ORIGINAL ARTICLE

Learning lessons from the National Health ServiceJasbir Sunner, BSc, MBA

Abstract—The Canadian College of Health Service Executives has recently formalized a learning partnership with the UK’s Instituteof Healthcare Management. The development of such a partnership offers Canadian healthcare leaders an opportunity to learnfrom the UK’s decade long multibillion pound effort to improve its healthcare system using a multipronged approach. This articleprovides an initial insight into the UK system starting with some of the high-level cultural differences between the UK and Canada.It is important to be aware of these differences as an appreciation of the context of the UK system can assist Canadian leaders inadapting the positive aspects to our system. The article describes some of the high-level cultural differences and then focuses on3 specific areas that hold salient lessons for Canada: (1) the evolution of the primary care system, (2) the collection of structuredand comparable consumer/patient feedback, and (3) a focus on quality (or clinical governance).

The complexity of health systems requires a deepunderstanding of their culture and history in order tointerpret and apply reform initiatives from one health

system to another. Over the last decade, many authorshave argued that healthcare systems are complex adaptivesystems, and applying linear or industrial managementprocesses to examine them does not give the best in-sights.1,2 In a similar vein, it is important to have a deepunderstanding of the cultural and structural differencesbetween the 2 systems in order to modify and apply re-form initiatives from the UK system in Canada.One of the biggest cultural differences between the

systems is that the National Health Service (NHS) is iden-tified as a single organizational entity by the government,by the people working within it, and by the general publicin the UK. (This article is speaking specifically about theEnglish NHS, not the local devolution to Scotland, NorthernIreland, and Wales although these too are considered “sin-gle entities” within those borders.) The concept of a “singleentity” permeates the system, and, as a result, the culturein the NHS is very different to the culture that exists in theCanadian health system.In England, the 1.3 million plus people that work in

individual acute, primary care and other NHS trusts identifythemselves as employees of the NHS. This national identityis reinforced through national employment policies (jobdescriptions/role definitions, pay, pensions, and servicerecognition) as well as public perception. By contrast,workers in the Canadian health system identify much more

From Humber River Regional Hospital, Ontario, Canada (Mr Sunner).Corresponding author: Jasbir Sunner, VP, Strategic Partnerships, Nephrol-

ogy & Support Services, Humber River Regional Hospital, 2111 Finch AvenueWest, Toronto, Ontario M3N 1N1, Canada

(e-mail: jsunner@hrrh.on.ca).Healthcare Management Forum 2010 17–201532-3382/$ - see front matter© 2010 Canadian College of Health Service Executives. Published by ElsevierInc. All rights reserved.

doi:10.1016/j.hcmf.2010.02.005

strongly with the specific organization they work for ratherthan an overarching health entity.The single-entity concept is reinforced through the De-

partment of Health (DH), which is the national body re-sponsible for the following: (1) setting the principles for theNHS, (2) approving financial allocations to the regions, and(3) creating a national health care structure that includesprovider incentives and payment mechanisms.The DH has a much greater span of control than any

Canadian regulatory body and, as a result, is able to pushthrough administrative changes to the NHS without muchresistance. Canada’s approach of checks and balances in-cludes the Canada Health Act principles and associatedfinancial transfer from Ottawa and a series of provincialplans responsible for the structure, incentives, and pay-ment mechanisms to providers. In provinces such as On-tario, independent organizational boards apply furtherchecks on the power of the provincial centre.Positive outcomes from the national nature of the NHS

include the following: (1) the National Institute for Healthand Clinical Excellence, which provides national guidanceon new technologies and medicines and clinical practiceguidelines; (2) structured and comparable patient feedbackthrough national surveys for patient satisfaction; and (3)national databases of patient and system information.The national nature of the NHS allows reforms to be

implemented in the UK in a direct manner so it is easier tomake systemic change happen in the UK health system.However, the centrally controlled system has just as manyweaknesses as strengths. Career progression in the NHS isadvanced by movement into the central planning or policybodies. As a result, there is less incentive for the moreambitious NHS organizational leaders to resist poorlythought-out proposals emanating from the centre. TheCanadian system has more of a “creative tension” betweenthe various levels of government and between govern-ments and local health providers.Difficulties associated with the national nature of the

NHS include the following:

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1. Constant restructuring: over the last 20 years, thestructure of the NHS has been reorganized on nu-merous occasions. According to most observers ofthe NHS, “reconfiguration of the health system isdistracting and costly.”3 The constant reorganizationslead to paralysis, wasted resources, and low morale.

