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The four health systems of the United Kingdom How do they compare?

April 2014

About 3 mins to read
  • Gwyn Bevan
  • Marina Karanikolos
  • Jo Exley
  • Ellen Nolte
  • Sheelah Connolly
  • Nicholas Mays

Key points

  • It does not seem that the increasing divergence of policies since devolution has been associated with a matching divergence of performance.
  • There is little sign that one country is consistently moving ahead of the others.
  • In relation to measures such as amenable mortality, the pre-devolution differences seem to have changed relatively little while overall rates of amenable mortality have been falling. During the 2000s, the relative decline in amenable mortality was similar between the four countries.
  • There are signs of a convergence in performance between the four UK countries, perhaps as a result of cross-border comparison and learning.

This report, published by the Health Foundation and the Nuffield Trust, assesses the performance of the NHS on the quality of patient care in all four UK countries since devolution.

Since political devolution in 1999, there has been increasing policy divergence between the health systems of the four countries of the United Kingdom (UK).

This report attempts to update earlier comparisons of the publicly financed health systems of England, Scotland, Wales and Northern Ireland in terms of funding, inputs and performance before and since devolution. It also includes comparisons with the North East of England, which has been chosen as a better comparator with the three devolved nations than England as a whole.

This report gives trends over time for a wider range of performance indicators from the late 1990s to 2011/12, or 2012/13 where data were available.

Accompanying report

In September 2014 an accompanying report was published, providing policy context. The impacts of asymmetric devolution on health care in the four countries of the UK looks at how each country's health care system has fared before and after devolution.

Infographic: Five things you need to know about the UK health systems

We have produced an infographic pulling out the key stories from the report:

Slide set

This slide set pulls together the top line messages and findings from the research.


A number of minor revisions have been made in response to issues identified following publication of the original publications. These are summarised below.

Hospital activity data

After publication of the source and summary reports, the authors were notified of inconsistencies in the hospital activity data used. We are grateful to Martin Chalkley (University of York) for identifying these inconsistencies. As a result, we have sought to make the data comparable by requesting amended data from NHS National Services Scotland. In order to provide comparable data for all countries, the authors have used ‘spells’ data for ordinary admissions for all countries. Ordinary admissions exclude maternity and births, mental health and regular attenders. (The original publication included all specialties for inpatient admissions for England, Wales and Northern Ireland.) 

Accordingly, changes have been made to sections of the summary report, and Chapters 4 and 6 of the source report, which relate to hospital inpatient activity and productivity.  Also, the data definitions relating to inpatient activity have been amended in Appendix 1 of the source report. These changes have not affected the conclusions or recommendations of the report. 

Discussion of ‘Barnett consequentials’

The report explores the variation in health spending increases between the four countries and looks at the ‘Barnett consequentials’ – the variations in block grants from the UK government to the devolved administrations arising from changes in central public spending. The published report combined these two. The updated version therefore clarifies that Barnett consequentials derive from the overall public spending total rather than health spend alone. 

Accordingly, changes have been made to the executive summary and Chapter 6 of the source report, and to the summary report.

UK Renal Registry citation

While providing a correct citation in the data appendix, the original versions of the summary and source reports referred incorrectly to the UK Renal Registry. This anomaly has now been corrected.

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