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To Save Cancer Patients in the UK, the NHS Needs a Dose of Competition

Andrew Haldenby
Medical Progress Today
November 5, 2007

It's not always possible to say that one country's public services are better than another's. Very often the data simply isn't there. But one area where the data is robust is healthcare. For England, the comparison is sobering. International surveys have consistently shown that UK patients—including cancer patients—can expect worse outcomes than if they were citizens of other developed countries.

This realisation is leading to a profound re–thinking of health policy in England's National Health Service (NHS); the new Government, under Gordon Brown, has actually commissioned a twelve–month review of the service. The success of this review will turn on the extent to which the NHS moves away from "socialised" medicine, and towards more market based services. As a result, while Rudi Giuliani's researchers may not have used the latest data, his basic message last week seems to me to be both right and important.

First, let's review the data on cancer patients. We are lucky that the most up–to–date information has just become available—the five–yearly EUROCARE review was published in September. It researched the proportion of patients in European countries that survive for five years after diagnosis, with the latest data being taken for the year 2002.

The review presented conclusive evidence that the UK performs more poorly than other developed countries. To quote from the editorial of the Lancet Oncology, the UK's leading academic cancer journal: "The reports show survival for gastric, colorectal, lung, breast, ovarian, kidney and prostrate cancer in England is lower than the European average." It noted that while survival has improved since recent years, other countries have improved at the same rate, so that the UK has continued to lag behind. It concluded that survival rates in the UK are similar to some former Communist countries that spend less than one–third of the UK's per capita healthcare budget.

On the specific case of prostate cancer, under 70 per cent of UK men survived for five years after diagnosis. This compared to 80 per cent or over for countries such as Austria, France, Germany, Italy, the Netherlands and Switzerland.

The EUROCARE study does not include the North American countries. But the American Cancer Society has showed that according to an earlier estimate, covering 1993–1995, 60 per cent of men in the UK survived for five years after diagnosis compared to 95 per cent of men in the US. I would expect the current rates to be under 70 per cent for the UK and all but 100 per cent in the US.

It is, therefore, likely that Rudi Giuliani's researchers gave him out–of–date numbers; he quoted a comparison of 44 per cent versus 82 per cent. But the true numbers support his basic argument.

Were I advising him, I would urge him to keep going. We are starting to understand that the reasons for the UK's poor performance in cancer and other diseases stem directly from the "socialised" medicine of which Mr. Giuliani was so critical.

The traditional explanation for the problems of the NHS was lack of money. This no longer applies. The current UK Government has lifted health spending up to the average of the European countries. But the UK remains behind the best performers—and, as the Lancet Oncology emphasised, on a level with some countries that spend much less.

Academic research points to a different explanation. Studies suggest that UK healthcare is slow to change, slow to innovate and poor in its use of new technology. It tends to spend its (now very considerable) resources on extra general staff and infrastructure rather than on specialist people and equipment. It is still heavily biased towards old–fashioned healthcare, based around traditional medium–sized hospitals on the edge of towns, rather than the modern approach which gives much more attention to prevention and to care in local settings ("primary care"). For example, the reason for the UK's poor performance on both cancer and stroke lies in large part because both diseases tend to be diagnosed too late due to the weakness of primary care.

This lack of innovation and sophistication is intimately tied to the "socialised" structure of our system. The service still operates nearly entirely as a monopoly; less than one per cent of NHS patients are treated by organisations not run by government, compared to 35 per cent in France and 50 per cent in Germany. While a minority of doctors and managers do succeed in innovating, they do so despite the system, not because of it. Unlike other areas of the UK economy, trades unions still have a strong influence on the leadership of the service, and act as a brake on change. Too often, decision–makers in the service still see themselves as part of government, and so pay most attention to the changing demands of political leaders rather than the needs of patients.

Confronted by this evidence, the UK Government is now seeking to move away from this "socialised" model, in particular by increasing competition. But the resistance from within the service has been considerable and the Government's reform drive now appears to be in retreat.

The lesson of UK health reform is to move away from "socialised" medicine. Our challenge is to provide guaranteed coverage and competition (on the Continental European model) together with guaranteed individual rights for patients (as on the Continent and the USA). The UK experience has profound lessons for reform minded politicians in America and indeed in other developed countries—particularly on what not to do.

Andrew Haldenby is Director of Reform, an independent London-based think tank specialising in public sector reform (
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