2. Less independence for delivery organizations andalmost no advocacy from the field: advocacy for par-ticular NHS entities involved in the delivery of health-care (eg, hospitals) is minimal in comparison to thestrength of Canadian advocacy organizations such asthe Ontario Hospital Association.

3. A historical lack of innovation and leadership in man-agement; progress on process improvement meth-odologies has been historically limited in the NHS(until the relatively recent work of the ModernisationAgency), and program management in the NHS isstill in its infancy. The development of academichealth science centres in the UK only happened veryrecently (and was heavily led and influenced by in-dividuals with experiences of such organizations inCanada). The NHS has local pockets of relativelystrong and innovative leaders, but managementleadership in the NHS continues to be a DH priorityand a focus for improvement since the publication ofthe Griffiths Report.4 The culture of the NHS has beenshaped by this national nature so that there is moreacceptance of government initiatives than therewould be in Canada. Canadian healthcare leadersand policy makers need to understand this culturaldifference in order to evaluate the UK reforms andmodify them for successful implementation with theCanadian system. In particular, policy makers shouldhave a deep understanding of the strengths andweaknesses of a single entity versus the creativetension that currently exists in the Canadian systemas they design future reform of the Canadian system.

THE EVOLUTION OF PRIMARY CARE

One sector in which the UK is well ahead of Canadianprovinces is primary care (specifically family doctors),which has been successfully integrated into the broaderhealth system. The UK has been able to evolve generalpractice from “a cottage industry of single-handed doctors,working from their own homes and with little support, intoa network of organized and sizeable groups, in good ac-commodation, with a substantial infrastructure and moreinfluence on other parts of the NHS.”5

The arrangement in the UK is very different than theaverage Canadian province, where primary care is more orless adjacent to the rest of the health system. The UK hasbeen able to accomplish this integration of primary careeven though general practitioners continue to view them-

selves as independent contractors, as they do in Canada.

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There is a structured participation by primary care practi-tioners in making health system decisions, and, conversely,the system has the ability to locally influence primary carepractice. For example, there is local monitoring of practiceactivities and performance in (1) chronic disease manage-ment, (2) prescribing, and (3) adherence to clinical path-ways determined with local hospitals.Part of the UK’s success can be attributed to looking

beyond the creation of new funding incentives and struc-tures for primary care providers such as Primary Care Trusts(PCTs) and General Practitioner (GP) fund holding. Manage-ment training/support and the equalization of the powerstructures between the acute and the primary/communitycare sector has been just as important in successfully im-plementing the reforms. The ability of the primary careorganizations to purchase and commission resources andobtain direct investment has made it much more attractivefor general practitioners to get involved and engaged withthe system. Salaries for Chief Executive Officers of PCTs arenow on a par with those of acute trusts. A major invest-ment in primary care physician leadership was accom-plished through initiatives such as the National PrimaryCare Development Team (now incorporated into the Im-provement Foundation) and the Primary Care Collabora-tive. The link between purchasing and primary care reformcould be of particular interest for Ontario, which is pro-ceeding down the path of the purchaser-provider splitwith the advent of Local Health Integration Networks(LHINs). PCTs have great expertise and history with regardsto provider performance management, outcomes evalua-tion, prioritization, funding initiatives, and integration,which are all important components of an LHIN.The UK’s success in developing and managing its pri-

mary care system is supported by strong evidence throughthe Commonwealth Funds’ Health Policy Survey of PrimaryCare Physicians;6 some of its findings were as follows: (1)97% of UK primary care physicians used electronic patientmedical records versus 37% of Canadian doctors, (2) 72%of UK doctors routinely received reminders for guideline-based interventions or tests compared with 27% of Cana-dian doctors using either manual or computerized systems,(3) 97% of UK practices sent patients reminders for fol-low-up or preventive care compared with 31% of theirequivalents in Canada, (4) 89% of practices in the UK hadarrangements for after-hours care versus 43% of Canadianpractices, (5) 89% of primary care practices routinely re-ceive and review data on patient clinical outcomes com-pared with 17% in Canada, and (6) 51% of British GPsindicated that they thought quality of care had improvedin the last 3 years compared with 17% in Canada. The starkdifferences described previously would indicate that thereare many lessons for Canada in how the UK has organizedsupported and incentivized (ie, managed) its primary care

system.

