BMJ 2015;350:h1750 doi: 10.1136/bmj.h1750 (Published 8 April 2015)
Page 1 of 4
Feature
FEATURE DATA BRIEFING
The NHS in Wales: faring worse than the rest of the UK? John Appleby examines whether government attempts to use the Welsh NHS to discredit the Labour Party are valid John Appleby chief economist, King’s Fund, London, UK Aneurin Bevan—founding father of the NHS and, of course, a Welshman—once said that the sound of a dropped bedpan in Tredegar would reverberate around the Palace of Westminster. What was true then has increasingly become the case now, but for different political reasons. With the Labour Party in charge in Wales (and hence in charge of the NHS in Wales), the Conservative/Liberal Democrat coalition government has not resisted the temptation to make unflattering comparisons between the Welsh and English NHS.1 For some, pointing out that on a variety of measures the Welsh NHS does not perform as well as the English NHS has the fishy smell of a red herring; a distraction from difficulties the English NHS has also been suffering recently.
But not only is a descriptive comparison of the performance of health services in different countries notoriously difficult, the attribution of any differences is particularly tricky. The hugely ambitious comparison and ranking of different countries’ health services performance by the World Health Organization in 2000,2 for example, was widely criticised on data, technical, and methodological grounds.3 4 A previous Data Briefing explored the problems of comparing countries’ health systems.5 Whether and to what extent different health systems perform differently— and why—are important policy questions, and the answers could help improve the way health services are run and boost benefits to patients. To pick one headline performance metric at random, why have a smaller proportion of patients in England waited more than four hours for emergency care in Wales over the past few years (fig 1⇓)? Is it because, as some have suggested, in Wales the NHS is run by Labour and in England by Conservatives and Liberal Democrats?1 Or is it more complicated than that? Politicians don’t, as Bevan implied, manage the daily work of health services. But in a tax funded system they determine overall spending and the system’s organisational and economic set up. Since 2010, in England (and Scotland and Northern Ireland) the political decision has been broadly to spend enough on the NHS to cover rising prices. In Wales, the decision was to spend less in real terms. Real spending per head of population
was cut by 5.7% in Wales between 2010-11 and 2012-13, by 2.1% in England, and by 0.9% in Scotland. In Northern Ireland spending rose by 2.4% (fig 2⇓).10
Welsh health spending per capita in 2012-13 was similar to the average for the whole of the UK and about 11% less than the highest spending region (the North East of England) and 12% more than the lowest spending (the South East of England) (fig 3⇓).
But spending alone doesn’t explain health system performance. If it did, Northern Irish accident and emergency patients might expect a bit more for their money (fig 1⇓).
Dismally, there is rarely a benefit in one area without a cost—a lost benefit—in another. While the NHS is protected in England relative to Wales, spending on adult social care has been cut in England by over 5% in real terms but only by 1.4% in Wales between 2010-11 and 2012-13 (fig 4⇓). As for political decisions about the way health services are organised and run, as a report from the Nuffield Trust and the Health Foundation concludes after perusing a raft of performance data and noting policy differences across the four UK countries, such as approaches to the use of competition, “There is . . . no evidence linking these diverging high-level differences in policies to a matching divergence in performance.”12
While it’s hard to believe there’s no link at all between policy and performance, it’s probably much weaker than policy wonks and politicians may want to believe. The policy factors are also heavily mediated by all the other (often difficult to measure) things that drive performance—from the skill and experience of managers and clinicians, to the epidemiological and other characteristics of the population. Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare. Provenance and peer review: Commissioned; externally peer reviewed.
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h1750 doi: 10.1136/bmj.h1750 (Published 8 April 2015)
Page 2 of 4
FEATURE
1 2 3 4 5 6 7 8
Hunt J. Here’s why Labour’s attempt to weaponise A&E is so inappropriate. 2015. Twitter @Jeremy_Hunt, 13 Mar 2015. https://twitter.com/Jeremy_Hunt/status/ 576404526347001856. World Health Organization. The world health report 2000. Health systems: improving performance. 2000. www.who.int/whr/2000/en/whr00_en.pdf?ua=1. Navarro V. The world health report 2000: can health care systems be compared using a single measure of performance? Am J Public Health 2002;92:31-4. Williams A. Science or marketing at WHO? A commentary on World Health 2000. Health Economics 2001;10:93-100. Appleby J. Does poor health justify NHS reform? BMJ 2011;342:d566. NHS England. A&E attendances and emergency admissions. 2015. www.england.nhs. uk/statistics/statistical-work-areas/ae-waiting-times-and-activity/. NHS Wales Informatics. Accident and Emergency. 2015. www.infoandstats.wales.nhs. uk/page.cfm?orgid=869&pid=62956. Information Serves Division. Data tables: emergency care. NHS National Services Scotland. 2015. www.isdscotland.org/Health-Topics/Emergency-Care/Publications/datatables.asp?id=1184#1184.
