DANIEL MITCHELL
Is there still such a thing as a UK NHS? In an increasingly divided UK, it is money and staffing – not healthcare policy differences – that matter, says Claire Reed
Last year, a survey asked people in England, Scotland and Wales to name the institution that made them proudest to be British. The most popular answer? The NHS. The survey missed the opportunity for what could have been an interesting
follow-up question, however – what do you think the ‘national’ means in National Health Service? The fact is that, since devolution in 1999, governments in Wales, Scotland, Northern Ireland and England have made different decisions on how to provide health
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Performance management
On the face of it, those policy variations seem likely to affect the quality of care nurses and other healthcare professionals are able to give. They cover issues such as whether prescriptions are free (yes in Northern Ireland, Scotland and Wales, no in England); whether patients should be able to choose which organisation provides their health care (yes in England, no elsewhere); and whether healthcare organisations should be strongly performance managed (definitely in England, more so now in Scotland, not in Wales and Northern Ireland). Politicians argue long and loud over these sorts of policies, believing they can help win and lose elections. But according to the Nuffield Trust study, such decisions are actually making very little difference to the quality of care. The authors of the report used 22 different indicators to compare healthcare performance in each country of the UK. In general, any gaps they found in performance
SUMMARY
care to their populations. The contrasts are so strong that some people suggest there is now no such thing as a UK or a British National Health Service. Among them are the authors of a recent report from healthcare research and analysis group the Nuffield Trust. In The Four Health Systems of the UK: How Do They Compare? (www.nuffieldtrust. org.uk/compare-UK-health), they argue that ‘the four countries are now on such different policy paths that it no longer makes sense to talk of a UK NHS’. It is a dramatic and controversial claim. RCN Wales associate director Peter Meredith-Smith says: ‘My personal view is that we do, across the UK, have an NHS that adheres to the principles on which it was founded – a comprehensive service which is funded by taxation and which delivers the services people need, when they need it. But I think there are and will be variations in terms of the way that care is delivered.’
‘The north east’s remarkable progress on reducing avoidable deaths and improving life expectancy suggest local conditions, such as funding and the quality of staff, are the real determinants of health service performance,’ says Nuffield Trust senior policy fellow Andy McKeon. It is a view shared by RCN Northern region director Glenn Turp. ‘One of the key things that has delivered [improvement] in the north east is longstanding, strong management at the top,’ he argues. ‘We have not seen the turnover of chief executives and chief nurses that colleagues have experienced in other regions. Longevity delivers a huge degree of stability to the rest of the team, and a long-term vision.’ Mr Turp acknowledges the importance of funding, pointing out that significant investment in public health programmes such as
Since devolution in 1999, there have been variations between healthcare policies in the four UK countries, making the existence of a national health service debatable. Research by the Nuffield Trust suggests that policy variations have not had as much impact on quality of care as funding and staffing levels. Author Claire Reed is a freelance journalist
were small. Health care was found to have improved across the UK in recent years: mortality rates have fallen, and life expectancy is longer regardless of which of the UK nations you call home. It seems that, even though their governments are making different choices about how to deliver health care, no one UK country now has significantly better healthcare performance than another. If the country does not appear to matter, the county or region might. Consider the north east of England. Its socioeconomic conditions are similar to those in the devolved countries. In the 1990s, it had similar mortality rates to Scotland. The Nuffield Trust report shows that by 2010, however, rates were 15 to 19 per cent higher north of the border. The obvious question is why. Why has the north east improved faster than other regions in England, and faster than the devolved countries? And if it is not government policy that affects quality of care, what is it? The conclusion the Nuffield Trust report draws will be unsurprising to many nurses: it seems it is in large part about the money. The researchers suggest it is no coincidence that the north east has had higher levels of investment in health care than other areas of England – it spent £2,100 per head on health care in 2012/13 compared with an English average of £1,912. Its nursing staffing levels are higher too, at 7.4 whole time equivalents per 1,000 head of population. That compares with just 5.8 across England (the figure is 7.1 in Wales, 7.5 in Northern Ireland, and 7.9 in Scotland).
THE NEW FUNDING SYSTEM WILL MAKE IMPROVEMENT IN THE NORTH EAST MORE CHALLENGING – Glenn Turp smoking cessation has yielded huge benefits in an area with poorer health than other areas of England. He fears ongoing improvement may be challenging, however. The reason? Money again. ‘Until recently, the funding formula [by which NHS England awards funds to clinical commissioning groups] took deprivation into account,’ Mr Turp explains. ‘What is hugely concerning us now is that the current government is changing the formula so that it is primarily linked to age, rather than age as well as other health factors. ‘One of the challenges for us is that people live longer and healthier in the south east, and shorter and in worse health the further north we get,’ he says. ‘But the new funding system will take huge chunks of money away. So there is a real worry that we will not be able to continue our trend of improvement.’
