International comparisons of healthcare quality

The interactive charts below explore a range of indicators across primary, acute and cancer care, where comparable international data is available. For more information, including data, methods and further analysis, see our in-depth report, Focus on: International comparisons of healthcare quality.

How does UK's flu immunisation coverage compare internationally?

Between 2000 and 2015, the UK had some of the highest levels of coverage of influenza vaccination amongst over 65 year olds compared to other OECD countries. In 2014, 72.8% of the population aged over 65 was immunised. The UK exceeded the WHO target of 75% coverage in 2005 and 2006. Korea generally shows the highest levels of coverage (79.8% in 2014), whilst Portugal consistently has some of the lowest levels of coverage (50.9% in 2014).

Within the UK there appear to be country-level variations (data not shown) – though comparisons between the countries of the UK need to be made with caution (Annual Surveillance Report 2015/16). In England the cumulative uptake of seasonal influenza vaccinations (2015-16) amongst the population aged 65 years and older was 71% and Scotland uptake was 74.5%, compared to 66.6% in Wales and 74.4% in Northern Ireland.

The Annual Surveillance Report 2015/16 concluded that there were moderate levels of influenza activity in the community in the UK in 2015 to 2016, with influenza A(H1N1)pdm09 the predominant circulating virus for the majority of the season, peaking late in week 11 of 2016 and influenza B peaking afterwards.

Updated March 2017.

How does UK's DTP immunisation coverage compare internationally?

Since 2008, the UK has improved upon the DTP vaccination rate: this increased from 91% in 2000 to 95% in 2014. Belgium, France and Greece had very high vaccination rates, with 99 per cent coverage in 2014. In 2014, Australia had the lowest coverage (92%) of the OECD countries compared here. As of 2006 most countries maintained a relatively steady level of coverage.

Updated March 2017.

How does UK's measles immunisation coverage compare internationally?

Between 2000 and 2004 the UK measles vaccination rate declined – falling from 88% to 81% over this period. From 2004 to 2014 the rate increased to 93%. The decline between 2000 and 2004 was likely due to safety concerns relating to measles, mumps and rubella (MMR) vaccine. In 2014, Portugal had the highest measles immunisations coverage (98%) whilst Italy had the lowest (86%). Immunisation coverage levels increased between 2000 and 2014 in the majority of countries.

Updated March 2017.

How does the rate of COPD and asthma admissions compare internationally over time?

Overall, COPD-related hospital admissions are more common than asthma- or diabetes-related hospital admissions.

When comparing the UK with other countries, for both COPD and asthma the age-standardised rate per 100,000 population is relatively high; for asthma, the UK is one of the worst performers of all the comparator countries. However, there has been a reduction in the number of hospital admissions for COPD and asthma in the UK in recent years. For COPD, there was a 16% reduction between 2006 and 2013 (from 253.8 admissions per 100,000 population in 2006 to 212.7 admissions per 100,000 population in 2013). For asthma, the rate dropped by 24 per cent between 2006 and 2013 (from 79.5 admissions per 100,000 population to 60.5 admissions per 100,000 population). This decline in the number of hospital admissions may reflect some improvement in the quality of care provided for these conditions.

Trends in the other countries under analysis in this report vary. For example, there has been a continuous sharp decline in Italy in the number of hospital admissions for COPD and in Ireland in the number of hospital admissions for asthma. In the other countries, trends are more stable. Of all the OECD countries, Italy has the lowest admission rate for COPD and Italy has the lowest rate for asthma. Trends in the UK seen in the OECD data reported here are broadly consistent with those reported in earlier work on adult hospital admissions for ambulatory care sensitive conditions in England (Blunt, 2013).

