I was reminded of this comparative work when the European Observatory on Health Systems and Policies published the latest UK health systems in transition (HiT) review, written with the support of The King’s Fund. The review describes the structure and performance of the UK health system in a way that allows it to be compared to the systems in other countries, not just within Europe but also further afield in the United States, Australia, Israel and Japan. It is possible to search the Observatory’s Health Systems and Policy Monitor website for descriptions of national health services and also to segment and compare findings on any aspect of health policy. This resource allows us to see what other health systems around the world are doing and how we compare.
The HiT is updated every five years or so, and this edition describes the health systems of the United Kingdom as a whole for the first time. We grappled for a long time with how to incorporate the differing systems of the four nations of the United Kingdom before realising that the differences in our systems are small compared to those within, for example, Sweden or Spain because divergence within the United Kingdom is a relatively recent phenomenon.
In comparison, Sweden has a long tradition of health care devolution – 21 politically elected county councils are responsible for health care provision, with the result that national health policy is filtered by county councils of numerous different political persuasions, leading to differences in, for example, how they contract with private providers depending on the importance they attach to equity of access.
In Spain, responsibility for health services was devolved to regional level autonomous communities over the 25 years that followed the establishment of a democratic government in 1978. The 17 autonomous communities, each with a regional minister, determine expenditure and are responsible for the organisation and management of their health systems. Matters of regional health policy (for example, the ‘basket’ of services provided locally) are recommended but not mandated by a committee of the 17 regional ministers. Again, autonomous communities can be characterised as being either right or left wing and their management of the local health system viewed accordingly.
This is very different to local commissioning as we understand it in England, where health commissioners are not politically constituted – although commissioning of social care is managed by elected local authorities. The emergent devolution in Greater Manchester is better viewed as delegation rather than as pure devolution – it is not yet dependent on any transfer of health functions via parliamentary orders, so that, in comparison to some other European countries, the NHS remains remarkably national with formal accountability remaining with NHS England. But the scheme is striking out from a long history of central control in the NHS.
Whatever the differences between national systems, some challenges are common to us all. The issues identified in the NHS five year forward view – the reworking of the interface between primary and secondary care, integration between physical and mental health, prevention of avoidable illness – are pertinent to almost every other health service. For example, some areas of Denmark are moving care into the community while centralising specialist provision, just as we intend to, while New Zealand has introduced measurement of whole-system performance, rather than measuring discrete elements, in order to encourage integration. It is important to evaluate the success of different health systems in tackling these shared challenges, so we can share the lessons learnt.
- To find out more about the London meetings of the European Health Policy Group (EHPG) – an informal network of academics and policy analysts – you can sign up to the EHPG JISCMAIL group by contacting Sarah Gregory.
“If only we could start from scratch”