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Wales may provide a preview of the effects of reduced money and increasing austerity. In 2012/13, the average waiting time for a hip or knee replacement there was about 170 days. In England and Scotland, the wait was 100 days fewer. ‘We are probably ahead of the curve in Wales, because the austerity measures have hit us particularly hard in funding settlement,’ says Mr Meredith-Smith. ‘We have probably suffered more than other parts of the UK in terms of how we have needed to respond to the austerity agenda. ‘Certainly last winter, deliberate decisions were made to effectively lengthen the waiting times for planned surgery to ensure the winter pressures agenda could be properly managed. Rightly or wrongly, the government made a judgement that the consequences of winter pressures not being managed was more serious.
Nursing perspective
‘For me, the clear message of the Nuffield Trust report is that if you start taking money out of the healthcare system in large measure – which is what is happening here in Wales – then it will have an impact,’ says Mr Meredith-Smith. But he adds, ‘Across the UK the nurses on the ground I speak to all say much the same thing, which is that it is tough out there. And the reason that it is tough out there is because there is too much to do, not enough time to do it properly, increasing and changing demand, and huge issues around staffing.’ ‘Wherever anybody is, the pressures are immense,’ says Mr Turp. ‘I do not underestimate the pressures the nursing workforce is facing – the massive shortage of nurses, and the skill mix challenge to deliver the best possible care.’ Whether we can still talk of a truly national health service across the UK may be open for debate. But it seems what is not is the effect austerity is going to have, regardless of country or healthcare system NS
‘COUNTRY MATTERS LESS TO QUALITY OF CARE THAN HOW YOU AND YOUR TEAM PRACTISE’ Sam Abdulla and Daniel Marsden have much in common. Both are learning disability nurses, both are co-ordinators of a Daniel Marsden regular Twitter chat for fellow nurses in that field, and both work in the south east of the country. One key difference is which country: Mr Abdulla practises in Scotland, and Mr Marsden in England. Ask them about their working lives, however, and both feel that the difference in their locations does not have much of an effect. ‘Certainly, the impression I get from Twitter is that we all have the same challenges,’ says Mr Abdulla, a community learning disability staff nurse. ‘We are all facing cuts and expectations to provide high quality services, but perhaps not able to easily get everything we would like to make services as perfect as we would like.’ ‘I suspect the roles are not significantly different,’ agrees Mr Marsden, who works as a practice development nurse. He points out that there are proportionately more learning disability nurses working in Scotland than in England, but concludes that ‘when you’re on the front line, you just work with what is there and get on with delivering the best care possible’. Mr Abdulla adds: ‘It is how you and your team practise that has the biggest effect on quality of care. Yes, there are service demands that can influence that one way or the other, but how the team operates probably has the biggest direct Sam Abdulla impact on client care.’
Billy Drysdale’s Scottish accent remains easily recognisable despite almost 15 years spent living and working south of the border in Cumbria. He left his home country shortly after devolution, and says he felt in no doubt that he was still part of one big national Billy Drysdale health service. ‘It is the NHS no matter where you are,’ says Mr Drysdale, chair of the RCN Cumbria branch, who works as an emergency department nurse. ‘There are just subtle differences between what has happened in Scotland and what is happening in England. ‘No matter which of the four countries you work in, nurses are passionate about looking after their patients. When you are on the front line, the wider policy context does not really make a difference.’ He admits he worries about the extent to which the NHS has become ‘a political football’, and about the increasing focus put on targets in Scotland. ‘I do not think that targets should be the be-all and end-all of how we deliver care,’ says Mr Drysdale. ‘In England, we are being made to meet the four-hour target so we can get paid. When my mother had a stroke and was in A&E in Scotland, they looked after her for her needs rather than for four-hour targets. ‘Of course, in Carlisle we are not just a conveyer belt turning people through within four hours just so we can meet the targets – patient care is the number one priority. But for me, targets are just how politicians make the system look like it is working properly.’
