The first point is that healthcare is intrinsically very ineffective (and inefficient). This for many complex reasons e.g

* most disease or ill health does not consist of single treatable conditions

* many treatments whilst effective statistically in trials don't work for many patients

* some cause iatrogenic disease i.e. the system manufactures illness itself

* people's needs when presenting are often primarily non-medical

* also people often present with something different to the underlying issue e.g. in somatisation

* healthcare is provided by a huge range of professions and systems that have to inter-relate

* payment regimes are often also complex and costly to administer.

Finally, and most importantly, only 20% or less of health gain can ever be attributed to healthcare systems, other determinants are responsible for most illness and indeed recovery.

Health care systems maybe operate at about 15% efficiency as opposed to the 40-60% that would be acceptable elsewhere. Whilst different to effectiveness there is a relationship as the resources are not elastic - you can't spend as much as you like to get better outcomes.

When it comes to failure, what do we mean by failure? Parts of the UK healthcare system could be said to be failing, e.g care for people with intellectual disabilities or children's mental health services. But the reasons are complex and these services have many dedicated staff. They just can't meet all the need or prevent all the deterioration. This failure, however defined could come about because of

* lack of resources (staff or money)

* poor organisation

* poor strategy and leadership or culture

But how do we define failure? We could say the US health system is a failure because it is the most inefficient in the world cost wise (20% of GDP for no more health gain than other developed countries) but it also has some of the best hospitals in the world! I think we have to look here at relative efficiency and effectiveness. Also poor countries will focus their healthcare on the low hanging fruit and communicable disease so they are likely to appear more efficient - but they are less effective if you take resourcing out of the picture: actually they are potentially more effective per case treated. Mental health services are intrinsically less efficient and effective at achieving outcomes simply because it is harder. So the benchmarks need to be different. It is a very complex and interesting issue, thanks for raising it!

I think we have to start at a more basic level - what is the purpose of healthcare systems - to cure, to provide care, to triage,,, for who? - everyone, those with resources/insurance.... and where,... in hospitals, outpatients centers, primary/general practice settings... for physical and/or mental and/or behavioral health....

I think these systems get into trouble because the choice along these and other dimensions are unclear, or they are trying to do more than one but are resourced for something else. they also suffer from the consequences of changing priorities. These circumstances provide opportunities for ill-informed and mismanagement and inefficiencies. Also, the patients/persons accessing and the staff at all levels also have agendas, may be ill-informed about the purposes and challenges in healthcare and their specific roles and may not agree with or value the stated and actual purposes of healthcare.

It would seem that strong, clear and agreed across stakeholders purposes of healthcare and associated resource allocations (which also require agreement) are elusive but probably needed.