Patients in the UK’s four nations have dramatically different experiences of the NHS, HSJ can reveal.

A comparison of health services in England, Scotland, Wales and Northern Ireland shows marked differences in the likelihood of emergency admission to hospital, staying overnight or being operated upon.

Healthcare information providers CHKS analysed statistics from the four nations exclusively for HSJ. Differences included the fact that patients having an elective operation in England are 40 per cent more likely to be treated as a day case than patients in Scotland.

Welsh residents are 20 per cent more likely to be admitted to hospital as an emergency than elsewhere. CHKS head of market intelligence Paul Robinson said: “This is about primary care and whether patients are being rushed in or not.”

The figures suggest differences in the organisation and efficiency of services. But they also point to different clinical standards.

Divergent policies

Nearly 10 years after devolution, the data has triggered debate on the benefit to patients of the nations’ divergent policies.

From 2004-07 emergency patients discharged within a day in England surged from 18 to 25 per cent. In Wales, the rate rose at a similar pace. But in Northern Ireland the increase was much more modest and in Scotland the rate fell.

London School of Economics professor of management science Gwyn Bevan said the increase in England was probably due to the four-hour accident and emergency waiting target. More patients turned up at A&E and hospitals admitted more to meet the target, even though they were soon discharged.

Despite a similar A&E waiting-time target, Wales did not see a surge in A&E attendances but the proportion of patients discharged on the same day rose by more than a third in the three years.

“The target in Wales hasn’t meant anything; it’s pretty low key,” Professor Bevan said.

King’s Fund senior research fellow Nick Goodwin said the increase in same-day discharges in both England and Wales could be due to financial pressure - from payment by results in England and relatively low per-head funding in Wales.

Market models

The similar trends “raise questions about whether the English system based on [market] reform is really doing any better than the other systems, which are moving away from that”, Mr Goodwin said.

Performing more elective operations as day cases has been a central plank of the English NHS’s quest for improved efficiency. By 2007, 71 per cent of elective patients did not have to stay overnight. But in Scotland the rate has hovered around 50 per cent and between 2004 and 2005 actually fell.

Nuffield Trust visiting research associate Scott Greer said: “2005 is the really entertaining date to look at. The Labour manifesto was full of the huge achievements of the English NHS, implying how much better the English model was over the Scottish one. So it is interesting that Scotland was moving away from the English model.”

A Scottish government spokesperson said the fall in day cases might reflect a shift of less complex procedures towards outpatients or the community sector, leaving hospitals dealing with more complex cases unsuitable for same-day treatment.

Each nation had a funding boost for health in 2001. But Mr Greer said the higher proportion of fixed costs in hospitals outside England meant “it felt like new money in England in a way it didn’t elsewhere”. Wales, for example, was affected by a drastic shortage of GPs in deprived post-industrial areas.

A Welsh Assembly government spokesperson denied Wales’s higher rate of emergency admissions reflected poor primary care. It was caused by the “long history of ill-health due to its industrial past”.

Learning from each other

NHS Confederation deputy policy director Jo Webber said it was important the countries learned from each other “to be able to pick the best of each”.

A Department of Health spokesperson said: “It is right and proper for each NHS to use their own policies and standard operational procedures to meet the differing needs of their national populations.”

The Northern Ireland health department denied the rising elective admissions reflected a greater propensity for surgical intervention and said in part the rates were due to delivering on “very challenging waiting time targets” from 2005-07.

Variations in UK nations

37% Increase in A&E attendances in England between 2004 and 2007. In the three other nations the rate rose by no more than 3 per cent

1 in 10 The rate of emergency admissions in 2007 in Wales. The rate continues to rise. Wales has the lowest rate of elective admissions but the highest rate of emergency admissions

43% Rise in proportion of emergency admissions discharged on the same day in England from 2004-07. In Wales it was 34 per cent. The rate in Scotland fell by 2 per cent and in Northern Ireland it rose by 12 per cent

12% Emergency admissions discharged in less than one day in Northern Ireland, compared with 25 per cent in England. Patients discharged in England are 37 per cent more likely to require emergency readmission within 28 days than in Northern Ireland

193 The number of elective admissions per 1,000 population in Northern Ireland in 2007 - 51 per cent higher than the rate in Wales

The four systems

England National targets to improve performance, especially on waiting times. Hospital funding follows the patient under the payment by results system and there is an increasing emphasis on a provider/commissioner split to improve efficiency and patient focus.

  • 2002-03 spend per head:£1,085

  • 2002-03 hospital beds per 1,000 population: 3.8

  • GPs per 1,000 population: 0.57

Scotland Abolished the quasi-internal market in 2004 and created 15 integrated health boards (later cut to 14), responsible for both purchasing and providing secondary and primary care. Services funded on block contracts.

  • 2002-03 spend per head:£1,262

  • 2002-03 hospital beds per 1,000 population: 6

  • GPs per 1,000 population: 0.76

Wales Twenty-two local health boards responsible for commissioning care from the 13 acute trusts (excluding the ambulance trust and since cut to eight) and commissioning and providing primary and community services. Funds most acute activity through block contracts with acute trusts. The Assembly government is now consulting on merging boards and trusts to create an integrated model akin to Scotland’s.

  • 2002-03 spend per head:£1,186

  • 2002-03 hospital beds per 1,000 population: 5

  • GPs per 1,000 population: 0.61

Northern Ireland Devolution slowed by suspension of the assembly in 2002 (restored 2007). Commissioner/provider split between four health and social service boards and 18 health and social service trusts - cut to five in 2007.

  • 2002-03 spend per head:£1,214

  • 2002-03 hospital beds per 1,000 population: 4.9

  • GPs per 1,000 population: 0.63

Source for figures: BMJ, 2005.

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See also Divide and rule: time for the UK to debate its four health systems and National service: health policy performance across the UK

The full figures are available here

*080828p5admission
*080828p5discharge
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