Is the NHS getting better or worse?

Editor—Smith's editorial is entitled “Is the NHS getting better or worse?”¹ Better or worse at what? Maybe one of the reasons we don't have the data to answer the question reliably is that the question is not well formed. This is a basic starting principle of evidence based medicine: to get a clear answer you need to ask a clear question. What do we want to know?

Maybe asking how much harm is caused by the NHS would be one question worth asking. What are the rates of iatrogenic morbidity and mortality? If those figures are shrinking then at least we can argue that the NHS is getting better at not subjecting patients to harm. However, to focus only on the question of harm, fails to provide us with answers about the positive impact of the NHS.

It's a bit like defining health as the absence of disease. Maybe we should ask about numbers—numbers of doctor-patient contacts, numbers of nurse-patient contacts, numbers of procedures carried out, amounts of drugs prescribed. At least these numbers are data. However, do they tell us anything other than how good the NHS is at being busy? Being busy is no guarantee of quality or effectiveness.

If the NHS exists to reduce the burden of human suffering then it will not be able to demonstrate whether it is achieving that simply by accumulating data. It needs to effectively describe patient experience.

It's not that we need better data to answer the question, it's that we need to have a debate about what question we want to ask. Then we need to devise the ways of understanding (not just measuring) the experience of the individual people the NHS was created to serve.