Learning from the four UK health systems

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Following devolution in 1999, the UK now has one National Health Service but four different versions of it. But hardly anyone seems to be paying attention to that fact. As a result, a huge opportunity is going to waste.

It is not just that England has gone down a road of applying more market-like pressures – particularly following Andrew Lansley's health reforms – while Scotland and Wales, in particular, have reverted to a more planned, managed, version of the NHS.

It is also that all four countries are facing exactly the same pressures in terms of heavily restricted finance, medical advances, ageing populations, a growing burden of often multiple chronic disease, and difficulties in coordinating health and social care.

Each faces, on the face of it, significant hospital reconfigurations. Each is trying to make quality a core focus of health care. Each is building clinical networks. Each is seeking public health answers to lifestyles that impact health and health care costs. And each is trying to resolve these issues by somewhat different routes.

Yet this natural 'experiment' or natural 'laboratory' for comparing and contrasting to learn ‘what works’ − or at least learn something about what works − is not being exploited, or to be more precise it is not remotely being exploited enough.

There are a whole bunch of reasons for that. Despite it being still, broadly, one NHS – at least when viewed from outside the UK – key data is often collected differently in the different countries, making comparison on outcomes difficult. There are huge political sensitivities around the issues. And there is a sense that many politicians in all four countries do not want questions about what works best either asked or funded, for fear that the answer may not be in their favour.

Today the Fund is publishing a brief paper that is essentially a call to arms, arguing that something should be done about that.

Sure there are difficulties in making comparisons – partly for the reasons outlined above – and there may be more to gain from narrower studies than from an attempt to answer a 'whole system' question about which approach to running the NHS works best.

But those difficulties do not prevent other international studies of how different health systems, or bits of health systems, work – even when the obstacles of finding comparable data and working with different cultures are far greater than within the UK.

One common health system with four different versions would normally be the sort of design model that health service researchers would die for, offering the opportunity for lessons that should interest politicians, managers, health service leaders, taxpayers and patients themselves. As the money gets ever tighter and the challenges ever greater, now is time for this opportunity no longer to be squandered.


Andy Hockey

Public affairs,
Comment date
13 June 2013
One area which would be of interest in terms of lessons to the range of stakeholders highlighted is alcohol misuse. The differences in coordination across public health, health services and social care between the 4 nations, the availability/use of data, approach to treatment services and outcomes measured would be an opportunity for research and learning.

David Oliver

Kings Fund Visiting Fellow/Consultant Physician,
Kings Fund/Royal Berkshire NHS Foundation Trust
Comment date
13 June 2013

I was involved in running integrated care workshops in south wales a few weeks back and despite the lack of purchaser-provider split, despite the presence of regional health boards funding all local health services, the issues raised by the group could easily have been any health economy in England. Too many older people with complex needs and frailty defaulting into high cost acute settings and staying too long for want of investment in prevention or responsive support outside hospital or capacity in step down services, different organisational values, language and priorities, poor use of shared information and trusted assessments, difficulties in cost shifting from buildings to services etc etc. And it is telling that if anything the performance of the English NHS post devolution appears to have been more efficient than that of the devolved nations. One thing i am fed up of is the tariff being blamed in England for all the system issues, as if hospital doctors like me (I saw 53 acute admissions on sat between 8am an 8pm, sending 22 back home again from the front door - not atypical) are busy admitting patients to generate tariff income for the trust when we are in fact desperate for beds. If tariff is the problem then how come we have such major variations in admission rates and bed occupancy within England and how come in the devolved nations who have scrapped the purchaser provider split they still face the same set of issues. It is but one small part of the range of system solutions but it is an easy target. "For every complex human problem there is a solution which is simple, obvious and wrong" HL Mencken.

I also think we have a second natural experiment which is transforming community services policy. English community services are now being run by a mismash of acute providers, mental health trusts, social enterprises etc - but which model will produce the best outcomes? I have my hunches...David Oliver


consultant physician,
Comment date
10 December 2014
I totally agree with you Andy!

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