While the focus in this analysis is not on respiratory deaths, it is worth noting that the inquiry by the All Party Parliamentary Group on Respiratory Health (2014) into respiratory deaths concluded that the quality of services and outcomes in the UK compared very poorly with other countries and that urgent action was needed. The inquiry report highlights that awareness in the population as well as among non-specialist professionals, and the effective implementation of numerous, existing, evidence-based clinical guidelines, should be the priority in order to prevent potentially unnecessary admissions and deaths. Other reports have highlighted concern about the quality of care provided to asthma and COPD patients (Department of Health, 2012; Healthcare Quality Improvement Partnership, 2014b).

Updated June 2017.

How does the rate of diabetes admissions compare internationally over time?

Diabetes is a common chronic condition for which inadequate management can lead to a range of short-term (e.g. diabetic coma) and long-term (e.g. cardiovascular disease, retinopathy and kidney disease) complications. The hospital admission rate in the UK for short- and long-term diabetes complications and uncontrolled diabetes without complications was stable between 2011 (66.3 admissions per 100,000) and 2013 (64.3 admissions per 100,000) one of the lowest rates among the comparator countries.

Both Italy and the Spain had lower rates of admission than the UK, with Italy having the lowest in 2013 (43.5 per 100,000). Despite lower hospital admissions, the estimated prevalence of diabetes in 2014 was higher in Spain(6.8%) than in the UK (5.8%) (OECD, Diabetes prevalence 2016). Ideally, we would like to measure hospital admissions within the diabetes population rather than the general population. Whilst hospital admission rates have been stable in the UK, many adults, but especially children, still do not receive the recommended care for diabetes Royal College of Paediatrics and Child Health, 2015) and there are large variations around Europe in the quality of care provided and diabetes outcomes (e.g. HbA1c control) (see SWEET project.

Updated June 2017.

How does the rate of diabetes lower extremity amputations admissions compare internationally over time?

Looking at the more specific indicator of hospital admission rates for diabetes lower extremity amputations, these have also been stable in the UK since 2006 – at an average of three amputations per 100,000 population. In many of the other countries under analysis, the rate has also been stable. The UK’s performance relative to other countries appears good. However, Italy had just 2.7 amputations per 100,000 population in 2013. Evidence from England suggests that many of the amputations could still be prevented with targeted preventative services and fast access to high-quality foot care (Kerr, 2012). Also, multidisciplinary diabetic foot care teams improve outcomes and reduce costs to the NHS (Kerr, 2012).

It is important to be mindful of the differences in coding practices (e.g. major/minor amputations) that are likely to have an impact on the observed differences between countries. OECD and country experts are working on further improving the quality of the diabetes data.

Updated June 2017.

How does antibiotic prescribing compare internationally?

The OECD collects data on prescribing in different countries using a system of average Defined Daily Doses to account for the volume of drugs. Since 2000 the volume of antibiotics prescribed in the UK has increased from 14.3 Defined Daily Dosage (DDD) per day per 1000 inhabitants to 19.4 in 2012. The UK prescribes fewer antibiotics than many other countries, but the increasing trend is worrying. Lowest antibiotic prescribing can be observed in the Netherlands, Germany and Sweden, with Sweden managing to be on a continuous decline since 2007.

Last updated: July 2015. 

Source: 

OECD, Health Statistics 2014

Cephalosporins and quinolones as a proportion of all antibiotics prescribed

As mentioned above, two drugs of particular importance are cephalosporins and quinolones as these are second-line antibiotics restricted for situations where first-line antibiotics have failed (OECD, 2013c). Reflecting the trend in England above, this figure shows that their prescribing in the UK as a proportion of all antibiotics prescribed has been on a sharp decline since 2007 and that the UK performs the best out of all the comparator countries. 

Last updated: July 2015. 

Source: 

European Centre for Disease Prevention and Control

How does UK's ischaemic stroke mortality rate compare internationally over time?