For personal use only: See rights and reprints http://www.bmj.com/permissions
9 10 11 12
Department of Health, Social Services and Public Safety. Emergency waiting times. Belfast: 2015. www.dhsspsni.gov.uk/waitingtimes-emergency.htm. HM Treasury. Public expenditure: Statistical analyses (PESA) Cm 8902. 2014. www.gov. uk/government/uploads/system/uploads/attachment_data/file/330717/PESA_2014_-_ print.pdf. Lupton R, Burchardt T, Fitzgerald A. The coalition’s social policy record: policy, spending and outcomes 2010-2015. Research report 4. 2015. http://sticerd.lse.ac.uk/dps/case/spcc/ RR04.pdf. Bevan G, Karanikolos M, Exley J, Nolte E, Connolly S, Mays N. The four health systems of the United Kingdom: how do they compare? Nuffield Trust, The Health Foundation, 2014. www.nuffieldtrust.org.uk/sites/files/nuffield/publication/140411_four_countries_ health_systems_summary_report.pdf.
Cite this as: BMJ 2015;350:h1750 © BMJ Publishing Group Ltd 2015
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h1750 doi: 10.1136/bmj.h1750 (Published 8 April 2015)
Page 3 of 4
FEATURE
Figures
Fig 1 Percentage of patients waiting longer than four hours in emergency departments (includes minor injury units, walk-in centres, etc), 2012-156-9
Fig 2 Health spending per person 2007-08 to 2012-13 at 2012-13 prices10
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h1750 doi: 10.1136/bmj.h1750 (Published 8 April 2015)
Page 4 of 4
FEATURE
Fig 3 Health spending per person in UK regions, 2012-1310
Fig 4 Total gross spending on adult social care per head, 2007-8 to 2012-13 (spending is calculated relative to 2007-08 (set at 100) in 2012-13 prices)11
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
Page 1 of 4
Feature
FEATURE DATA BRIEFING
The NHS in Wales: faring worse than the rest of the UK? John Appleby examines whether government attempts to use the Welsh NHS to discredit the Labour Party are valid John Appleby chief economist, King’s Fund, London, UK Aneurin Bevan—founding father of the NHS and, of course, a Welshman—once said that the sound of a dropped bedpan in Tredegar would reverberate around the Palace of Westminster. What was true then has increasingly become the case now, but for different political reasons. With the Labour Party in charge in Wales (and hence in charge of the NHS in Wales), the Conservative/Liberal Democrat coalition government has not resisted the temptation to make unflattering comparisons between the Welsh and English NHS.1 For some, pointing out that on a variety of measures the Welsh NHS does not perform as well as the English NHS has the fishy smell of a red herring; a distraction from difficulties the English NHS has also been suffering recently.
But not only is a descriptive comparison of the performance of health services in different countries notoriously difficult, the attribution of any differences is particularly tricky. The hugely ambitious comparison and ranking of different countries’ health services performance by the World Health Organization in 2000,2 for example, was widely criticised on data, technical, and methodological grounds.3 4 A previous Data Briefing explored the problems of comparing countries’ health systems.5 Whether and to what extent different health systems perform differently— and why—are important policy questions, and the answers could help improve the way health services are run and boost benefits to patients. To pick one headline performance metric at random, why have a smaller proportion of patients in England waited more than four hours for emergency care in Wales over the past few years (fig 1⇓)? Is it because, as some have suggested, in Wales the NHS is run by Labour and in England by Conservatives and Liberal Democrats?1 Or is it more complicated than that? Politicians don’t, as Bevan implied, manage the daily work of health services. But in a tax funded system they determine overall spending and the system’s organisational and economic set up. Since 2010, in England (and Scotland and Northern Ireland) the political decision has been broadly to spend enough on the NHS to cover rising prices. In Wales, the decision was to spend less in real terms. Real spending per head of population
was cut by 5.7% in Wales between 2010-11 and 2012-13, by 2.1% in England, and by 0.9% in Scotland. In Northern Ireland spending rose by 2.4% (fig 2⇓).10
Welsh health spending per capita in 2012-13 was similar to the average for the whole of the UK and about 11% less than the highest spending region (the North East of England) and 12% more than the lowest spending (the South East of England) (fig 3⇓).
