Comparing public services across the UK – providing health and social care context

By stewartb

It is regrettable that mainstream media coverage nowadays in Scotland too often only aggregates and amplifies the negatives about our public services. And even more insidious is the failure to provide context or perspective: it is reasonable to expect better from BBC Scotland as a public service broadcaster but the failure there is egregious. (Regular visitors to this site have plenty evidence of this now and will have a view as to why this has come about!)

It is with this background that a recent (April 2021) report from the Institute for Government (IfG) is noteworthy. Covering the post-devolution period from 1999 to the start of the coronavirus pandemic in March 2020, it examines the choices made and actions taken by the governments in Belfast, Cardiff, Edinburgh and London regarding public services. Specifically, it examines three areas: (i) health and the NHS, (ii) adult social care, and (iii) school education. The IfG points to a diversity of policy choices and to a mixed record of achievement.

This blog post focuses on some contextual issues influencing the IfG’s subsequent assessment of health and adult social care.

Contextual findings

‘The four nations have very different populations, and Scotland, Wales and Northern Ireland have higher average needs for health care than England.’

The IfG acknowledges that London and south-east England are very different from the rest of England: ‘the people there are younger, in better health, and have higher incomes.’

From this it concludes that comparing statistics for each of the three devolved nations to England as a whole is problematic: ‘For this reason, we compare the three devolved nations to the North East of England where possible, as the population there is more demographically and socioeconomically similar to the other nations than the rest of England. ….. Comparing the North East and the devolved nations allows us to better identify the effects of differences in policy, isolated from differences in the populations.

The IfG recognises other key differences impacting public service delivery: ‘Sparsely populated areas mean higher costs for providing public services. All else being equal, it costs more to provide services when governments have to provide multiple facilities (such as numerous small GP practices distributed across spread out villages). England has a significantly higher population density than the other three nations, while Scotland has the lowest.’

On age, it finds that Wales has the oldest population and Northern Ireland the youngest. Scotland and England fall between the two. However, North East England has a higher proportion of people aged over 65 than Scotland or England: it is more comparable to Wales.

‘England has the highest income per person among the four nations, mostly owing to London and the south-east. The North East has the lowest income per person of the nine English regions, and is very similar to Wales and Northern Ireland.’ It is arguable that some divergence between Scotland and the whole of England on this metric can be discerned in the graph below during the past decade of Tory governments in Westminster.

The following graph of annual age-standardised mortality rates shows the number of people dying each year, adjusted to allow fair comparison over time and between geographies. A higher mortality rate is one indication of higher underlying needs.

In 2017–19, the IfG reports that England had the highest life expectancy at birth, and Scotland the lowest.  However, ‘disability-free life expectancy’ – how long people can expect to live without a limiting long-term illness – shows a different pattern. England again performs best on this measure but North East England performs worse than any of the devolved nations and by some way. Scotland’s disability-free life expectancy for both men and women is similar and both are also similar to the value for women in England as a whole.

Wales also has the highest prevalence of disability among the four nations. North East England has an even higher prevalence of disability than Wales.

On public health, the IfG highlights a number of factors:

  • Scotland has consistently had higher mortality since at least the 1950s
  • the trends in the four nations were very similar before and have remained similar after devolution
  • due to improvements in treatments for heart disease and stroke and reductions in smoking, among other factors, mortality steadily declined from 1981 to 2011
  • since 2011 it has declined much more slowly.

This slowdown in all nations is caused, according to the IfG, by a number of factors: STEEP SPENDING CUTS in the years following the 2008 financial crisis (my emphasis), multiple bad winter flu outbreaks in the 2010s, and increases in Alzheimer’s and dementia.  One might ponder which single government has had direct and complete control over which of these contributing factors? Which government’s exercise of this control impacts on all the other three governments and nations whether they like it or not?


Here are some personal observations based on the IfG’s contextual findings:

  1. overall trends in public health and demographic statistics for NI, Scotland and Wales are difficult to shift in a differential way between the four nations – and are likely to remain so when only limited policy levers are available to the devolved governments, unlike Westminster
  2. the use of North East of England statistics here is further evidence that Westminster’s governance of England has been far from optimal for the whole of that country, and for a long time
    1. the statistics for the North East reveal something of the stark disparities between English regions that can also be seen in recent reporting of deaths from drug misuse (see ONS (2021) Deaths related to drug poisoning in England and Wales: 2020 registrations).
  3. continuous Labour administrations in Wales post-devolution has NOT resulted in any marked differential improvement in the metrics plotted by the IfG – arguably limited agency available to devolved governments is the crucial constraint on achieving differential shifts
  4. the imposition of austerity post 2009 was a policy choice of government in Westminster, by a party of government that only a majority in England voted for: that policy choice impacted all parts of the UK.


Atkins et al (2021) Devolved public services – The NHS, schools and social care in the four nations. Institute for Government report.  ( )

2 thoughts on “Comparing public services across the UK – providing health and social care context

  1. These graphs are the reason why the BBC is called: Bias Broadcasting Corporation. I like Scottish people, but, you really need to stand up for yourselves more often. It does not make sense how they don’t respect your changes in environment since you are no longer apart of central government. You have your own parliament and your healthcare is better than the English for sure. Thank you for confirming this through evidence.

    Liked by 2 people

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