Beyond the politics: the truth behind the UK health systems

Criticism of the Welsh NHS is a popular sport for English ministers. David Cameron takes regular pot shots at longer waiting times and failure to hit A&E targets.

To the politically cynical, it looks like a straightforward attempt to brand Labour, who governs in Wales, as a party that cannot manage the NHS.

It may also be an attempt to show that the ‘English’ approach to managing the NHS, with the development of a market, competition and a variety of private, voluntary and other providers, is producing better results than that in Wales which abolished the ‘internal’ market in 2009 and makes little use of private providers.

Not surprisingly, Welsh Ministers have responded in kind, with the Health Minister calling the English NHS ‘a shambles’.

But beneath the yah-boo froth of politics, what is the truth of comparisons across the UK, and what does it mean for the future of the NHS?

The Nuffield Trust and the Health Foundation today published the results of an independent investigation into performance of the four UK countries over the past 15 years since devolution began. On the indicators available, three key points emerge.

Using these comparators, it is clear the impact so far of competition in England has been over-hyped – both ways

First, devolution has brought different decisions about funding levels, priorities and targets. Yes, patients wait longer in Wales, and Northern Ireland, partly because the targets set were less demanding than those for England.

Waiting times significantly lengthened in Wales after 2010 (they have too in England but only a little) as austerity set in and the Welsh Government, alone amongst the four countries, decided not to protect NHS spending but to cut it by roughly one per cent a year in cash terms.

Second, more general measures of performance like the number of preventable deaths and in stroke care show Wales moving in line with England but not closing the historical gap. Indeed, this is also true of Northern Ireland. On other indicators in the report, the longer term trend across the four countries is one of improvement and convergence, even if historical differences remain. But then inequality gaps have proved notoriously hard to close in England.

Third, Scotland’s performance on waiting times (and other areas) matches that of England having been significantly longer in the early 2000s. They abolished the purchaser provider split in 2004 and make little use of the private sector, but they crucially introduced more exacting targets backed up by tougher performance management.

The message from this study is that targets and performance management, which all four countries use, work but outside this, whatever the chosen approach to structure and governance, the overall rate of improvement in health care looks broadly similar.

Using these comparators, it is clear the impact so far of competition in England has been over-hyped – both ways. It has neither been as positive nor as negative as people on either side of the argument portray. Maybe it will in the future but the jury is out.

There are deeper issues at work to which politicians in all four countries would do well to pay attention.

The quality, quantity and stability of staff at a local level are crucial. The report shows that the North East has made significant progress on improving health care. They have had more money over the past decade than many other English areas and so have more doctors and nurses. But they also have a more stable high quality workforce than say London and the South East, helped by national pay rates.

Issues of recruitment and retention, including relative pay, numbers and skills all demand more attention nationally than they currently receive.

Supporting the workforce is also critical. Politicians like to have battles to fight to show their reforming zeal. Challenge is sometimes essential. But most progress for patients will be achieved by spreading learning of what works, making sure everyone from ministers to professionals and patients are working to the same goals, and measuring the outcomes that matter most to patients.

This is how care for the increasing number of frail elderly people and those with chronic illnesses will be improved. Financial wheezes, incentives and reorganising management structures will largely be at the margins.

Finally, money matters. The English NHS looks likely to hit the financial buffers soon. The Welsh cut in health spending over the last three years may be a lesson in what can happen. Continued zero real terms growth in health spending for the next five years will certainly see a deteriorating and crisis-ridden NHS.

This article was first posted on The Guardian’s Comment is Free website.