Would the NHS be different if you lived somewhere else in the UK?

Think of the NHS. What first springs to mind?

Would it be different, do you think, if you lived somewhere else in the UK?

If you thought of a comprehensive health service free at the point of access then no. However, if you thought of clinical commissioning groups you are probably reading this in England; the NHS exists in four countries, each with distinct political, structural and cultural contexts. Does this mean there are four different national health services or one NHS that manages homogeneity despite devolution?

A quick summary of the political contexts in each country

All of the devolved nations’ governments that were up for election on 5 May have won another term; Scottish National Party in Scotland, Labour will lead the Welsh Assembly and the Democratic Unionists and Sinn Fein reappointed their First Minister and Deputy First Minister (respectively) in Northern Ireland. This offers some continuity to each ‘devolved’ NHS for the next five years. In England there has also been relative political continuity (from Conservatives in coalition to having a majority government) although individual Ministers have had distinct approaches meaning very different relationships between Whitehall and the NHS. 

If you look back at the manifestos of the reappointed devolved nations’ governments they covered the usual suspects: money, primary care, mental health and workforce. There weren’t any pledges for transformation of the NHS, in fact consistency and consensus were the menu of the day on 5 May. Last month our series of blogs looked at what the party manifestos might mean for health in Scotland, Wales and Northern Ireland. Now that the dust is settling, we have invited guest bloggers to give their perspectives post-election. Mark Hellowell talks about what the election results mean for Scotland and next week Dan Bristow will do the same for Wales. Lourda Geoghegan will also be sharing her views once the programme for government has been agreed in Northern Ireland.

So, one NHS or four?

Culturally, things do seem different across the UK. Ten years in to devolution, Greer and Rowland (2007) reported a commitment in Scotland, Northern Ireland and Wales to ‘communities and participation’ rather than ‘markets and technical solutions’ in England. That cohesion of policy ideology and collaboration made possible by small systems remains tangible and striking almost 20 years in.

Structurally things are also different across the UK. Northern Ireland and England use a commissioner provider split to plan and deliver services while in Scotland and Wales this doesn’t exist. There are fewer layers between government and the NHS in the devolved nations -if you were to draw the systems on a page, undoubtedly England would have the most complicated picture.  

In Northern Ireland and more recently in Scotland the framework of the NHS should help promote integration across health and social care. Language is similar but the terms are shorthand for the different architecture in each country and mean translation is often required to talk about the UK’s NHS; where would you go to get a definition of an English health and wellbeing board, Northern Irish health and social care board, Scottish integration board and Welsh health board?

But do these differences mean different outcomes, different challenges?

I think we can get caught up in the ‘natural experiment’ devolution provides and forget that all UK countries are trying to provide an NHS based in common roots and values, to populations with broadly similar demographics.

Talking to people involved in NHS policy across the UK similar issues crop up; population health, inequalities, money, changing demographics and high demand. The recent report from the OECD (The Organisation for Economic Co-operation and Development) comparing UK health systems showed that although there are some differences, the similarities between the systems prevail. Tim Gardner discusses this further in his blog this month.

Mark Hellowell and Katherine Smith also highlight how countries can learn from each other, they discuss the different approaches countries are taking to using pricing and taxation to improve public health.

It’s too early to say how structural integration is working in Scotland but in our interview with Bernadette O’Connor this month she says that being part of an integrated health and social care trust in Northern Ireland didn’t remove the challenges of different budgets for acute and community services. However, it does seem to be encouraging a more holistic and integrated approach when it comes to quality improvement. The fact that the overall strategic direction and management of health and social care is in the hands of one body has created an opportunity to involve social care and acute service professionals in improvement work in a way you don’t find elsewhere in the UK. South Eastern Health and Social Care Trust is the first provider in the UK to deliver quality improvement work in social care contexts through its Safety, Quality and Experience programme.

So back to my initial question, what did you think of? Having recently had two children, I think of the incredible midwives who helped me deliver them at home. I’m hedging my bets and guessing you also thought of something that could be applied across the UK, to ‘the’ NHS (if it wasn’t, I’d love to know what it was). There is such an appetite at the moment for change, even transformation of the NHS, it would seem a shame to get lost in the differences and not tackle the difficult issues and celebrate the solutions collectively.

Emma Ryan is Policy Fellow at the Health Foundation