Between Sarah Palin pronouncing the NHS ‘evil’ and the Twitter feed declaring that from experience they love the NHS, inside 140 characters, there is some room for thoughtful reflection about where we are on health systems. Sadly it is emerging as the last redoubt of the Anerican Right for whom uncontrolled guns, unbridled markets and unregulated healthcare are the essence of the American Dream. But it is worth trying to weave a path between some of the wilder Republican allegations about the NHS as the fearful vision of socialised health provision on the one hand and the over-ready boasts that the NHS is the best health system in the world on the other. Issues of cost, coverage, quality of care, access and after-care are far too complex for simplistic comparisons, and lessons need to be learned, not lies fabricated to protect vested interests. Here are some of the factors that need to be assessed for a more balanced appraisal.

The cost of healthcare systems varies dramatically between countries. In America it is by far the highest – 16% of US GDP, totalling over $2 trillion a year. In the EU the relative cost as a proportion of GDP is half that. In France and Germany it is 9%, and in the UK rather less at 8%. These variations matter hugely since in the UK each extra 1% of GDP wpuld add £15bn to the health budget. The first point therefore is that on any count the NHS scores highly on value for money. The US healthcare system is relative to GDP twice as expensive as the NHS, yet nobody could claim that it was twice as good – indeed in a number of respects it is clearly worse.
The most obvious US healthcare weakness is its poor coverage – 47 million Americans, as Obama keeps reminding the country, lack any form of health insurance, and therefore are not treated at all or end up in State or community hospitals with inferior second-class care. That is one in six of all Americans. Such lamentable discrimination – by income, by class, by race – does not exist to anything like the same extent in any other Western State. In a rich country with huge expenditures on health, universal access to good-quality healthcare is an index of liberty.
But best achievements are not all one way. Breast cancer survival rates (for at least 5 years from diagnosis) are 12-14% higher in the US than in Britain. For prostate cancer a Lancet global study recently found that 92% of Americans were still alive after 5 years, compared with only 51% of Britons. In the case of heart attacks, there is little difference: 40% in the UK wo suffer one die from it, compared with 38% in the US. Other claims being made iabout UK medical practice in the current firestorm of charge and counter-charge in the US are simply mischievous or downright false – that there is a ban on receiving treatment above a certain age (untrue), that patients are denied treatment above a certain cost (untrue, though NICE does assess the amount and quality of extended life it is hoped the patient will gain), that services such as kidney dialysis and open heart surgery are rationed (untrue, though some people with serious kidney failure cannot obtain dialysis because patient numbers are increasing by 6% a year), and that women under 25 cannot receive screening for cervical cancer (untrue).
But it is still relevant to ask, for example, why breast cancer survival rates are lower in the UK than in France and Germany. We also need to consider whether the huge increase in health expenditure over the last decade, from 6% to over 8% of GDP, was concentrated far too much on hospital PFIs, which have turned out poor value for money, rather than on frontline personnel and ill-health preventive care.

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