An innovative international study has used electronic medical records to compare the cost and quality of care between health care systems in 11 OECD countries, including the NHS in England. 

The International Collaborative on Costs, Outcomes and Needs in Care (ICCONIC) study has been led by researchers at Harvard University and LSE, and co-funded by the Commonwealth Fund and the Health Foundation. The data for England – compiled and analysed by the Health Foundation – has focused on two groups of high-need older patients which represent priority areas for the NHS and other health systems – those hospitalised with a hip fracture and those hospitalised with heart failure who also have diabetes.  

Looking at pre-pandemic data from 2014/15 to 2017/18, the study found that, for both groups of patients, England had the highest mortality rates of any country, despite performing relatively well on several other measures of quality of hospital care. One year after hip fracture surgery, almost a third (31%) of patients in England had died of any cause compared with less than a quarter of patients in in Canada (23%), Australia (22%) and France (20%).  

Another key area where England stands out from other countries included in the analysis is the length of time that hip fracture patients spend in hospital. Patients in England spent an average of 21.7 days in hospital after their surgery – the highest of all 11 countries evaluated.  

The findings add weight to national audits that have identified several areas for improvement in the care of hip fracture patients. More generally, the study provides further evidence that, while the NHS remains a relatively low-cost health care system that performs well in some areas, mortality rates for some patients are higher than in comparable countries – including in key areas such as cancer and cardiovascular disease.

The Health Foundation says the findings warrant further investigation – it notes that it is notoriously difficult to draw comparisons between health care systems that serve different populations and collect information about patients in different ways, and that doing so often raises more questions than it answers. The independent charity says that the results ultimately highlight major gaps in the available data in England and the need for investment to better understand what is happening to patient care across acute hospitals, rehabilitation services, support in the community and social care. 

However, by using patient-level data (which was not shared between countries) and enabling comparisons across primary, secondary and post-acute care, the ICCONIC study provides health care policymakers with vital information on how current care strategies are influencing the quality of care in the NHS in England, while also highlighting opportunities to significantly improve productivity. The Health Foundation says that such improvements in productivity are much needed as the NHS grapples with a growing elective care backlog that has accumulated during the pandemic and widespread workforce shortages. 

A key area highlighted by the study is the potential to free up additional capacity by reducing the time that patients remain in hospital after hip fracture surgery – the most common reason for emergency surgery. The Health Foundation says that there is broad agreement that hospital is not the best place for a frail older patient to stay following surgery as it is not conducive to rehabilitation. By investing in post-hospital care, there may be scope to reduce the length of hospital stays for hip fracture patients and free up additional capacity to deal with the backlog of care. 

In contrast to England, countries such as the Netherlands, Sweden and Canada have been able to provide accessible post-hospital care for hip fracture rehabilitation in either community-based or short-term residential care settings, resulting in much shorter hospital stays than patients in England. 

High mortality among hip fracture patients is occurring despite England performing well on other care quality measures – for example, over 82% of hip fracture patients in England received hip surgery within 48 hours of admission, second only to 85% of patients in Sweden. This is recommended as a key component of high-quality care. However, one year after their initial admission, 31% of English patients had died, compared with only 25% of Swedish patients. 

Dr Jennifer Dixon, Chief Executive of the Health Foundation, said: 

‘The findings of the ICCONIC study warrant urgent further investigation, particularly the finding of higher mortality among patients with hip fracture in the year after their admission for emergency treatment. The study suggests there is a significant opportunity to achieve higher quality care for patients, in part by learning from how other health systems deliver care and the investment it takes to do so.  

‘That patients in England with hip fracture spend far longer in hospital after surgery than they would in other countries also highlights an opportunity to improve efficiency by reducing the avoidable use of hospital care. Less avoidably long stays would mean existing capacity could be better used to address the backlogs in hospital care as a result of the pandemic. This could contribute to both better outcomes for patients and - as hip fracture is the most common reason for emergency surgery - significantly improved productivity for hospitals across the country. 

‘This ICCONIC study is innovative in using patient level data to compare the quality of care across different health systems. The findings should be viewed alongside other comparative studies which together can give a more rounded picture of the performance of the health system in England relative to other countries for the investment made.  

‘The study also highlights the lack of high-quality data that is available across the wider system of health and care which limits our understanding of what is happening on the ground, and the ability of clinical teams and NHS policymakers to act to improve care. However, there is now a clear opportunity with the introduction of new integrated care systems to make a step change in terms of linking up patient data and using the insights generated by this to reduce delays in discharge and improve quality of care and patient experience.’ 

Dr Irene Papanicolas, Associate Professor of Health Economics at the London School of Economics, said:

‘The ICCONIC study is unique in that it compares similar patients care trajectories across the health and care systems within their own countries. This perspective allows us to compare how efficient and effective different countries are in caring for patients with high needs. England stands out both because of the low cost with which it is able to provide care. However, England also has higher year long mortality than other countries participating in the study. Further work is needed to understand what England can do to improve patient outcomes.’

Further information

On the findings for heart failure in the ICCONIC study, the Health Foundation says that the relatively high mortality observed for patients in England is likely to be, at least partly, the product of the way in which care for heart failure is delivered in different countries. Patients have been selected for inclusion in the study based on being admitted to hospital with heart failure. In countries like England (where patients receive more of their care via general practice) only serious cases are admitted to hospital, whereas in other countries care is more hospital-based, meaning patients selected for inclusion may be less sick to begin with. By contrast, in any country, hip fractures almost always require hospital admission for surgery. 

However, the Health Foundation also notes that there is room for improvement in the assessment, diagnosis and management of heart failure. The National Heart Failure Audit has found that rates of specialist follow-up for heart failure patients are below 50%, less than half of patients are seen on a dedicated cardiology ward, and rates of referral for cardiac rehabilitation are very poor. This latter point is particularly concerning given that patients who received rehabilitation have higher quality of life and lower mortality.

Media contact

Simon Perry
020 7257 2093

Long read

Caring for older patients with complex needs

Less than a minute to read

Long read

How does the NHS in England compare with health care systems in 11 OECD countries?

Further reading

Long read

Caring for older patients with complex needs

Less than a minute to read

Long read

How does the NHS in England compare with health care systems in 11 OECD countries?


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