This is the first in a new series from the Trust looking at each of the four health services of the UK in a detailed and qualitative way, while asking what lessons they hold for the other countries.
It looks at how health care in Scotland is different, where its approach seems to solve problems being faced elsewhere in the UK, and whether that approach could be transplanted to England, Wales and Northern Ireland. It also assesses whether there are areas where Scotland could learn from its peers.
- Scotland has a unique system of improving the quality of health care. It focuses on engaging the altruistic professional motivations of frontline staff to do better, and building their skills to improve. Success is defined based on specific measurements of safety and effectiveness that make sense to clinicians.
- Scotland’s smaller size as a country supports a more personalised, less formal approach than in England. The Scottish NHS has also benefited from a continuous focus on quality improvement over many years. It uses a consistent, coherent method where better ways of working are tested on a small scale, quickly changed, and then rolled out. This is overseen by a single organisation that both monitors the quality of care and also helps staff to improve it.
- While comparing performance is very difficult, Scotland has had particular success in some priority areas like reducing the numbers of stillbirths. Scotland’s system provides possible alternatives for an English system with a tendency towards too many short-term, top-down initiatives that often fail to reach the front line. It also provides one possible model for a Northern Irish NHS yet to have a pervasive commitment to quality improvement, and a Welsh system described as needing better ways to hold health boards to account while supporting them in improving care.
- While Scotland also faces particular issues of unequal health outcomes and very remote areas, there are pioneering initiatives to address these, and should be considered in other parts of the UK facing similar issues.
- Scotland has a longer history of drives towards making different parts of the health and social care system work together. It has used legislation to get these efforts underway, while recognising that ultimately local relationships are the deciding factor – there is much for England and Wales to learn from this.
- However, like other UK countries, Scotland has struggled so far to move care out of hospital. There will be a need for Scottish health service leaders and politicians to face up to the difficult and unpopular decisions this may require, and to be ready for some initiatives not to work.
- The Scottish NHS faces a serious financial predicament. The need for savings is at least as great as for other UK countries, and health boards are struggling to find ways to deliver them. Limited national planning for the next few years and a polarised, hostile political context make an honest national debate difficult. While the strengths of the Scottish NHS could help it to save money, there is also a risk that they are undermined by the intense financial squeeze.
We plan to study the Welsh and Northern Irish health services in a continuing series of papers asking what each country can teach each other.
Dayan M and Edwards N (2017), Learning from Scotland’s NHS. Research report. Nuffield Trust.