Dr Phil Hammond, broadcaster and GP returner in Bristol

How many NHSs are there? Just within England, there is huge variability in the service in terms of access to and types of treatment. The Chief Medical Officer, Sir Liam Donaldson, recently complained that people in poorer areas are still likely to be subjected to surgery (tonsillectomies, hysterectomies, wisdom tooth extractions), whereas people in richer areas get the latest conservative treatments.1 But this variation within the NHS in England is nothing compared with that seen across the UK.

During the run up to the last election, Tony Blair ridiculed Wales over long waiting times compared with England. Given that Wales is theoretically served by the same NHS that Blair had promised to turn around, it seemed a brave call, and one that caused huge embarrassment to Welsh Labour MPs.

But the Welsh Assembly has chosen to take their NHS in a different direction to Westminster's relentless focus on competition and privatization. In Wales, the emphasis is on tackling the causes of ill health, rather than trying to micromanage the NHS. So who will have the last laugh?

Instead of spending hundreds of millions of pounds abolishing community health councils (CHCs), or setting up a Commission for Public and Patient Involvement in Health, and closing it down again, Wales simply kept the CHCs. It has invested in free breakfasts for primary school children, and free prescriptions for all.

Devolved Parliament in Scotland has funded free personal care for the elderly; whereas in England, thousands of elderly patients are denied nursing care on the NHS because their medical needs are reclassified as 'social'. These patients often have to sell their homes to pay for care.

The Scottish Parliament also managed to reconfigure its health services with broad support from the public and health service staff, in marked contrast to the divisive battles over privatization that the English NHS is enduring.

In Scotland and Wales, the ethos is more about trusting professionals to do their jobs out of a sense of vocation, rather than rely on market forces and excessive regulations to do it for them; primary care trusts, payment by results, star ratings, compulsory choice, and practice based commissioning don't even exist in these countries.

The downside for Scotland and Wales is that their nationalist approach has ducked the politically combustible issue of hospital closures.

In Wales, the mindset is that each area should offer uniform services, which is neither efficient nor cost-effective (hence the huge waiting lists). In Northern Ireland hospital activity is 26% lower than England per bed.2 Scotland is using the private sector to get waiting lists down, although much less so than England, and only when there is a real need (as opposed to the English stance of competition for the sake of it).

Scotland's reform programme seems to be the most coordinated, with its focus on networks and partnerships. In England, the volume and haste of new initiatives, some of which directly contradict others, has meant that not even senior managers are clear about what they're supposed to be aiming for.

What is clear is that there is no UK focus in health policy, and it will be some years before we discover who got it right. The three smaller countries have the advantage of watching the English NHS crash and burn, and then cherry picking the good bits.

In the mean time, go to England for quick operations, Wales for free prescriptions, Scotland for long-term care, and Northern Ireland if you don't like change.

(1) http://www.guardian.co.uk/medicine/story/0,,1826211,00.html
(2) http://www.bma.org.uk/ap.nsf/Content/hprsummer06~Devolution?OpenDocument&Highlight=2,northern,ireland,hospital,activity,26

Guidelines in Practice, September 2006, Volume 9(9)
© 2006MGP Ltd
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