulsory so sorted ahead of time. Checking into the NHS usually involves answering the same questions and multiple times and providing information on one's condition that they already have so producing an ID card doesn't seem to me to be that onerous.

  And what do you mean by "subjective"? It's based on detailed studies of costs, outcomes, waiting times  etc. It's a lot more objective than personal anecdote.

   The fact the the NHS is prepared to provide free care no questions asked to people who might have no right to it doesn't seem to me to be a brilliant idea for a system under huge financial pressure.

I can only assume you either have very little experience of the NHS or that your manner has necessitated 'special' treatment.

Of course it's subjective. You're not just talking simply about clinical outcome, you're talking about millions of individuals unique experience of the service. How can an individuals experience be anything other than subjective?

I have limited experience but have elderly relatives and other friends who have had lots. Let's just say that their experiences have been "mixed". Interesting my elderly aunt thought her experience had been great, but she was unaware that we had had to set up a rota of neighbours and relatives to be there several hours a day to make sure that she was fed and watered. It was actually a doctor (one of a succession) who suggested I do my best to get her out of hospital asap because "we're great at acute but not so good at chronic". So I did, which was a trial in iteself.

   Dying, or waiting months for treatment which make it harder to treat are not "subjective. Clinical outcomes are somewhat important.The whole point of all the surveys (with the exception of the CW fund) is that they attempt to use objective criteria, not peoples' personal judgements.

From the Nuffield etc survey.

"Key weaknesses include:

The UK’s NHS performs worse than the average in the treatment of eight out of the 12 most common causes of death, including deaths within 30 days of having a heart attack and within five years of being diagnosed with breast cancer, rectal cancer, colon cancer, pancreatic cancer and lung cancer, despite narrowing the gap in recent years

It is the third-poorest performer compared to the 18 developed countries on the overall rate at which people die when successful medical care could have saved their lives (known as ‘amenable mortality’)

It has consistently higher rates of death for babies at birth or just after (perinatal mortality), and in the month after birth (neonatal mortality): seven in 1,000 babies died at birth or in the week afterwards in the UK in 2016, compared to an average of 5.5 across the comparator countries."

If you read into it a bit more you'd find that hospital stays for the elderly should be kept at a minimum chiefly on grounds of mobility and muscle wastage (a hospital bed being a poor place to encourage activity) combined with the fact that hospitals are great places for the elderly and their compromised immune systems to pick up infections. That doctors advice would have been replicated by any half decent doctor the world over.

I said that it's the overall experience that has to be considered. Experience is subjective by its very nature.

Yes you can go on and on about mortality stats country by country but until you can compare the UK with another country with the same rates of obesity, alcohol and drug consumption, diet, rates of exercise and a thousand other genetic, sociological and psychological factors then your comparisons are fatally flawed.

But when you see people doing excellent work, it's hard to imagine it being done much better. BTW, city lawyers are probably one of the few professions I was not thinking of.

Why are you repeatedly referring to north staffs?

  No, that wasn't the nature of the conversation. They planned to keep her in and I questioned it on the basis that she was not improving and was getting no treatment. Given that she was returning to a perfectly good care home (which they knew) she would have been a perfect candidate to send back there quickly but that hadn't registered.I know perfectly well that short stays in hospitals are encouraged and why.

  i'm not just "going on about mortality rates". I'm going on about specific outcomes for specific illnesses and from specific treatments (or lack of treatment). Of course these will be complicated by the other conditions etc of the patient but nevertheless they are not meaningless.

   What do you think of the Journard article I referred to above? Have you any information to suggest that adjusting for these baseline factors would dramatically improve the UK's relative performance? If not, how do you think performance should be measured? Should virtually all the existing metrics be ignored? In which case how should decisions be made?

Weird... it's not like Neil . I think Roy Lilley had it right on Mid Staffs,  and  his ideas have clear wider implications for the NHS as a whole..

https://www.theguardian.com/healthcare-network/2013/feb/13/fix-nhs-frontlin...

You wrote....

It was actually a doctor (one of a succession) who suggested I do my best to get her out of hospital asap because "we're great at acute but not so good at chronic". So I did, which was a trial in iteself.

So you're saying that a succession of doctors (presumably NHS doctors concerned with her care) advised you to get her discharged which you found difficult???

If a succession of doctors were advising that your relative be discharged who exactly were the staff members keeping her in, the porters? A mentally competent patient is perfectly entitled to discharge themselves in any case. Knowing how short of beds many hospitals are and knowing how keen NHS bed managers are to free up space you'll forgive me if I find your account somewhat confusing.

No, she was seen by a succession of doctors who appeared not to communicate with each other. Her treatment (a chest drain), as far as we could tell, was complete but they were keeping her in and we were worried that she was getting worse rather than better and  we couldn't see the benefit of her staying in hospital. So I spoke to one of the doctors to point this out. She (the doctor)agreed that there seemed to be no point in keeping her in and made the comment about treatment of chronic cases.

Thanks for the clarification and I'm sorry that your family member received sub-par service but the overwhelming majority of people in this country regard the NHS with a great deal of love and affection. Personally I don't think this is because service users don't know any better or, more simply, are just a bit thick.