In the UK, cardiovascular and circulatory diseases represent the second highest burden of disease (28.8% of total years of life lost) after cancer (Institute for Health Metrics and Evaluation, 2013). Ischaemic heart disease represents 15.9% of years of life lost and 6.8% is due to cerebrovascular diseases (of which 3% is due to haemorrhagic and other non-ischaemic stroke and 3.8% is due to ischaemic stroke) (Institute for Health Metrics and Evaluation, 2013). The majority of strokes in England are ischaemic – that is, where a clot blocks blood flow to part of the brain; haemorrhagic strokes happen when a blood vessel bursts and bleeds into the brain. (NHS Choices)

Mortality rates, which are used as a proxy for the quality of acute care, have been stable or declining over time in most of the countries included in the chart. For ischaemic stroke, patient-based 30-day in-hospital and out-of-hospital mortality rates have been declining rapidly in the UK (they fell from 17 per 100 patients in 2008 to 11 per 100 patients in 2013) but still remain above most of the comparator countries (New Zealand’s rate was also 11 per 100 patients in 2013). Korea has the lowest rate of all the OECD countries with 5 deaths per 100. According to the data for admission-based ischaemic stroke, 30-day in-hospital mortality has also been declining in the UK and there were 9.2 deaths per 100 hospital discharges in 2013. Japan has the lowest rate of all the OECD countries.

Updated January 2017.

How does UK's haemorrhagic stroke mortality rate compare internationally over time?

The rate of 30-day mortality after admission to hospital for haemorrhagic stroke (based on patient data) in the UK declined between 2008 (35.2 per 1,000) and 2013 (28.3 per 1,000). In 2013 the rate in the UK was lower than that of New Zealand (32 per 1,000) but higher than Korea (17.4 per 1,000), Sweden (23.3 per 1,000) and Spain (25.9 per 1,000).

The 30-day mortality rate (based on admissions data) demonstrates a similar trend to the data discussed above, with the rate declining in the UK and other countries. In 2013 the rate in the UK (26.5 per 1,000) was relatively high compared to the other countries in the graph.

Though the decline in the mortality rate shown in the graphs is positive it is also important to note that inaccuracies in routine data and differences in stroke care around the world make international comparisons challenging.

In the UK, since the 1990s, the Royal College of Physicians has carried out work to improve quality of care for patients who have had a stroke. Most recently it has set up the Sentinel Stroke National Audit Programme (SSNAP), which aims to improve quality by auditing stroke services against evidence-based standards. Since December 2012, this audit has collected data on a quarterly basis for every stroke patient in England, Wales and Northern Ireland, looking across the entire care pathway – acute care, rehabilitation, six-month follow-up and outcomes. The most recent audit reports highlight that there have been significant improvements in the organisation and provision of stroke care services. However, large unacceptable variations remain and not all patients have access to the same high-quality care Sentinel Stroke National
Audit Programme (SSNAP)
. Variations are mainly in staff mix and skills (nurses, care assistants and consultants), access to clinical psychology and social care, stroke specific early supported discharge, organisation of stroke units, CCG involvement in services development and strategic planning. A Cochrane review of evidence suggests that stroke patients who receive organised inpatient care in dedicated stroke units are more likely to be alive and lead an independent life one year after a stroke (Stroke Unit Trialists’ Collaboration, 2013). Stroke Unit Trialists' Collaboration

In addition to these a review by the National Confidential Enquiry into Patient Outcome and Death (2013) on the quality of care received by patients with aneurysmal subarachnoid haemorrhage has provided a range of recommendations for improving the quality of care for haemorrhagic stroke. The report specifically highlights the importance of appropriate education for professionals about clinical presentation, establishing formal networks linking different levels of care, and introducing standard protocols of care at secondary and tertiary level.

Updated January 2017.

How does UK's acute myocardial infarction mortality rate compare internationally over time?

Similar to strokes, acute myocardial infarctions (AMIs) – or heart attacks – require early diagnosis and fast specialist treatment, together with cardiac rehabilitation in order to reduce the probability of recurrent heart attacks or death, and improve quality of life (National Institute for Cardiovascular Outcomes Research, 2013, 2014).