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LEARNING LESSONS FROM THE NATIONAL HEALTH SERVICE

STRUCTURED AND COMPARABLE CONSUMER/PATIENT FEEDBACK

The national nature of the NHS enabled the developmentof national consumer surveys on the services being deliv-ered in the NHS. Comparable data can be collected andused to see how various parts of the service or country areperforming with respect to the delivery of care to thewhole or subsegments of the population.The Healthcare Commission (now the Care Quality Com-

mission) has performed annual surveys in partnership withthe Picker Institute or the National Centre for Social Re-search since 2004. The surveys are tailored with specificquestions to the type of institution and service being eval-uated and include such things as (1) acute care trusts (bothinpatient and emergency department surveys), (2) ambu-lance surveys, (3) mental health services, and (4) maternityservices. The surveys are developed with consumer in-volvement, and the results of the surveys influence theannual performance rating of all NHS organizations. A keybenefit of having structured longitudinal consumer feed-back is that it helps providers to understand consumerrequirements and their own relative performance in ad-dressing these needs.The systematic engagement of patients in the health

system can assist in the drive to provide more patient-centred and quality care. In most industries, listening toconsumers and their issues is a fundamental element ofquality control and product improvement.A recent innovation in patient feedback is that from April

2009 all acute trusts are collecting Patient-Reported Out-come Measures (PROMs) for a number of specific clinicalprocedures such as hip and knee replacements. PROMs willbe asking patients about their health and quality of lifebefore their operation and about their health and theeffectiveness of the surgery after their operation. This datewill assist NHS organizations in understanding the clinicaloutcomes of their services from the patient’s perspective.According to the Department of Health,7 the PROMs

data could be used for the following purposes:

1. To evaluate the relative clinical quality of providers ofelective procedures: PROMs data can be used byclinicians, managers, regulators, and PCT commis-sioners to benchmark providers’ performance and forclinical audit. It can also be used by patients and GPsexercising choice.

2. To identify what works well: the efficacy and cost-effectiveness of different technical approaches tocare can be evaluated by using PROMs in associationwith other measures.

3. To assess the appropriateness of referrals to second-ary care: PROMs data can be used to establishwhether referrals for elective procedures are appro-priate by examining variation in baseline PROMs

scores across the country.

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4. To support the reduction of health inequalities.5. To empower commissioners: PCT commissioners can

use the data to establish the quality of services forwhich they are contracting with providers.

The Canadian health system could learn from the NHSexperience in designing, collecting, interpreting, and tak-ing action on standardized patient feedback from acrossthe country.

QUALITY

One of the major planks of reform under the Blair’s Labourgovernment over the last 10 years has been the focus onimproving the quality of care in the NHS. The focus onquality improvement has been described as: “The world’smost ambitious, comprehensive, systemic and intention-ally funded effort to create predictable and sustainablecapacity for improving the quality of a nation’s health caresystem.”8

Quality improvement in the NHS has occurred at thesame time as a major investment in buildings, reform, newmanagement techniques, human resources, and salariesfor the entire NHS. The NHS funding has increased from£33Bn in 1996/1997 (the year Labour came to power) to£90.4Bn in 2007/2008 and an expected £110Bn in 2011.There are more doctors, nurses, and allied health profes-sionals working in the NHS. There are new structures,expanded and more precise targets, better equipped GPpractices, and a greater knowledge of improvement meth-odologies in the NHS. Therefore, it is difficult to attributesuccess in reducing mortality and morbidity or improvingservice delivery solely or directly to the focus on qualityimprovement. However, it is undeniable that improvingquality of care through initiatives and agencies such as theNational Service Frameworks, the Modernisation Agency,the Healthcare Commission (now incorporated into theCare Quality Commission), and the National Institute forHealth and Clinical Excellence has become a major focus ofthe NHS.Quest for Quality, Refining the NHS Reforms,9 one of the

most comprehensive studies of the NHS quality agendaover the last 10 years was recently published by the Nuf-field Institute. The authors summarized their findingsaround 6 parameters of quality:

1. Effectiveness and appropriateness: there is now moreeffort in the NHS to achieve evidence-based stan-dards of care for a number of clinical conditions;mortality rates for the major disease groups havedropped, although there are continuing deficienciesin care for a range of clinical areas.

