The NHS: a tale of four nations
Elliot Bidgood, 18 June 2013
The King’s Fund have published a very interesting summary of the differences between the UK’s four health services, which have diverged in their management styles since 1999 due to devolution. Some variances, such as the lack of prescription fees outside of England, are well-known, but there are also more fundamental divides – as I have mentioned previously, Northern Ireland already has a version of the routine integration of health and social care that policymakers in Great Britain now hunger for, while over the past 10-20 years England has undergone many reorganisations and radical experimentation with commissioning, patient choice and internal competition of the kind not seen in the other home nations. Researcher and former Financial Times public policy editor Nicholas Timmins observes that in light of the fact that “One common health system with four different versions would normally be the sort of design model that health service researchers would die for”, the relative paucity of detailed comparative data is surprising, and even suggests that there is a reluctance among politicians to make these investigations, “for fear that the answer may not be in their favour.”
We do of course know that English people are healthiest, despite receiving the least spending per head and having fewer GPs than Scotland, but at current it is difficult to separate the well-known public health causes of this from the impact of the differing health system setups (Civitas has looked at this previously).
The King’s Fund report found that despite common challenges – funding pressures, population ageing, obesity, technology costs and the need for community-based care – learning between the four services was often “indirect”, in part due to a lack of comprehensive or comparable evidence. Nevertheless, it is more straightforward to compare UK health internally than with the rest of the world (though the latter also remains a worthwhile endeavour), and comparisons could prove particularly useful in one of the great debates in health policy today – whether pluralistic competition or ‘collaboration’ is the best way to ensure quality and cost-efficiency. Indeed, given an observation by Timmins that policymakers in the remainder of the UK have tended to observe developments in England in order to learn from implementation failures and decide whether or not to follow suit, it seems much of the future of UK health policy could ride on the outcomes of English reforms. In the meantime, however, Timmins stressed that even “In the absence of [comparable] data, academics and others should do whatever is possible with what is available.” We would do well to heed his advice.
An upcoming Civitas report entitled After Francis: Standards & Care Quality in the NHS will touch on competition, the example of Northern Irish integration and other issues in the NHS at the current time. For more of our work on health, including books and research papers, visit our website here.