The figures for 30-day AMI mortality show a declining trend and there is convergence across most of the countries. Between 2008 and 2013, 30-day mortality after admission to hospital for AMI (based on patient data) in the UK declined from 12 per 100 patients in 2008 to 9.1 per 100 in 2013. Thirty-day mortality (based on admission data) in the UK also declined, from 9.4 per 100 in 2008 to 7.6 per 100 in 2013.

While not directly comparable with these OECD AMI indicators, a report from the Myocardial Ischaemia National Audit Project (MINAP) showed there was a decline between 2003–04 and 2011–14 in same-hospital 30-day mortality rates(National Institute for Cardiovascular Outcomes Research, 2014). This finding suggests there have been significant improvements in the care provided to patients who have had a heart attack. However, the same report also expresses reservations about using unadjusted health outcome indicators to measure quality of care and conduct international comparisons of outcomes – due to differences in data collection, definitions and patient characteristics.

Updated January 2017.

How does breast cancer screening coverage compare to other countries?

Breast cancer screening coverage of females aged 50-69 in the UK has been steady over the years with an average of 76%. UK has one of the highest screening rates of the comparator OECD countries, with higher rates only in Finland (84.8%) and the Netherlands (80.1%) in 2011. 

Last updated: July 2015.

Source: 

Organisation for Economic Co-operation and Development, Health Data

How does cervical cancer screening coverage compare to other countries?

Data collection varies in each country. Some countries collect survey data and some have screening programmes, symbols in the chart denote data collection: ^ = Survey data * = Programme data.

When compared to other countries, the UK has had one of the highest cervical cancer screening rates since 2000. However, there has been a gradual decline in the proportion of women screened, from 84% in 2000 to 78% in 2013. Screening rates have been more or less steady since 2008 with an average of 76.4% females aged 20-69 screened.

Source: 
Organisation for Economic Co-operation and Development, Health Data

How does five-year breast cancer survival in the UK compare to other countries?

Five-year relative survival for breast cancer has been steadily improving in the UK over time, reaching 82% in 2007-2012. However, despite relatively high breast cancer screening coverage in the UK, when compared to several other OECD countries, the UK continues to lag behind in survival; United States has reached the highest five-year relative survival levels in 2003-2008 (89.3%) and Sweden in 2007-2012 (87.4%).

Source: 
Organisation for Economic Co-operation and Development, Health Data

How does five-year cervical cancer survival in the UK compare to other countries?

International trends in five-year relative survival for cervical cancer show more cross country variation over time than for five-year relative breast cancer survival. While survival has been improving in the UK, the country is still one of the worst performers relative to the other OECD countries included, with a five-year survival of only 60.9% in 2007-2012. This is despite a relatively high cervical cancer screening coverage. In comparison, survival in Sweden in the same year was 67.3% while survival in Korea reached 76.8% in 2005-2010.

Source: 
Organisation for Economic Co-operation and Development, Health Data

How does five-year colorectal cancer survival in the UK compare to other countries?

Trends for five-year relative colorectal cancer survival resemble the trends for five-year relative breast cancer survival. While there has been a continuous increase in the UK over time, in 2007-2012 five-year relative survival reached only 54.5%. In the same period in Sweden it was as high as 63.9%, Australia reached 66.2% in 2005-2010 and Korea was the OECD's best performing country, with a five-year relative survival of 72.8%.

Overall, as survival rates capture both how good the system is in detecting the disease and whether people have rapid access to effective treatment, it is essential to better understand what could be done to further improve survival rates and close the gap with other OECD countries.

Given that cervical and breast cancer screening coverage is already relatively high in the UK, it would be important to further examine any potential delays in diagnosis (after screening or first presentation with symptoms) and access to effective treatment. However, there is still plenty of scope to improve colorectal cancer screening coverage (von Wagner et al, 2011) (http://ije.oxfordjournals.org/content/40/3/712.short). In addition, changes to the screening programme (e.g. a new bowel scope screening programme) may also increase the proportion of cancers detected by screening.

Source: 
Organisation for Economic Co-operation and Development, Health Data

How does breast cancer mortality compare internationally over time?

