The NHS – is it truly national?

The Nuffield Trust’s report into the state of the NHS since devolution has painted a picture of a health service that has fragmented across the four nations.

The Nuffield Trust’s report into the state of the NHS since devolution has painted a picture of a health service that has fragmented as governments in London, Edinburgh, Cardiff and Belfast take differing policy decisions on the provision of health services, starkly highlighted yesterday by the decision by NICE not to approve for use in England and Wales a drug for the treatment arthritis that is available in Scotland, as reported by Left Foot Forward.

The report, the first of its kind, also comes in the wake of the debate on how best to tackle alcohol abuse and binge drinking, which Left Foot Forward examined on Monday. Nuffield undertook an assessment of NHS performance across the UK at fixed points in 1996/7, 2002/3 and 2006/7, using indicators such as expenditure, staffing levels, activity, staff productivity and waiting times.

Key findings include:

• Despite Scotland, Wales and Northern Ireland having the highest per capita spending on health, it is England that “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”, despite having spent less and having fewer doctors, nurses and managers per head of population;

• Although it has the highest rates of spending, highest numbers of hospital doctors, GPs and nurses per capita, Scotland – which has the poorest health – had the lowest rates of staff productivity and lowest rates of inpatient admissions per head of population in 2006/7;

• In 2006, Wales had the lowest rates of day cases but the highest rates of outpatient admissions, whilst Northern Ireland had the lowest rates of outpatient attendances but the highest rates of inpatient admissions and day cases; and

Wales and Northern Ireland have performed poorly on waiting times compared to England. It was not possible to compare Scotland as waiting times North of the border are measured in a different way.

Commenting on the report, the Nuffield Trust’s Director, Dr Jenifer Dixon, said:

“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.”

However, Dr Hamish Meldrum, Chairman of the British Medical Association, cast doubt over the ability to measure performance in this way. Dr Meldrum said:

“Measuring the performance of any health system, and achieving meaningful comparisons with others, is always difficult.

“While ‘productivity’ is important, it is by no means the only measure of how well the NHS is performing.”

Unsurprisingly, reaction to the report has been mixed.



The NHS in Scotland was reported to have has the lowest productivity of the UK, with the lowest admission rates, despite Scotland having the poorest health. Responding to the report, a spokesperson for the Scottish Government said:

“This report is based on data that’s at least three years old and is out of date. Since then there have been significant improvements in NHS Scotland’s performance.

Defending NHS Scotland’s performance, SNP Health Secretary Nicola Sturgeon said:

“Some of the challenges NHS Scotland faces are unique certainly in a UK context such as some of the more deep-seated issues of deprivation and ill health and of course our dispersed geography.

“Now these are not excuses for bad performance, but they do mean that it is not always possible to make crude comparisons between one part of the UK and another.”

Mindful that the period covered by the report was one that saw Labour leading a coalition government at Holyrood, Shadow Health Secretary Jackie Baillie said:

Scotland has the unenviable record of having some of the highest levels of poor health across the UK. It is therefore not surprising that we spend more to address the consequences of that poor health.”



In Wales, criticism was levied against the methodology used by the Nuffield Trust. Mike Ponton, Director of the NHS Confederation in Wales, said:

“The report measures performance in terms of productivity, but this method misses out much of what the NHS does and fails to measure what really matters – the quality and safety of care. High levels of activity, such as in-patient admissions or outpatient attendances, are not necessarily a good thing.

“What really matters is keeping people healthy and out of hospital – what we want to see is reduced hospital attendances and admissions. More sophisticated methods are needed to measure the quality of care, whether the patient is made to feel better, and whether they are satisfied with their treatment – not how many times they have turned up at the hospital doors.”

Defending the Assembly Government’s record on health, a spokesperson said:

“Despite being based on data from 2006, when we were at the start of a major drive to reduce waiting times, it is encouraging to note that the report acknowledges that the NHS in Wales is leading the way and making significant steps to improve patient services and health care – most notably with the introduction of free prescriptions and the refocus of organisations to meet the needs of the population.

