By Jennifer Dixon, London School of Hygiene & Tropical Medicine
Health and healthcare policy have been a matter for the separate administrations in Scotland, Wales and Northern Ireland since devolution in the late 1990s. While there have been many similarities in the policies the four UK countries since then, there have been some very high profile differences.
For example, developing competition between providers has been championed in England but rejected in Scotland, Wales and Northern Ireland. The split of purchasing from the provision of care was reversed in Scotland and Wales, but kept in England and Northern Ireland. And in Scotland and Wales prescription charges were scrapped, and free personal social care made more widely available in Scotland.
But what effect, if any, have these policy differences had on overall performance? To find out, we at the Health Foundation along with the Nuffield Trust commissioned researchers from the London School of Hygiene and Tropical Medicine and the London School of Economics to measure performance against 22 indicators, including mortality rates (avoidable deaths), life expectancy and ambulance response times. Drawing on largely publicly available data up to 2011-12, and in some instances 2012-13, the subsequent report revealed some interesting results.
Of the four nations, England performed marginally better in a number of areas including mortality rates, life expectancy and ambulance response times. However, nurse staffing levels were lower than in the other three countries. In Scotland, waiting times for planned surgery were down (similar to England) as were ambulance response times.
Wales on the other hand did not do as well when it came to waiting times, which have deteriorated since 2010, particularly for common procedures such as hip or knee operations. The difference between the typical waiting time for one of these procedures in Wales in 2012-13, for example, was 170 days compared to just 70 in England and Scotland.
Northern Ireland has improved on most indicators, but MRSA mortality rates still remain higher than in both England and Wales.
What this means and for whom
Four major messages come from what we found. The first is for the public. On the national indicators analysed, there were improvements across all four countries in investment, staffing levels, amount of activity provided and health outcomes. This is good news, although there is clearly a marked variation in performance within each country.
The second is for politicians. The main message here is that while the overall set of policies is producing results, no one policy cocktail consistently produces faster improvements over another, despite all the rhetoric.
This may be because there are many more similarities in policies than differences across all four nations. Or that where there are policy differences, they haven’t yet made enough of a difference to show up in the indicators. Some humility then is needed by politicians of all political stripes; how the health systems perform seems to be influenced far more by a bigger set of forces.
However, the data suggests that there may be two exceptions, both of which can be influenced by politicians. One of these is funding: the study period coincided with a large growth in public funding for healthcare, which can be associated with the improvements seen in performance. However, between 2010-11 and 2012-13, Wales saw a reduction in spending, potentially the reason for the lengthening of waiting times.
The second exception is targets and performance management. The data suggest that clear targets and strong performance management – as in the case of waiting times and rates of hospital acquired infection – produce results. This seems to be the case in Scotland, where waiting times on a range of indicators show marked improvement, particularly over the last five years. And part of the reason why, in Wales, performance against the less-stringent targets for waiting times has dipped since 2010, may not just be because of changes in funding, but because of less emphasis on the English-style tight performance management.
This isn’t a message for politicians to let rip with a vast number of targets and go for a heavy grip. Too many targets demoralise staff, cause collateral damage (other local priorities pushed aside) and can lead to stressed staff altering the figures.
The third major message in the report is for local staff: the managers, nurses and doctors. More than anything, it looks as though performance of the health system is down to you. Our study looked closely at the performance of one region in England (the north-east) relative to Scotland, Wales and Northern Ireland, because it was more similar on a number of characteristics than England as a whole. In the north east of England, a combination of faster funding growth, plus local conditions, seem to have produced the most marked reduction in mortality over the last two decades.
The fourth message is for the treasury. Probably due, in part, to devolution, it is becoming harder to compare data across the four countries over time, as all four countries decide to define data differently. If achieving value for money in public services is an objective of the treasury, isn’t it time to exert some leverage to expect all four countries to collect and count data in the same way, as well as do it their own way?
The issue that looms large is the impact of large scale reforms of the health system of the type we have seen in England, with the implantation of the Health & Social Care Act. Received wisdom is that the disruption it has caused will produce a dent in the trend for improvement in England relative to the other UK countries. But we’ll have to wait for the next instalment of the study to find out.
Jennifer Dixon is Chief Executive of the Healthcare Foundation charity. She is also She is also a trustee of NatCen Social Research and a member of the Care Quality Commission (CQC) board.