Diverging health policy and mortality
Authors: Nigel Edwards
Journal: Journal of the Royal Society of Medicine (2011)

The measure of deaths where the effectiveness of the healthcare system can make a difference is increasingly seen as one important way of comparing health systems. The UK's relative performance in the international league table of amenable mortality has been disappointing although there are signs of improvement both absolutely and relative to other countries.1 The data presented here show some significant improvement, particularly in ischaemic heart disease and circulatory diseases.2 Parts of the UK have also made significant progress in reducing avoidable mortality from respiratory disease.

The authors' breakdown of the UK into its constituent parts also raises interesting questions about whether policy choices can make a difference. While there are caveats that the authors point out here and elsewhere that limit what amenable mortality can tell us about health system performance, other data are available that shed light on differences between performance in England and the devolved administrations and seem to point in the same direction. In a controversial comparison of England with the devolved administrations. Bevan found that in 2006 ‘despite its lower level of expenditure and staffing, compared with Scotland, the North East region delivered 18 per cent more outpatient attendances (105,000 to 89,300), almost 40 per cent more day cases (10,500 to 7,600) and more than 50 per cent more inpatient admissions (20,700 to 13,500)’.3 Scotland had more doctors and nurses but seemed to do less with them. Propper et al.'s study of ‘targets and terror’ seems to support a view that some elements of the English NHS's approach to management produced better results in those areas that were measured and although a number of these related to access rather than directly to improvements in clinical care, some were in areas that might be expected to have an impact on amenable mortality, for example the prescription of statins.4 It would however, be unwise to base too many policy prescriptions on this, there is significant ‘noise’ from the rapid change in all the systems, the fact that England used almost every health policy instrument available in a system that is free at the point of use and, as the authors point out, the possibility that a range of factors are not captured in this analysis.

One issue that is of interest is the implications for the current reforms of these data. The Impact Statement published to accompany the controversial Health and Social Care Bill cites poor performance in mortality amenable to healthcare as one of the reasons for making significant changes to the NHS in England. But it is not specific about how the policy proposals in the Bill relate to the problems of poor chronic disease management, cancer detection and other contributors to this problem. Many of these may lie in primary care or in the interface between primary and secondary care. The GP or clinical consortiums that will be created will not be responsible for commissioning primary care although it is hoped that GPs will apply peer pressure to work with their colleagues to improve standards. Framing the relationship between GPs and the specialists responsible for chronic disease management as one governed by contracts and which uses incentives and other contractual and transactional mechanisms is a concern to some people as it seems to have the potential to further undermine important professional relationships. There has been a general worry that GPs and hospital specialists have been forced apart by previous reforms and that this may be a contributory factor in some of the poor outcomes seen in chronic disease and in care for children, recently highlighted as a major concern. There is a similar concern about the extent to which poor outcomes for cancer are the result of late diagnosis in primary care. Some of these problems may be related to a combination of a gate-keeping approach and a lack of appropriate training.5 Further separation by creating a ‘commissioner/provider’ split at the level of the GP could make this worse and is certainly a concern unless the GP groups are prepared to examine these hypotheses and take action to improve primary and secondary care.

One solution may be better integration between primary and secondary care and this has been a major theme in responses to the recent ‘listening exercise’. This recognizes the importance of ensuring that GPs have access to specialist advice on diagnosis and management, access to appropriate diagnostics and that there is good coordination of the care of patients. The Bill and the impact statement appears to make the assumption that GPs are responsible for the coordination of their patient's care but although the UK seems to perform reasonably well on some dimensions of this, it is common to hear about situations where this is patchy and where patients are unsure who is in charge. Indeed in a recent speech the Secretary of State told of his personal experiences of this.6 The reforms seem to suggest that giving GPs additional commissioning powers will improve coordination although international evidence suggests that the UK is in fact surprisingly good at this.7

It seems likely that organized systems of care, built on a primary care platform, with specialist input, shared records, evidence-based guidelines, patient involvement and self-management, community support and all the other elements of the chronic disease model are likely to make a positive impact.8 The answer in cancer is less clear but is probably similar, possibly with more emphasis on patient behaviour and earlier detection. Well-designed local experiments to try and deal with these issues are required and it is to be hoped that these will be facilitated rather than obstructed by the latest reorganization.