But spending alone doesn’t explain health system performance. If it did, Northern Irish accident and emergency patients might expect a bit more for their money (fig 1⇓).
Dismally, there is rarely a benefit in one area without a cost—a lost benefit—in another. While the NHS is protected in England relative to Wales, spending on adult social care has been cut in England by over 5% in real terms but only by 1.4% in Wales between 2010-11 and 2012-13 (fig 4⇓). As for political decisions about the way health services are organised and run, as a report from the Nuffield Trust and the Health Foundation concludes after perusing a raft of performance data and noting policy differences across the four UK countries, such as approaches to the use of competition, “There is . . . no evidence linking these diverging high-level differences in policies to a matching divergence in performance.”12
While it’s hard to believe there’s no link at all between policy and performance, it’s probably much weaker than policy wonks and politicians may want to believe. The policy factors are also heavily mediated by all the other (often difficult to measure) things that drive performance—from the skill and experience of managers and clinicians, to the epidemiological and other characteristics of the population. Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare. Provenance and peer review: Commissioned; externally peer reviewed.
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h1750 doi: 10.1136/bmj.h1750 (Published 8 April 2015)
Page 2 of 4
FEATURE
1 2 3 4 5 6 7 8
Hunt J. Here’s why Labour’s attempt to weaponise A&E is so inappropriate. 2015. Twitter @Jeremy_Hunt, 13 Mar 2015. https://twitter.com/Jeremy_Hunt/status/ 576404526347001856. World Health Organization. The world health report 2000. Health systems: improving performance. 2000. www.who.int/whr/2000/en/whr00_en.pdf?ua=1. Navarro V. The world health report 2000: can health care systems be compared using a single measure of performance? Am J Public Health 2002;92:31-4. Williams A. Science or marketing at WHO? A commentary on World Health 2000. Health Economics 2001;10:93-100. Appleby J. Does poor health justify NHS reform? BMJ 2011;342:d566. NHS England. A&E attendances and emergency admissions. 2015. www.england.nhs. uk/statistics/statistical-work-areas/ae-waiting-times-and-activity/. NHS Wales Informatics. Accident and Emergency. 2015. www.infoandstats.wales.nhs. uk/page.cfm?orgid=869&pid=62956. Information Serves Division. Data tables: emergency care. NHS National Services Scotland. 2015. www.isdscotland.org/Health-Topics/Emergency-Care/Publications/datatables.asp?id=1184#1184.
For personal use only: See rights and reprints http://www.bmj.com/permissions
9 10 11 12
Department of Health, Social Services and Public Safety. Emergency waiting times. Belfast: 2015. www.dhsspsni.gov.uk/waitingtimes-emergency.htm. HM Treasury. Public expenditure: Statistical analyses (PESA) Cm 8902. 2014. www.gov. uk/government/uploads/system/uploads/attachment_data/file/330717/PESA_2014_-_ print.pdf. Lupton R, Burchardt T, Fitzgerald A. The coalition’s social policy record: policy, spending and outcomes 2010-2015. Research report 4. 2015. http://sticerd.lse.ac.uk/dps/case/spcc/ RR04.pdf. Bevan G, Karanikolos M, Exley J, Nolte E, Connolly S, Mays N. The four health systems of the United Kingdom: how do they compare? Nuffield Trust, The Health Foundation, 2014. www.nuffieldtrust.org.uk/sites/files/nuffield/publication/140411_four_countries_ health_systems_summary_report.pdf.
Cite this as: BMJ 2015;350:h1750 © BMJ Publishing Group Ltd 2015
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h1750 doi: 10.1136/bmj.h1750 (Published 8 April 2015)
Page 3 of 4
FEATURE
Figures
Fig 1 Percentage of patients waiting longer than four hours in emergency departments (includes minor injury units, walk-in centres, etc), 2012-156-9
Fig 2 Health spending per person 2007-08 to 2012-13 at 2012-13 prices10
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h1750 doi: 10.1136/bmj.h1750 (Published 8 April 2015)
Page 4 of 4
FEATURE
Fig 3 Health spending per person in UK regions, 2012-1310
Fig 4 Total gross spending on adult social care per head, 2007-8 to 2012-13 (spending is calculated relative to 2007-08 (set at 100) in 2012-13 prices)11
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
