Devolution points way to different types of NHS

Which system will cope with the financial squeeze?

All modern health services are trying to improve the quality of their care while giving greater value for money.

And in the UK, with an ageing population, expensive new treatments, and an unprecedented financial squeeze, this need has never been more pressing.

The NHS is taking different approaches to meeting these challenges in different parts of the UK.

The gulf between the services is growing, with important implications for the patients they serve.

The widening cultural divide between the NHS in England and in other parts of the UK can be encapsulated in two words, "choice" and "competition".

Dr Charles Alessi, a GP based in south-west London, says the NHS has already helped to transform access to care. And he believes that it will raise standards.

"We have a multitude of hospitals around us and they're clearly in competition with each other. As long as it's not destructive, that's great. Because all it does is ensure that they try harder.

"This is the world we live in. This is the system which seems to provide the best service for patients."

NHS headquarters

Dr Alessi is a keen advocate of the government's plans for the NHS in England.

The proposals are being reviewed, but the intention is clear - to promote competition, with new organisations coming in to provide services, offer choice for patients, and respond to the demands of GPs, who will control the bulk of the NHS budget.

That is why ministers like to describe the GP surgery as the new headquarters of the NHS.

However, critics fear that a wider market in healthcare, including NHS trusts, charities and private companies, could cause confusion, waste and neglect.

Many of the patients seen by GPs have multiple long-term conditions, including diabetes, heart disease, arthritis and bronchitis.

And Dr Jennifer Dixon, from the health think tank the Nuffield Trust, fears the new system could be unable to cope.

"The consequences of fragmentation could be that patients fall through the cracks, and if they fall through the cracks their health will suffer and as a result they will end up using more and more hospital care. That, I think everybody recognises, is not something that we want."

Collaboration

In Scotland the emphasis is much more on collaboration than competition. Fourteen health boards plan and provide services. There is no competition, no market, and few opportunities for the private sector.

A GP at the Gorbals Health Centre in Glasgow, Dr Gary Hamilton, says what his patients want above all else is a good local service.

"I'm not sure if anyone can guarantee that the best is being offered. I suppose you can look at morbidity and mortality figures. And I hope that management are looking at these. We certainly don't get the figures."

So how does he ensure that he is making a good referral?

"We look at the hospitals. We know the doctors. I can think of many that I particularly like and admire. And I'm more than happy for them to be looking after my patients."

Some critics say the relationship between doctors and managers in Scotland is too "cosy" to drive the improvements that are needed.

However Dr Jean Turner, from the Scotland Patient's Association, says there are ways of raising standards. She cites the impact of the Healthcare Environment Inspectorate (HEI), carrying out spot checks to improve conditions in hospitals.

"Each doctor and each nurse should be committed to doing their job to the best of their ability. But if they're busy they maybe don't stick to the criteria and they're not so careful. HEI comes in, they make sure, so we love them. We love HEI."

'Soviet' planning

The NHS in Wales has a lot of similarities with Scotland, including free prescriptions, a push for free hospital car parking, and the rejection of the market and the private sector.

But Professor Siobhan McClelland, a health economist at the University of Glamorgan, says in Wales decision-making is more centralised.

"It is almost - pejoratively you could say - a soviet way of making decisions and planning health services from the centre. The view being that those politicians who are elected to do that - it's their responsibility to make those decisions and the buck stops with them as it will do at the assembly elections."

Northern Ireland too has its own distinct system with closer ties between health and social care for example.

But like the rest of the UK it faces a massive squeeze on health spending. And it is this tough new financial climate that will expose the strengths and weaknesses of these different approaches as never before.