Inspiration close to home

In this comment piece, Dr David Steel, former chief executive of Quality Improvement Scotland, welcomes the Nuffield’s new report on learning from Scotland’s NHS, and gives his take on why it’s worth looking north of the border.

Blog post

Published: 05/07/2017

The Nuffield Trust’s new report, Learning from Scotland’s NHS, is to be warmly welcomed from at least two perspectives – both important to me personally. Since retirement in 2009, I have sought to contribute to comparative studies of the four different health systems in the UK, and for 10 years before that I led the organisations responsible for putting in place the distinctive approach adopted in Scotland to quality and safety in health care.

Four health systems in the UK: an underexploited field laboratory

Over the last 30 years there has been increasing divergence in the four health systems in the UK. While they all share common principles, they have adopted very different structures and processes, and some significant differences in policy have emerged. The NHS has therefore become a field laboratory that is ideally suited for comparative analysis and cross-border learning. However, the former has been limited and the latter almost non-existent.

Quantitative analysis of comparative performance has proved very difficult, not least because of differences in the way data are defined and collected and, when it has been attempted, such as in the Nuffield’s reports in 2010 and 2014, the validity of some of the data and thus the conclusions drawn have been challenged. With a few exceptions, such as Nick Timmins’ King’s Fund paper in 2013, so-called comparative analysis has amounted to little more than descriptions of each system and of the differences among them.

The Nuffield’s latest contribution, focusing on four themes (quality improvement, integration, workforce and finance), makes a significant stride in the right direction. It is based on both qualitative (including 24 interviews with academics, health service managers and senior officials) and quantitative data, and there is a real attempt to learn lessons and to assess their wider relevance and the scope for transferability across borders.

Will policy-makers and practitioners listen and learn?

Whether it will succeed in encouraging learning and, where appropriate, transplantation, is much more difficult to gauge. Over my NHS career – seven years in England and 23 in Scotland – and since I have been struck by the limited interest in what is happening in the rest of the UK (in marked contrast with enthusiasm for learning about developments further afield, such as in the USA, Scandinavia or Australia), despite fundamental differences in health systems and in the context in which they operate.

As this report demonstrates, context is also important within the UK but, in health care as in many other areas, ‘we have far more in common with each other than things that divide us’.

A particular gripe – which is my second reason for welcoming this report – is the tendency in England to caricature Scotland (and, particularly in recent years, Wales) as basket-cases, wedded to the past and impervious to change. Similarly it is all too common for the commentariat to reject out of hand approaches that do not conform to current conventional wisdom, without first evaluating in detail why they have been adopted and how they operate in practice. A recent example is criticism by the OECD’s Reviews of Health Care Quality: Raising Standards of the combination in Scotland of responsibility for scrutiny and improvement in a single organisation.

This new report redresses this omission, and hopefully this will give it greater impact upon policy-makers and practitioners than previous exhortations, for example in the King’s Fund’s 2016 Quality Improvement in the English NHS, to look north for inspiration.

Nor are policy-makers and researchers from Scotland free from blame. All too often there has been a blind faith and smugness that what happens in Scotland is best, and a hyper-sensitivity to criticism from beyond Hadrian’s Wall.

The report addresses this too, by presenting – alongside the benefits of the approaches adopted in Scotland – a balanced assessment of the drawbacks, of the performance of the system in Scotland relative to the rest of the UK, and of any opportunity costs, for example in terms of challenges ducked.

Fit for the future?

The report, rightly in my view, highlights the benefits that flow from policy continuity and institutional stability in Scotland, but recognises that it has not stood still. Rather, change has occurred incrementally with policy evolving, building upon what exists already rather than sweeping it away.

However, this must be a continuing process – where we are now is a staging point not a destination. It is important therefore to assess how well the Scottish system or indeed any other is tackling emerging challenges such as spreading and sustaining improvements, and apply them beyond what have traditionally been regarded as the boundaries of health care – and how well fitted it is to face future challenges that are not yet fully recognised.  

The Nuffield Trust is to be applauded for its intention to do more of this kind of comparative work, and it is well placed to promote debate with practitioners about cross-border learning. Hopefully this report will also encourage other researchers to take advantage of the opportunities the UK now presents, and it will stimulate practitioners to be more open to learning from the experience of their near neighbours, by facilitating comparisons (such as by adopting consistent data definitions), by becoming less sensitive about the conclusions that are drawn, and by showing greater willingness to share and adopt approaches that have been shown to work elsewhere.   

Please note that views expressed in guest blogs on our website are the authors' own and do not necessarily reflect the views of the Nuffield Trust.

Suggested citation

Steel D (2017) ‘Inspiration close to home’. Nuffield Trust comment.