The four UK health systems: Learning from each other

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This paper aims to probe what it sees as a woefully under-explored area: the differences between the United Kingdom's four separate health systems. These systems, it argues, are diverging in terms of structures, management approaches, and the way social care relates to health.

In theory, this divergence should offer a unique opportunity to establish ‘what works’ in these different approaches. In practice, the exercise is hampered by hard-to-compare data and a political reluctance to back comparative studies.

Much more could be done to facilitate such studies. To this end, the paper explores devolution, finance and politics, documenting areas that diverge and those where cross-border transfer of policy has occurred. It concludes by listing opportunities for cross-border learning that are being ignored.

Key findings

  • Learning between the different systems has occurred, albeit indirectly and despite great reluctance to share knowledge. But many more opportunities for cross-border learning are being missed and each government must strive to make data more comparable.
  • All four countries face the same basic issues – severe financial pressure; flat or declining rates of spending; pressures from technological advance, an ageing society, obesity and other health problems. There is broad consensus on moving more care out of hospital and into communities, implying a significant reconfiguration of hospitals in each nation.
  • England’s adherence to and extension of market-like mechanisms in managing health differentiates it most dramatically from the other three services – which characterise themselves as having learned what not to do from the English experience.
  • Use of targets is an obvious example of lessons learnt. Devolved nations overcame their initial reluctance about them, once English waiting times fell sharply after targets were introduced.

Policy implications

  • Lack of timely and genuinely comparable data means that it is hard to say which country is getting better value for money from its health service. The four health departments should therefore agree specific indicators, establish which data is needed to make comparisons and identify how best to collect that data.
  • More comparable data could over time help determine whether competition is producing better or worse outcomes than more consensual, partnership-type approaches. It could also potentially answer smaller but vital questions related to organising clinical care, methods for integrating care, the merits of abolishing prescription charges among others. 
  • In the absence of such data, academics and others should do whatever is possible with what is available.



Cornwall carers partnership board trustee carers rights chair carers forum memory cafe dementia carers group
Comment date
22 June 2013
When the Government started the dementia strategy meetings I spoke about the NHS and Social services not working together, and was told I was being discourteous. The problem is people with dementia in the middle to latter stage cannot communicate. Therefore it is vital that the NHS and SS are working as one with these people as they need intervention from both parties, which is never going to work whilst one party charges on a means tested basis and the other does not. whilst is widely known that hospital is not the best place for people with dementia, there should be in place an alternative for people to be placed where they are going to receive professional care, as it is not always possible for them to be in their own home when needing 24/7 care and no family member to look after them. Ordinary residential homes are not adequate as they do not have 24/7 nurses on duty, and as there are significant cases of UTI's and hospital admissions this would in the long term save a substantial amount of money. There would be one member of staff to four patients compared with one to one at home, which is not sustainable.

Ed Macalister-Smith

NHS Leadership Coach,
Comment date
16 June 2013
A really helpful and timely prompt to compare systems, especially as the proposed Nicholson Strategy Review has had explicit mention of looking at the benefits or otherwise of the purchaser-provider split. Some rapid non-political, non-dogmatic academic analysis of this issue would be really valuable...

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