What cycling can teach the devolved NHS about working as a group

Last month I got up unpleasantly early on a Sunday morning, met up with a small group of fellow cyclists and went for a long(ish) ride around some very scenic – and extraordinarily cold – country lanes.

The dynamics of cycling in a decent size group are moderately interesting: the cyclist at the front bears the brunt of the wind, but provides shelter for everyone behind them. By working together – with everyone taking their turn on the front, then having a rest – the group can ride substantially faster than they would have done individually. It’s why competitors in the Tour de France usually congregate together in an enormous group.

This got me thinking – once I’d got my breath back – about some of the findings of the recent OECD analysis on the state of quality in the four countries of the UK.

Health is a devolved policy area in the UK. There are – unsurprisingly – some important differences in how each country has chosen to organise its national health service. But if I ever had to explain the NHS to a Martian, I’d probably start by talking about comprehensive health care services available to everyone, based on need not ability to pay, free at the point of delivery and primarily funded from taxation.

It’s these fundamental principles that arguably mean the four NHSs have more in common with each other than with most (though not all) of the health systems in other countries. The OECD also highlights all four countries’ commitment to improving quality in the face of rising demand and financial constraints.

That’s the good news.  There is also, however, some bad news. The OECD also highlights the lack of any standing mechanisms to facilitate that learning and collaboration. We may often speak of learning from international comparisons, but – despite comparable health systems and a common language – there tends to be much less talk of intra-national comparisons.

Part of the reason we don’t is what the OECD describes as the ‘surprisingly limited’ number of comparable quality indicators between the four countries. This echoes earlier research, published by the Health Foundation and Nuffield Trust, into how the performance of the four health services have fared since health policy became a devolved matter in the late 1990s.

There are examples of countries that can meaningfully compare performance between their sub-national health systems.

The Canadian Institute for Health Information collects and publishes data comparing performance across the country’s ten provinces, each of which has its own health system. It also produces some very nice looking interactive graphs, including this one on waiting times.

In Germany, a federal committee (the Gemeinsamer Bundesausschuss, or G-BA) requires all hospitals that provide care funded by statutory health insurance to report performance against around 300 quality indicators.

I’m not suggesting for a moment that the UK adopt the German or Canadian model of intra-national quality comparisons. Context is hugely important and blithely assuming that something cut and pasted from country A will achieve the same results in country B is a common pitfall of international comparisons.

But why hasn’t the UK developed its own distinctive way of doing things? Well, there’s undeniably a political dimension to intra-country comparisons.  In Wales, for example, media coverage of the OECD report was reported in the context of a difference of opinion between English and Welsh health ministers about the performance of their respective health services.

I suspect – though I claim no insider knowledge of this – the main culprit is more likely to be the time and effort needed to make such comparisons meaningful: perhaps it’s just not been a big enough priority for all four countries.

And that’s a pity, because the OECD report is a reminder that there’s more to unite us than separates us, and that there remains enormous potential for health policymakers in England, Northern Ireland, Scotland, and Wales to learn from each other’s successes and failures.

Tapping that potential will require mutual trust and reciprocity. In cycling, working together as a group is almost a default position, though it rarely lasts for long if people aren’t willing to take their turn on the front. When that trust and reciprocity is there, however, everyone gets to go faster. 

Tim Gardner is Senior Policy Fellow at the Health Foundation.