Some UK countries spending more on the NHS but delivering less, finds major new Nuffield Trust report

A unique analysis published today of the performance of the NHS across the four countries of the UK before and after devolution has found striking differences in performance with some countries spending more on health care and employing greater numbers of health staff but performing worse when it comes to a range of indicators, such as waiting times and crude productivity of staff.

The report by the independent health charity the Nuffield Trust examines the performance of the health services in England, Scotland, Wales and Northern Ireland across three time points – 1996/7, 2002/3 and 2006/7. It also examines the performance of the ten English regions and compares them with the NHS in England as a whole and the NHS in each of the devolved countries in 2006/7. This is the first time such an analysis has been conducted. Performance was tracked against a number of key indicators, including expenditure, staffing levels, activity (outpatient appointments, inpatient admissions and day cases), crude productivity of staff and waiting times.

The main findings are:

• Historically Scotland, Wales and Northern Ireland have had higher levels of funding per capita for NHS care than England. However, the research suggests the NHS in England spends less and has fewer doctors, nurses and managers per head of population than the health services in the devolved countries, but that it is making better use of the resources it has in terms of delivering higher levels of activity, crude productivity of its staff and lower waiting times.
• Scotland has the highest levels of poor health, the highest rates of expenditure, the highest rates of hospital doctors, GPs and nurses per capita, and yet it has the lowest rates of crude productivity of its staff and the lowest rates of inpatient admissions per head of population in 2006/7.
• In 2006, Wales had the lowest rate of day cases but the highest rate of outpatient attendances, while Northern Ireland had the lowest rate of outpatient attendances but the highest rate of inpatient admissions and day cases.
• The performance of Wales and Northern Ireland in key measures of waiting has been poor compared with England (Scotland’s waiting times could not be compared with those of England, Wales and Northern Ireland at the three time points because they were measured in a different way). By 2006, virtually no patients in England waited more than three months for an outpatient appointment, whereas in Wales and Northern Ireland 44 per cent and 61 per cent of patients did. By 2006, virtually all patients in England who needed inpatient or day case treatment were seen within six months, while in Wales and Northern Ireland 79 per cent and 84 per cent of patients waited longer than this.

Dr Jennifer Dixon, Chief Executive of The Nuffield Trust, said: ‘A key question for the NHS in all four countries, especially in the current economic climate, must be whether or not value for money is being obtained. While this research suggests that efficiencies can be made in health services throughout the UK, the marked differences in crude productivity of staff in the three devolved nations relative to England raise challenging questions.

‘Some of the differences and trends may be because of the historical differences in funding levels, which are not directly related to policies implemented after devolution. But some will reflect the different policies pursued by each of the four nations since 1999, in particular the greater pressure put on NHS bodies in England to improve performance in a few key areas such as waiting and efficiency, via targets, strong performance management, public reporting of performance by regulators, and financial incentives.

‘We believe the research raises important questions about the efficiency of care across the devolved nations. There is a lack of comparable data that allow differences in performance across the UK to be analysed in depth in future. Without such comparable data, UK taxpayers and HM Treasury cannot know whether they are securing value for money for their health services.’

The report found that the differences in performance on waiting times and staff productivity are more pronounced when the devolved nations are compared with regions of England that are similar on a range of health and socio-economic indicators. Putting London to one side, which distorts the national averages of staff productivity for England*, the devolved nations are still outliers on waiting times and staff productivity relative to English regions that are most similar to them on a range of health and socioeconomic indicators.

For example, the North East of England provides a good benchmark for comparisons with Scotland. In 2006 for a population of 100,000, expenditure in Scotland would have been about £180m, compared to £170m for the North East region. Yet Scotland’s six per cent of additional funding resulted in 14 per cent more hospital doctors (250 to 180) and GPs (81 to 71), nearly 50 per cent more nurses (1,100 to 740), and nearly 75 per cent more managers and support staff (730 to 420). Despite its lower level of expenditure and staffing, the North East region compared with Scotland delivered 18 per cent more outpatient attendances (105,000 to 89,300), almost 40 per cent more day cases (10,500 to 7,600) and more than 50 per cent more inpatient admissions (20,700 to 13,500). Consequently, the staff in the North East had far higher levels of crude productivity than in Scotland.

The report looks only at statistics that can be measured in the same way in the English regions and the devolved countries at three selected time points. It is possible that the comparative statistics that are available fail to capture some important dimensions of performance. The report recommends that other dimensions, such as staff and patient experience and health outcomes, should therefore be the subject of further research. However, it also concludes that previously published studies do not point to consistent higher levels of quality of care in the devolved nations that might partly offset the lower crude productivity levels of staff relative to England.