Breast cancer mortality in the UK has been declining and fell from 37.7 deaths per 100,000 women in 2001 to 29.1 deaths per 100,000 women in 2013. However, the UK is consistently amongst the four countries with the highest mortality rate. The comparator countries with the lowest mortality rates are Korea, Japan and Spain. Since the late 1990s the incidence of breast cancer has been increasing in both the UK (from 68.8 per 100,000 women in 1998 to 95 per 100,000 women in 2012) and Spain (from 49.6 per 100,000 women in 1998 to 67.3 per 100,000 women in 2012).

Updated June 2017.

How does cervical cancer mortality compare internationally over time?

Cervical cancer mortality rates in the UK fell between 2001 and 2006 (from 3.6 to 2.8 deaths per 100,000 women) and since then they have plateaued at 2.7 deaths per 100,000 women – one of the highest mortality rates of all the comparator countries. Italy consistently has the lowest death rate of only one death per 100,000 women. Incidence rates for cervical cancer in Italy and the UK are very similar and have shown a decline: in Italy the rate fell from 9.1 per 100,000 women in 2000 to 6.7 per 100,000 women in 2012, while in the UK the incidence rate fell from 9.3 per 100,000 women in 2000 to 7.1 per 100,000 women in 2012.

Updated June 2017.

How does colorectal cancer mortality compare internationally over time?

Colorectal cancer mortality has been slowly declining over time. In the UK it fell from 20.6 deaths per 100,000 population in 2001 to 17.9 deaths per 100,000 population in 2013 and the UK’s performance on this indicator lies in between the comparator countries. Greece generally has the lowest mortality rates of the comparator countries (13.5 deaths per 100,000 population in 2012).

Updated June 2017.

About this data

Definitions and comparability for all the indicators discussed above are taken directly from the OECD report Health at a Glance 2013: OECD indicators. Detailed information about the definitions and the source and methods for each country can be found on the OECD website.

Choice of countries 

In these indicators we compare the UK to a pool of 14 countries considered to be relevant comparators for one or more of the following reasons:

  • They are a similar western European country or have a similar level of economic development.
  • They have a minimum population of approximately 10 million people.
  • They have a similar type of health system to the UK.
  • They are historically relevant.

The following 14 countries were selected for comparison: Australia, Belgium, Canada, France, Germany, Greece, Ireland, Italy, the Netherlands, New Zealand, Portugal, Spain, Sweden and the US. For indicators where the OECD best is not one of these 14 comparator countries or the UK, we highlight the best performer from the OECD overall for illustrative purposes.

It should be noted that not all of the countries report data on all of the indicators or do so regularly. Lack of data can actually be a signal for possible gaps in performance but we do not explicitly focus on under-reporting here. The OECD publishes UK-wide data and so in this report we look at the performance of the UK as a whole. These data are supplied at the UK level by the Department of Health. In most cases, a breakdown of the figures for England, Wales, Scotland and Northern Ireland is not available.

For more information, see the related QualityWatch report: Focus on: International comparions of healthcare quality

Flu vaccinations

For the schedule of vaccinations please see the NHS Choices website.

For all vaccinations some caution should be exercised when comparing coverage figures over time due to data quality issues reported by some data providers. Apparent trends could reflect changes in the quality of data reported as well as real changes in vaccination coverage. Please see individual data collections for any additional information associated with this data.

'Influenza vaccination rate' refers to the number of people aged 65 and over who have received an annual influenza vaccination, divided by the total number of people over 65 years of age. The main limitation in terms of data comparability arises from the use of different data sources, whether survey or programme, which are susceptible to different types of errors and biases. For example, data from population surveys may reflect some variation due to recall errors and irregularity of administration. A number of countries changed the way in which influenza vaccination rates were calculated between 2005 and 2011. These countries are: Chile, Denmark, Germany, Israel, Luxembourg, New Zealand, Slovenia, Switzerland and the United Kingdom.

