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Major report reveals impact of devolution on patient care

NHSA major new report published today by the Nuffield Trust and Health Foundation has found significant improvements in  the performance of the NHS in all four UK countries since devolution.

The report, authored by six leading health academics including Professor Gwyn Bevan from LSE, shows that Scotland has made particular progress, linked to tougher sanctions and targets, but since 2010 waiting times in Wales have risen as austerity has set in.

The four health systems of the UK: How do they compare?| finds that the performance gap between the NHS in England and the rest of the UK has narrowed in recent years, with no single country consistently ahead of the others. finds that the performance gap between the NHS in England and the rest of the UK has narrowed in recent years, with no single country consistently ahead of the others.

This is despite considerable policy differences between each country, such as England’s greater emphasis on patient choice and the use of private sector providers, and the rejection of competition in Northern Ireland, Scotland and Wales.

The research is the only longitudinal analysis of its kind, building on a previous report published by the Nuffield Trust in 2010. Today's report is based on an in-depth analysis of around 20 indicators, comparing the performance of the four UK health system over the past two decades.

On spending on health care, the study finds:

  • All countries substantially increased investment in their health systems doubling in cash terms (not adjusted for inflation) the amount spent on health care across the UK between 2000/01 and 2012/13 and investing in more staff.
  • But there have been divergent spending decisions, with Scotland spending almost £900 million from the money notionally available for health on other services or on making existing services free of charge including free personal care for older people, and Wales spending around £450 million on other services.
  • Spending across the board has slowed in response to austerity. Over the three years from 2010/11 to 2012/13, the annual rates of change were: growth in Northern Ireland of two per cent; England and Scotland of one per cent; and a reduction in Wales of one per cent.

Since the previous study in 2010 which used data up to 2006/7:

  • England performs marginally better across a number of key indicators, including amenable mortality rates, life expectancy and ambulance response times. But, the gap has narrowed on many indicators and differences between the countries are often small. Nurse staffing levels have been lower in England than in the other three countries over the period studied.
  • Scotland shows a marked upturn in performance on indicators associated with targets and performance management, such as waiting times for planned surgery, which now broadly match England’s, and ambulance response times.
  • Wales demonstrates improved performance on a number of indicators, but shows deteriorating performance on waiting times since 2010, with striking rises in waits for common procedures such as knee or hip operations. In 2012/13 a typical Welsh patient waited about 170 days for a hip or knee replacement compared to about 70 days in England and Scotland.
  • Northern Ireland has improved performance on most indicators, but MRSA mortality rates remain higher than both England and Wales. There are no comparable waiting time data for Northern Ireland in recent years.

The report also analyses the North East of England as a comparator to the devolved countries, chosen because it shares many characteristics with them. Notable findings include:

  • The North East has benefited from higher investment than the average for England, now spending similar amounts to Scotland (£2,150 per head in 2012/13 compared to £2115 in Scotland, while the English average was £1,912).
  • The region saw marked improvements during the 2000s in treatment rates, hospital staffing, mortality rates and life expectancy.
  • In the 1990s, its overall mortality rates were similar to Scotland’s, but by 2010 these rates were 15 to 19 per cent higher in Scotland, compared to the North East. The region had similar life expectancy to Scotland in 1991, but by 2011 men and women lived a year longer than their Scottish neighbours.

Professor Gwyn Bevan from LSE’s Department of Management said:

"This report gives an account of the changing ‘natural experiment’ between the four health systems of the UK. 

“Before devolution, health spend per capita in Scotland was about 25 per cent higher than in England, but similar policies of provider competition applied throughout the UK. 

“The most recent data show similar health spend per capita in the North East of England and Scotland, but the system in the North East is designed for provider competition which has been absent in Scotland since 2004.

“The report also illustrates issues from the devolution settlement: the inadequacy of the Barnett formula, which is used to determine funding of public services, and differences in charges and entitlements between people living on different sides of national borders."

Andy McKeon, Senior Policy Fellow at the Nuffield Trust, said:

“Our study period coincided with the biggest sustained injection of cash the four health systems have ever seen, so it’s perhaps unsurprising that staff numbers have increased and performance has improved.

“But what is interesting is that, despite hotly contested policy differences in structure, targets, competition, patient choice and the use of non-NHS providers, no one country is emerging as a consistent front-runner on health system performance.

“The North East’s remarkable progress on reducing avoidable deaths and improving life expectancy suggest that local conditions, such as funding and the quality of staff are the real determinants of health service performance.

“Only time will tell if the four countries’ progress made to date will be sustained as austerity starts to bite. But Wales’s lengthening waiting times should set alarm bells ringing amongst policy makers when considering its possible impacts.”

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

“It is very good news for the public that the quality of health care is improving across the UK. But what is also humbling for politicians is that so far no one policy cocktail seems to be more effective than another on NHS performance.

“This is despite all the rhetoric about the benefits or otherwise of introducing competition among providers. Clear targets and effective performance management can produce results, for instance, reducing waiting times, but we do know that this regime will only work in a small number of areas of performance.

“The progress of the NHS towards better quality of care depends on local conditions as well as the level of funding available. There is no shortage of enthusiasm and talent in the NHS, particularly at the coal face. Supporting local clinical teams is likely to be the best long term strategy to improve the quality of care.”

Study leader, Professor Nicholas Mays, from the London School of Hygiene and Tropical Medicine, said:

“In analysing the health services in the four countries, we have had to rely on a limited and diminishing set of comparable data, which makes it ever harder to make meaningful comparisons. This risks leaving policy-makers in the dark when it comes to designing changes that lead to higher quality care.

“Better and more comparable data are not at odds with each country pursuing its own distinct policy agenda. Rather, routinely published comparable data should enable each to see how their policies are working as well holding them to account for the performance of their health services.”

For all media enquiries, contact the Press and Public Affairs Office at the Nuffield Trust: +44 (0)20 7462 0555, pressoffice@nuffieldtrust.org.uk|  

Editors' notes

  • The four health systems of the UK: How do they compare? is by Professor Gwyn Bevan (London School of Economics and Political Science), Marina Karanikolos (European Observatory on Health Systems and Policies and London School of Hygiene and Tropical), Josephine Exley (RAND Europe), Ellen Nolte (RAND Europe), Sheelah Connolly (Trinity College Dublin) and Nicholas Mays (London School of Hygiene and Tropical Medicine).
  • The report compares performance across 22 indicators, examining inputs and outputs, processes of care and outcome measures. These include public expenditure, numbers of GPs, nurses and hospital doctors, waiting times for common procedures, ambulance response times and mortality rates.
  • The indicators in the report stop by 2012/13 so the report cannot assess the impact of the 2012 Health and Social Care Act or any of the changes in response to the Francis Inquiry in England. or any of the changes in response to the in England.
  • The last comparative study, published by the Nuffield Trust in 2010, examined data up to 2006/7 and highlighted the English NHS as a clear front-runner.
  • The Health Foundation is an independent charity working to improve the quality of health care in the UK. It exists to support people working in health care practice and policy to make lasting improvements to health services. The Health Foundation carries out research and in-depth policy analysis, runs improvement programmes to put ideas into practice in the NHS, supports and develops leaders and shares evidence to encourage wider change.

11 April 2014

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