How do the health care systems in the UK compare internationally?

Two years ago I wrote about how health systems in other countries were grappling with the problems of how to support an ageing population with high rates of co-morbidities. I was interested in the fact that the same policy problem can generate different solutions depending on the context in which it sits – so while it may appear that there is a sort of ‘free will’ in decisions about policy, in reality decisions will always depend on the limitations of funding and political structures.

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.

King's Fund

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”

Charities issue warning to health devolution plans

Let the “in-fighting” begin

Charity leaders are warning the Government’s moves to give Greater Manchester power over health and social care spending could be flawed because voluntary organisations appear to have been forgotten in plans.

Under the policy, which has been championed by the Chancellor, George Osborne, 10 councils will come together under an elected mayor to take over the region’s £6bn health and social care budget.


Ministers hope the scheme will be a trailblazer for the transfer of power from Whitehall to English regions. But the Association of Chief Executives of Voluntary Organisations (Acevo) protested that the detailed planning in Manchester barely recognised the role of charities in delivering social care for children, the elderly and vulnerable adults.

It includes providing “meals on wheels” and befriending services for older people, help for homeless teenagers and transport for all ages.

Acevo accused the Government of a “grave oversight” after a memorandum of understanding setting out plans said that the “role of the third and private sector in the arrangements… remains to be determined”.

Its chief executive, Sir Stephen Bubb told The Independent newspaper: “I welcome devolution with open arms as a magnificent opportunity to reform and restore services, but it appears the rhetoric doesn’t match the reality.”

He said that the voluntary sector, which would be crucial for delivering services, should be treated as an “aside in a flagship devolution document” and said it was essential to get the Manchester scheme right.

A Government spokesman insisted the agreement would closely involve the third sector. “strengthening communities and supporting individuals through working together with the third sector will be central to the approach the Government take,” he said.

“Unfortunately there will be many “ruffled feathers” to groom and parties to unite before major improvements reach the end-user”