2. Access: waiting times for hospital admission, outpa-tient, and cancer care have reduced significantly, butongoing problems remain with some specialties, di-

agnostics, and community aftercare.

Spring/Printemps 2010 19

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3. Capacity: there have been significant increases in thenumber of staff, renewed and new facilities, andinvestments in medical technologies, but some inad-equacies still remain.

4. Safety: progress on reducing the number of hospital-acquired infections but continuing difficulties inmonitoring how safe health services are.

5. Patient centredness: a steady state in patient-re-ported experience of care.

6. Equity: although healthcare remains available to alland largely free at the point of use, there is a wid-ening of the gap in life expectancy and infant mor-tality between more deprived populations and En-gland as a whole.

CONCLUSIONS

The NHS and the Canadian health system were founded onthe same principles of universality, comprehensiveness,and free access at the point of delivery. For the most part,the 2 countries also face similar challenges, an aging pop-ulation, increasing health costs, and dealing with a diverseand multicultural population and increasingly high expec-tations from the public. However, because of specific cul-tural and historical reasons, the 2 systems diverged as theyevolved. Attempts to share learning from each system willbe more effective if there is an understanding of the spe-cific cultural, contextual, and historical differences in theapplication of policy and reform.The 3 key themes discussed in this article are only a

representative sample of the ideas, reforms, and activitiesof the NHS that could be useful for Canadian healthcareleaders to understand better. However, there are manyother specific examples of healthcare reform that could beexamined in more detail depending on the province or theissue.Ontario and, in particular, the Ministry of Health and

Long-Term Care along with the LHINs could benefit greatlyfrom understanding the NHS reforms of the last 10 to 20years. Although LHINs are not direct structural compara-tors to the UK’s PCTs, it may assist them in developing theirown planning and performance tools if they understandthe evolution of the ability of PCTs to manage these com-plex issues.Alberta Health Services, the nascent single governance

board for all healthcare delivery in Alberta, could benefitfrom understanding the problems that existed in the cen-trally controlled NHS model that many of the reforms of

the last 20 years have tried to address.

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Finally, Health Ministries across the country could ben-efit from a much greater examination of the policies of thelast 20 years that have led to a much more structured,integrated, and involved primary physician care system inthe UK. The Canadian College of Health Service Executivesand the Institute of Healthcare Management should becommended on the formalization of their partnership, butit will require a concerted effort and a deep understandingof the systems’ similarities and differences to import suc-cessful initiatives to Canada from the UK. The continuingpartnership will also inform Canada as the growth in theNHS is curtailed and it starts dealing with lower resourcesand reduced budgets.As the authors of the Nuffield study point out, under-

standing the NHS can provide critical lessons because “En-gland is an exemplar for other healthcare systems of theworld seeking to improve performance and deliver qualitycare and, as such, should be subject to critical analysis andstudy. At this juncture, with a decade of experience, a . . .look at the NHS . . . reforms is important not only forEngland, but for a worldwide audience.”10

REFERENCES

1. Crossing the quality chasm. A new health system for the 21stcentury/Committee on Quality Health Care in America, Insti-tute of Medicine, Washington, 2001.

2. Complicated and Complex Systems. What would SuccessfulReform of Medicare Look Like? Commission the Future ofHealth Care in Canada, S. Glouberman & B. Zimmerman, 2002

3. Quest for Quality, Refining the NHS Reforms, Leatherman andSutherland, Nuffield Trust, London, UK; 2008

4. Griffiths Report. NHS Management Inquiry Report. London:Kings Fund, London, UK; 1983

5. From Cradle to Grave–Fifty years of the NHS, Geoffrey Rivett,Kings Fund. London, UK; 1998

6. Schoen C, Osborn R, Doty MM, Squires D, Peugh J, andApplebaum S, “A Survey of Primary Care Physicians in 11Countries, 2009: Perspectives on Care, Costs, and Experi-ences,” Health Affairs Web Exclusive, Nov. 5, 2009: w1171–w1183.

7. Guidance on the Routine Collection of PROMs–Department ofHealth, December 2008

8. Quest for Quality, Refining the NHS Reforms, Leatherman andSutherland–Nuffield Trust, London, UK; 2008

9. Quest for Quality, Refining the NHS Reforms, Leatherman andSutherland–Nuffield Trust, London, UK; 2008

10. Quest for Quality, Refining the NHS Reforms, Leatherman and

Sutherland–Nuffield Trust, London, UK; 2008

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