Childhood vaccination programmes

Vaccination rates reflect the percentage of children that receive the respective vaccination in the recommended timeframe. The age of complete immunisation differs across countries due to different immunisation schedules. For those countries recommending the first dose of a vaccine after age one, the indicator is calculated as the proportion of children less than two years of age who have received that vaccine. Thus, these indicators are based on the actual policy in a given country. Some countries administer combination vaccines (e.g. DTP for diphtheria, tetanus and pertussis) while others administer the vaccinations separately. Some countries ascertain vaccinations based on surveys and others based on encounter data, which may influence the results.

Mortality following a stroke

The admission-based case-fatality rate is defined as the number of people aged 45 and over who died within 30 days of being admitted to hospital for ischemic stroke, where the death occurs in the same hospital as the initial stroke admission. The in- and out-of-hospital case-fatality rate is defined as the number of people who die within 30 days of being admitted to hospital with a stroke, where the death may occur in the same hospital, a different hospital or out of hospital. Rates were age-sex standardised to the 2010 OECD population aged 45+ admitted to hospital for stroke. The change in the population structure in this edition of Health at a Glance compared with previous editions (where rates were standardised using the 2005 OECD population of all ages) has led to a general increase in the standardised rates for all countries.

Mortality following acute myocardial infarction (AMI)

The admission-based case-fatality rate following AMI is defined as the number of people aged 45 and over who die within 30 days of being admitted to hospital with an AMI, where the death occurs in the same hospital as the initial AMI admission. The in- and out-of-hospital case-fatality rate is defined as the number of people who die within 30 days of being admitted to hospital with an AMI, where the death may occur in the same hospital, a different hospital, or out of hospital. Rates were age-sex standardised to the 2010 OECD population aged 45+ admitted to hospital for AMI. The change in the population structure in this edition of Health at a Glance compared with previous editions (where rates were standardised using the 2005 OECD population of all ages) has led to a general increase in the standardised rates for all countries.

Breast and cervical cancer screening coverage

Number of women aged 20-69 who have been screened for cervical cancer within the past three years (or according to the specific screening frequency recommended in each country) divided by the number of women aged 20-69 answering the survey question (for survey-based data) or eligible for an organised screening programme (for programme-based data). In many countries, the recommended screening frequency will be every three years. Countries were selected based on data availability. Note: ^ - Survey data * - Programme data.

Cancer survival

Relative survival is the ratio of the observed survival experienced by cancer patients over a specified period of time after diagnosis to the expected survival in a comparable group from the general population in terms of age, sex and time period. Relative survival captures the excess mortality that can be attributed to the diagnosis. For example, relative survival of 80% mean that 80% of the patients that were expected to be alive after five years, given their age at diagnosis and sex, are in fact still alive (OECD Health at a Glance, 2013).  

Cancer survival calculated through period analysis is up-to-date estimate of cancer patient survival using more recent incidence and follow-up periods than cohort analysis which uses survival information of a complete five-year follow-up period. In the United Kingdom, cohort analysis was used for 2001-06 data while 2006-11 data are calculated through period analysis. The reference periods vary slightly across countries. All the survival estimates presented here have been age-standardised using the International Cancer Survival Standard (ICSS) population (Corazziari et al., 2004). The survival is not adjusted for tumour stage at diagnosis, hampering assessment of the relative impact of early detection and better treatment (OECD Health at a Glance, 2013).

Cancer mortality

Mortality rates are based on numbers of deaths registered in a country in a year divided by the size of the corresponding population. The rates have been directly age-standardised to the 2010 OECD population to remove variations arising from differences in age structures across countries and over time. The source is the WHO Mortality Database. Deaths from all cancers are classified to ICD-10 codes C00-C97. Mathers and others (2005) have provided a general assessment of the coverage, completeness and reliability of data on causes of death. Mortality rates of colorectal cancer are based on ICD-10 codes C18-C21 (colon, rectosigmoid junction, rectum, and anus).

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