24 july 9 :: vol 28 noRCNi.com 45 :: 2014by ${individualUser.displayName} on Nov 24, 2015. For personal use only. NoNURSING STANDARD Downloaded from other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Is there still such a thing as a UK NHS? In an increasingly divided UK, it is money and staffing – not healthcare policy differences – that matter, says Claire Reed
Last year, a survey asked people in England, Scotland and Wales to name the institution that made them proudest to be British. The most popular answer? The NHS. The survey missed the opportunity for what could have been an interesting
follow-up question, however – what do you think the ‘national’ means in National Health Service? The fact is that, since devolution in 1999, governments in Wales, Scotland, Northern Ireland and England have made different decisions on how to provide health
22 july 9 :: vol 28 noRCNi.com 45 :: 2014by ${individualUser.displayName} on Nov 24, 2015. For personal use only. NoNURSING STANDARD Downloaded from other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Performance management
On the face of it, those policy variations seem likely to affect the quality of care nurses and other healthcare professionals are able to give. They cover issues such as whether prescriptions are free (yes in Northern Ireland, Scotland and Wales, no in England); whether patients should be able to choose which organisation provides their health care (yes in England, no elsewhere); and whether healthcare organisations should be strongly performance managed (definitely in England, more so now in Scotland, not in Wales and Northern Ireland). Politicians argue long and loud over these sorts of policies, believing they can help win and lose elections. But according to the Nuffield Trust study, such decisions are actually making very little difference to the quality of care. The authors of the report used 22 different indicators to compare healthcare performance in each country of the UK. In general, any gaps they found in performance
SUMMARY
care to their populations. The contrasts are so strong that some people suggest there is now no such thing as a UK or a British National Health Service. Among them are the authors of a recent report from healthcare research and analysis group the Nuffield Trust. In The Four Health Systems of the UK: How Do They Compare? (www.nuffieldtrust. org.uk/compare-UK-health), they argue that ‘the four countries are now on such different policy paths that it no longer makes sense to talk of a UK NHS’. It is a dramatic and controversial claim. RCN Wales associate director Peter Meredith-Smith says: ‘My personal view is that we do, across the UK, have an NHS that adheres to the principles on which it was founded – a comprehensive service which is funded by taxation and which delivers the services people need, when they need it. But I think there are and will be variations in terms of the way that care is delivered.’
‘The north east’s remarkable progress on reducing avoidable deaths and improving life expectancy suggest local conditions, such as funding and the quality of staff, are the real determinants of health service performance,’ says Nuffield Trust senior policy fellow Andy McKeon. It is a view shared by RCN Northern region director Glenn Turp. ‘One of the key things that has delivered [improvement] in the north east is longstanding, strong management at the top,’ he argues. ‘We have not seen the turnover of chief executives and chief nurses that colleagues have experienced in other regions. Longevity delivers a huge degree of stability to the rest of the team, and a long-term vision.’ Mr Turp acknowledges the importance of funding, pointing out that significant investment in public health programmes such as
Since devolution in 1999, there have been variations between healthcare policies in the four UK countries, making the existence of a national health service debatable. Research by the Nuffield Trust suggests that policy variations have not had as much impact on quality of care as funding and staffing levels. Author Claire Reed is a freelance journalist
were small. Health care was found to have improved across the UK in recent years: mortality rates have fallen, and life expectancy is longer regardless of which of the UK nations you call home. It seems that, even though their governments are making different choices about how to deliver health care, no one UK country now has significantly better healthcare performance than another. If the country does not appear to matter, the county or region might. Consider the north east of England. Its socioeconomic conditions are similar to those in the devolved countries. In the 1990s, it had similar mortality rates to Scotland. The Nuffield Trust report shows that by 2010, however, rates were 15 to 19 per cent higher north of the border. The obvious question is why. Why has the north east improved faster than other regions in England, and faster than the devolved countries? And if it is not government policy that affects quality of care, what is it? The conclusion the Nuffield Trust report draws will be unsurprising to many nurses: it seems it is in large part about the money. The researchers suggest it is no coincidence that the north east has had higher levels of investment in health care than other areas of England – it spent £2,100 per head on health care in 2012/13 compared with an English average of £1,912. Its nursing staffing levels are higher too, at 7.4 whole time equivalents per 1,000 head of population. That compares with just 5.8 across England (the figure is 7.1 in Wales, 7.5 in Northern Ireland, and 7.9 in Scotland).
THE NEW FUNDING SYSTEM WILL MAKE IMPROVEMENT IN THE NORTH EAST MORE CHALLENGING – Glenn Turp smoking cessation has yielded huge benefits in an area with poorer health than other areas of England. He fears ongoing improvement may be challenging, however. The reason? Money again. ‘Until recently, the funding formula [by which NHS England awards funds to clinical commissioning groups] took deprivation into account,’ Mr Turp explains. ‘What is hugely concerning us now is that the current government is changing the formula so that it is primarily linked to age, rather than age as well as other health factors. ‘One of the challenges for us is that people live longer and healthier in the south east, and shorter and in worse health the further north we get,’ he says. ‘But the new funding system will take huge chunks of money away. So there is a real worry that we will not be able to continue our trend of improvement.’
