The four health systems of the UK: How do they compare?

This report assesses the performance of the NHS on the quality of patient care in all four UK countries since devolution.

Since political devolution in 1999, there has been increasing policy divergence between the health systems of the four countries of the United Kingdom (UK). This report attempts to update earlier comparisons of the publicly financed health systems of England, Scotland, Wales and Northern Ireland in terms of funding, inputs and performance before and since devolution.

It also includes comparisons with the North East of England, which has been chosen as a better comparator with the three devolved nations than England as a whole.

Wales’s lengthening waiting times should set alarm bells ringing amongst policy-makers when considering its possible impacts Andy McKeon, Senior Policy Fellow, Nuffield Trust

The four health systems of the UK: How do they compare? is authored by six leading health academics: Professor Gwyn Bevan, Marina Karanikolos, Jo Exley, Ellen Nolte, Sheelah Connolly and Professor Nicholas Mays. The team was led by Professor Nicholas Mays of the London School of Hygiene and Tropical Medicine.

The research is the only longitudinal analysis of its kind, building on a previous report published by the Nuffield Trust in 2010 and revised in 2011. That report presented three snapshots before and after devolution, with the most recent data being for 2006/07. This latest report gives trends over time for a wider range of performance indicators from the late 1990s to 2011/12, or 2012/13 where data were available.

The report is accompanied two appendices, which include all the data and reference material. Further analysis of the history of the devolution settlement and the health policies of the four countries will be included in an analysis by Professor Gwyn Bevan, to be published later in 2014.

A number of minor revisions have been made in response to issues identified  following publication of the original publications. These are summarised below.

Hospital activity data

After publication of the source and summary reports, the authors were notified of inconsistencies in the hospital activity data used. We are grateful to Martin Chalkley (University of York) for identifying these inconsistencies. As a result, we have sought to make the data comparable by requesting amended data from NHS National Services Scotland. In order to provide comparable data for all countries, the authors have used ‘spells’ data for ordinary admissions for all countries. Ordinary admissions exclude maternity and births, mental health and regular attenders. (The original publication included all specialties for inpatient admissions for England, Wales and Northern Ireland.) 

Accordingly, changes have been made to sections of the summary report, and Chapters 4 and 6 of the source report, which relate to hospital inpatient activity and productivity.  Also, the data definitions relating to inpatient activity have been amended in Appendix 1 of the source report. These changes have not affected the conclusions or recommendations of the report. 

Discussion of ‘Barnett consequentials’

The report explores the variation in health spending increases between the four countries and looks at the ‘Barnett consequentials’¬¬– the variations in block grants from the UK government to the devolved administrations arising from changes in central public spending. The published report combined these two. The updated version therefore clarifies that Barnett consequentials derive from the overall public spending total rather than health spend alone. 

Accordingly, changes have been made to the executive summary and Chapter 6 of the source report, and to the summary report.

UK Renal Registry citation

While providing a correct citation in the data appendix, the original versions of the summary and source reports referred incorrectly to the UK Renal Registry. This anomaly has now been corrected.



Suggested citation

Bevan G, Karanikolos M, Exley J, Nolte E, Connolly S and Mays N (2014) The four health systems of the UK: How do they compare? Research report. Nuffield Trust and Health Foundation.