“However, despite this overall acknowledgement of our progress, much of the report is dated, and therefore does not accurately reflect the NHS in Wales today. Five years ago, we had in excess of 100,000 patients in Wales waiting over six months for treatment. Of these, almost 8,000 patients were waiting over 18 months for definitive treatment.

“The latest figures show that during November, more than nine out of 10 patients were treated within 26 weeks from initial referral to start of definitive treatment, with many patients treated far quicker than that, and 98% of patients waiting were waiting less than 26 weeks.”

Conservative Health Spokesman Andrew R T Davies was not quite so positive. He said:

“Patients and staff have long had concerns that too much money is wasted on bureaucracy and not enough is reaching the frontline, where it could make a significant difference to the experiences of patients.”


Northern Ireland

On Northern Ireland, one of the report’s authors, Professor Nick Mayes of the London School of Hygiene and Tropical Medicine, said:

“Northern Ireland for a long time has had higher spending, more resources, more beds, more doctors, more nurses, more GPS and tends to have longer waiting times and lower levels of productivity as measured by the relationship between the number of staff and what we measure in terms of the services delivered.”

Defending its record, a statement from the Department of Health in Belfast stated that the review included Personal Social Services, and that:

Therefore, to compare like with like, it is necessary to reduce the figure of 9.4 (managers) per 1,000 of to 6.6 per 1,000 of the population. With the implementation of the Review of Public Administration, this figure will fall to below 6 per 1,000 of the population. This is less than the Scottish figure and in line with that reported by Wales.”

In November, Left Foot Forward reported the remarks by DUP Finance Minister, Sammy Wilson, that there was scope for greater productivity within the health service in Northern Ireland.

Whilst the Nuffield Trust’s report paints a picture of a fragmented NHS across the UK, its findings could perhaps be just the tip of an ice burg. As BBC Wales Health Correspondent Hywel Griffith concludes:

“Perhaps the most salient part of the report deals with the future rather than the past. Its authors warn that the years of feast in spending on health across the UK could be followed by relative famine – making it harder than ever for Wales, Scotland and Northern Ireland to catch up.

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7 Responses to “The NHS – is it truly national?”

  1. tim

    Sadly the devolved admins have in Wales and Scotland inparticular have concentrated on grandstanding issues such as prescritpion charges, car parking and flagship expensive drugs as a way of bolstering political support at home.

    Meanwhile money is flushed down the toilet in Wales on cervical cancer screening for under 25’s rather than getting waiting lists down, and Scotland still can’t do routine 20 week scans on all pregnant women, but regards ludicrously expensive untested drugs as a flag of pride.

  2. ANiN

    After Labours privatisation and fragmentation of the NHS there is little sense of any NHS left.

    No wonder UNISONS polling amongst Health Workers finds more more will vote against Neo Liberal Labour or not vote than vote for it.

    Labour has privatised NHS services even Thatcher would not touch

    Health Workers are sick of Labours continous attacks on jobs,pay,conditions, stewards and now pensions and massive cuts in public services. So typical of Blue Labour

    Labours a bunch of corrupt, rightwing,, Neo Liberal, warmongering, privatisers

    The Unions should cut the link with Labour
    whats the point of paying Labour to privatise and outsource our jobs destroy our pensions and use the private and voluntary sectors to undermine our pay and our Union organisation?

    Apart from the morality of funding a Party that is covered in the blood of 1000,000 Iraqi civilians

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  5. Alex Flamson

    It emerges today that the Nuffield’s figures over-estimated the number of doctors in Scotland by 27% which of course will grossly distort any attempt to look at efficiency there.

    This assessment also doesn’t mention that patients in Scotland were the most satisfied with the service they’d received (one of the only stats not affected by the over-estimation of doctors) or that hospitals in England receive more funding by booking more appointments, while the Scottish system is not incentivised to get people out of beds as soon as possible, or the fact that London was “put to one side” when considering England’s figures as it was atypical of English regions.

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