NURSING julyNo9 other :: vol uses 28 no 45 :: permission. 2014 23 DownloadedSTANDARD from RCNi.com by ${individualUser.displayName} on Nov 24, 2015. For personal use only. without Copyright © 2015 RCNi Ltd. All rights reserved.
Wales may provide a preview of the effects of reduced money and increasing austerity. In 2012/13, the average waiting time for a hip or knee replacement there was about 170 days. In England and Scotland, the wait was 100 days fewer. ‘We are probably ahead of the curve in Wales, because the austerity measures have hit us particularly hard in funding settlement,’ says Mr Meredith-Smith. ‘We have probably suffered more than other parts of the UK in terms of how we have needed to respond to the austerity agenda. ‘Certainly last winter, deliberate decisions were made to effectively lengthen the waiting times for planned surgery to ensure the winter pressures agenda could be properly managed. Rightly or wrongly, the government made a judgement that the consequences of winter pressures not being managed was more serious.
Nursing perspective
‘For me, the clear message of the Nuffield Trust report is that if you start taking money out of the healthcare system in large measure – which is what is happening here in Wales – then it will have an impact,’ says Mr Meredith-Smith. But he adds, ‘Across the UK the nurses on the ground I speak to all say much the same thing, which is that it is tough out there. And the reason that it is tough out there is because there is too much to do, not enough time to do it properly, increasing and changing demand, and huge issues around staffing.’ ‘Wherever anybody is, the pressures are immense,’ says Mr Turp. ‘I do not underestimate the pressures the nursing workforce is facing – the massive shortage of nurses, and the skill mix challenge to deliver the best possible care.’ Whether we can still talk of a truly national health service across the UK may be open for debate. But it seems what is not is the effect austerity is going to have, regardless of country or healthcare system NS
‘COUNTRY MATTERS LESS TO QUALITY OF CARE THAN HOW YOU AND YOUR TEAM PRACTISE’ Sam Abdulla and Daniel Marsden have much in common. Both are learning disability nurses, both are co-ordinators of a Daniel Marsden regular Twitter chat for fellow nurses in that field, and both work in the south east of the country. One key difference is which country: Mr Abdulla practises in Scotland, and Mr Marsden in England. Ask them about their working lives, however, and both feel that the difference in their locations does not have much of an effect. ‘Certainly, the impression I get from Twitter is that we all have the same challenges,’ says Mr Abdulla, a community learning disability staff nurse. ‘We are all facing cuts and expectations to provide high quality services, but perhaps not able to easily get everything we would like to make services as perfect as we would like.’ ‘I suspect the roles are not significantly different,’ agrees Mr Marsden, who works as a practice development nurse. He points out that there are proportionately more learning disability nurses working in Scotland than in England, but concludes that ‘when you’re on the front line, you just work with what is there and get on with delivering the best care possible’. Mr Abdulla adds: ‘It is how you and your team practise that has the biggest effect on quality of care. Yes, there are service demands that can influence that one way or the other, but how the team operates probably has the biggest direct Sam Abdulla impact on client care.’
Billy Drysdale’s Scottish accent remains easily recognisable despite almost 15 years spent living and working south of the border in Cumbria. He left his home country shortly after devolution, and says he felt in no doubt that he was still part of one big national Billy Drysdale health service. ‘It is the NHS no matter where you are,’ says Mr Drysdale, chair of the RCN Cumbria branch, who works as an emergency department nurse. ‘There are just subtle differences between what has happened in Scotland and what is happening in England. ‘No matter which of the four countries you work in, nurses are passionate about looking after their patients. When you are on the front line, the wider policy context does not really make a difference.’ He admits he worries about the extent to which the NHS has become ‘a political football’, and about the increasing focus put on targets in Scotland. ‘I do not think that targets should be the be-all and end-all of how we deliver care,’ says Mr Drysdale. ‘In England, we are being made to meet the four-hour target so we can get paid. When my mother had a stroke and was in A&E in Scotland, they looked after her for her needs rather than for four-hour targets. ‘Of course, in Carlisle we are not just a conveyer belt turning people through within four hours just so we can meet the targets – patient care is the number one priority. But for me, targets are just how politicians make the system look like it is working properly.’
24 july 9 :: vol 28 noRCNi.com 45 :: 2014by ${individualUser.displayName} on Nov 24, 2015. For personal use only. NoNURSING STANDARD Downloaded from other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
