Page last updated at 05:03 GMT, Friday, 4 July 2008 06:03 UK

A four-way split on the NHS

By Nick Triggle
Health reporter, BBC News

Hospital ward
The devolved administrations have pursued different policies

The NHS was set up as a universal health service for the UK.

But post devolution it has become clear that very different paths are being followed by England, Scotland, Wales and Northern Ireland.

Is this important? Yes, it seems. A BBC poll of more than 1,000 people shows that seven in 10 believe it matters that people get a different service depending on where they live.

So what do the four NHS's look like?


The Department of Health arguably has the hardest job of all.

Responsible for providing care to about 50m of the 60m people in the UK, it has set about making the NHS more effective by creating a marketplace.

In echoes of the Tories' internal market, Labour has created buyers, the primary care trusts, and sellers, NHS trusts which run hospitals.

England - 18 weeks by end of 2008
Scotland - 18 weeks by end of 2011
Wales - 26 weeks by end of 2009
Northern Ireland - 13 weeks by March 2009

Patients are treated as consumers and have been given choice over where they receive treatment, while funding has been overhauled so that hospitals and other health centres get paid per patient treated.

What is more, private sector providers have been invited in to compete with NHS trusts for patients.

The result? Dramatic improvements in waiting times that the other nations have tried to replicate, but a complete breakdown in the relationship between the medical profession and ministers.

It means by the end of the year, patients will be guaranteed treatment within 18 weeks of GP referrals - the shortest waiting time in the UK.

More recently, ministers have turned their attentions to GPs.

Family doctors have been forced to open for longer, while the review of the NHS by health minister Lord Darzi is expected to pave the way for doctors to be housed in super-surgeries known as polyclinics.

But to date, there has been limited reform of social care. That is likely to be rectified in the next year with a key policy paper due to be published.

Under pressure, ministers have already ruled out the so-called free personal care provided in Scotland.

Instead, many experts have suggested some form of top-up system whereby the state provides a basic level with people allowed to use their own money to buy extra.


In many ways, Scotland is the polar opposite of England.

There is no split between purchaser and buyer with 15 health boards responsible for both commissioning and providing services.

And use of the private sector is kept to a minimum with NHS treatment only contracted out where the health service is unable to provide it.

The model of care was created five years ago and led to a reduction in managers, with senior doctors taking a lead in overseeing care.

It means the clashes between the medical profession and politicians seen south of the border are relatively rare.

But progress on waiting times has been much slower. With Scottish ministers promising 18-week waits only by 2011 - three years after the target in England.

England - 1,676
Scotland - 1,919
Wales - 1,758
Northern Ireland - 1,770

However, Scotland was widely praised for its decision to give free personal care to the elderly.

Elsewhere in the UK, if an individual has assets of more than 22,250 they have to pay for basic help such as cleaning, washing and dressing.

But the wisdom of the policy has been questioned recently with experts saying it is not sustainable and many patients complaining local authorities are rationing care.


Wales has grabbed the attention for its decision to scrap prescription charging.

The change in 2007 has had reverberations across the UK.

Scotland has already said it will follow suit and is in the process of phasing out charges, Northern Ireland is reviewing them, while England, to much criticism, has said it will not follow suit.

Wales is also leading the way on the widely unpopular hospital car park charges. They will be phased out by 2011.

England - 7.10
Scotland - Charges being phased out by 2011
Wales - No charge since April 2007
Northern Ireland - Under review

Meanwhile, much good work has been achieved in the area of public health with the close alignment between the 22 local authority boundaries and NHS boards playing a key role in this proactive approach.

It has meant improvements to school nutrition and child obesity programmes have been introduced long before they took off elsewhere.

But while Wales has received favourable headlines for these policies, it has also suffered its fair share of attacks.

The Welsh government has been perhaps most vulnerable over waiting times.

During the election campaign last year, opposition parties were quick to point out waits for treatments had increased since devolution.

Ministers have responded by setting their own waiting target - 26 weeks by the end of 2009.


While the polyclinics debate has being raging in England, it may come as a surprise to learn that Northern Ireland has been experimenting with something very similar in recent years.

Parts of the country, in particular in Belfast, have set up the so-called super-surgeries.

This has seen GPs, nurses and social care staff working side-by-side in large health centres.

England - Men 77.2, women 81.5
Scotland - Men 74.6, women 79.6
Wales - Men 76.6, women 80.9
Northern Ireland - Men 76.1, women 81

This is not quite as radical as some of the centres being proposed in England, which will see a host of hospital care also included.

But it does mark a sea-change in NHS provision, which since 1948 has tended to be split down distinct professional lines.

It has also meant many of the clashes seen in the other countries between councils and NHS trusts over the care of patients released from hospital have been avoided.

The model of care is born from the fact that each of the five trusts have responsibility for both social care and NHS care.

But in many other respects, NHS policy has developed at a much slower pace than elsewhere because of the political situation which has meant only limited periods of self-rule.

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