London School of Hygiene & Tropical Medicine

The study found that there have been significant improvements in the performance of the health services across all four countries, with particular progress linked to tougher sanctions and targets in Scotland from 2005, but since 2010 waiting times in Wales have risen as austerity has set in.

Since political devolution in 1999, there has been increasing policy divergence between the health systems of the four countries of the UK.  This raises questions as to whether health system performance is improving and at the same or different rates across the UK as a result.

The new report finds that the performance gap between the NHS in England and in the rest of the UK has narrowed in the last decade with no country consistently ahead of the others. Differences in policy, such as England's greater emphasis on patient choice and the use of private sector providers, and the rejection of competition in Northern Ireland, Scotland and Wales, have not yet seemed to produce obvious differences in performance at the system level.

Report lead author, Professor Nicholas Mays from the London School of Hygiene & Tropical Medicine, said: "What is interesting is that, despite hotly contested policy differences in structure, targets, competition, patient choice and the use of non-NHS providers, no single country is emerging as a consistent front-runner on health system performance.   There is little obvious sign of the benefits or otherwise of introducing competition among providers in England.  By contrast, it is clear that targets and effective performance management can produce results, for instance, in reducing waiting times.  England and Scotland both show this.  However, this regime will only work in a small number of areas of performance."

The report is based on in-depth analysis of around 20 indicators, comparing the performance of the four UK publicly financed health systems over the past two decades.

On spending on healthcare, the study finds:

• All countries substantially increased investment in their health systems doubling in cash terms (not adjusted for inflation) the amount spent on healthcare across the UK between 2000 and 2013 and investing in more staff. Nurse staffing levels have been lower in England than in the other three countries over the period studied.  Spending across the board has slowed since 2010 in response to austerity.
• There have been divergent spending decisions, with Scotland spending almost £900m from the money notionally available for health on other services including free personal care for older people and Wales spending around £450m on other services.

And on health care performance:

• England performs marginally better across a number of key indicators, including avoidable mortality rates, life expectancy and ambulance response times. But on a number of indicators the gap has narrowed and differences between the countries are often small.
• Scotland shows a marked upturn in performance on indicators associated with targets and performance management, such as waiting times (which now broadly match England's) and ambulance response times.
• Wales demonstrates improved performance on a number of indicators, but showed deteriorating performance on waiting times since 2010, with striking rises in waits for common procedures such as knee or hip operations. In 2012/13 a typical Welsh patient waited about 170 days for a hip or knee replacement compared to about 70 days in England and Scotland.
• Northern Ireland has improved performance on most indicators, but MRSA hospital infection rates remain higher than both England and Wales.

The authors also highlighted the importance of improving the range of comparable data that are collected in the future. Professor Nicholas Mays said: "In analysing the health services in the four countries, we have had to rely on a limited and diminishing set of comparable data, which makes it ever harder to make meaningful comparisons. This risks leaving policymakers in the dark when it comes to designing changes that lead to higher quality care. It is therefore important to continue to have routinely published comparable data, so that each country is able to see how their policies are working, and can be held to account for the performance of their health services."

Publication

• 'The four health systems of the UK: How do they compare?' by Gwyn Bevan, Marina Karanikolos, Jo Exley, Ellen Notle, Sheelah Connolly and Nicholas Mays. Published by the Nuffield Trust and Health Foundation.