Has devolution improved NHS performance?

Health and health care policy have been a matter for the devolved administrations in Scotland, Wales and Northern Ireland since devolution in the late 1990s. Among the cocktail of policies pursued across all four UK countries since then, there has been much similarity but also some 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 the overall performance of publicly funded health care?

To try and answer this question, 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 find out. The report, The four health systems of the United Kingdom: how do they compare?, shows the results of analysing data up to 2011/12, and in some instances 2012/13. The 22 indicators examine health inputs, processes and outcomes of care, drawn largely from publicly available data.

There are four major messages…

The first is for the public. On the national indicators analysed, there have been improvements across all four countries in investment, staffing levels, amount of activity provided and health outcomes. This is good news, although there is clearly marked variation in performance within each country.

The second is for politicians. The main message here is that the overall set of policies is producing results, but no one policy cocktail consistently produces faster improvements over another, despite all the rhetoric. This may be because the similarities in policies vastly outweigh the differences across all four nations. Or it could be that where there are differences in policies, they do not yet reach a therapeutic dosage across the nation as a whole to show up in the indicators examined in this study. Some humility then is needed by politicians of all political stripe – how the health systems perform seems to be influenced far more by a bigger set of forces.

However, the data suggest that there may be two exceptions, both of which are within the politicians’ tool box. First, funding: the study period coincided with a large growth in public funding for health care – associated with the improvements observed. However, between 2010/11 and 2012/13, Wales has seen a reduction in spending and a potentially associated lengthening of waiting times. The typical wait for a hip or knee replacement in Wales is now 170 days compared to about 70 in England and Scotland.

The second exception – 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. 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 heavy grip from the centre. 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: managers and clinicians. More than anything, it looks as though performance of the health system is down to you. The study looked closely at the performance of one region in England (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 seems to have produced the most marked reduction in mortality over the last two decades. Support for local staff to do a better job must be a crucial policy going forward.

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 elephant in the room in the analysis 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 in England. Received wisdom is that the disruption will produce a dent in the trendline 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 is Chief Executive of the Health Foundation, www.twitter.com/JenniferTHF