NHS Scotland and NHS England: How do they each differ?

The current UK Covid inquiry concludes hearings this week on its current module, which has been examining how the pandemic impacted on healthcare systems.

One of the more unexpected angles to crop during evidence were conflicting views on how structural differences between the NHS in Scotland and England affected Covid management.

Scotland's chief medical officer Professor Sir Gregor Smith said that it was "much more difficult" to enact a blanket response.

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This was rejected in evidence last week by pandemic-era Health Secretaries, Jeane Freeman and Humza Yousaf.

So what did they say - and how do the two systems differ?

'Off the hook'

While giving evidence in September, Prof Smith said that the Scottish healthcare system "differs quite significantly" from its English counterpart due to the lack of an equivalent body to NHS England.

In Scotland, the NHS is split up into health boards whose chief executives report directly to the Cabinet Secretary for Health.

In England, hospital trusts fall under NHS England, the body responsible for overseeing the funding, planning and delivery of healthcare on behalf of the UK Government.

Prof Smith said it would be his "personal preference" to replicate something similar here as the governance structure made a "once-for-country approach" simpler to deliver.

He explained: "England has NHS England as a separate public entity, public body.

"There isn't an equivalent in Scotland.

"Instead you have 22 health boards, 14 of which are territorial health boards.

"So if you want a once-for-Scotland approach, that is much more difficult because you don't have a national entity."

Scotland's chief medical officer, Professor Sir Gregor Smith arrives to give evidence to the UK Covid inquiry on September 25 2024 (Image: PA) In her evidence Ms Freeman disputed this, noting that as Cabinet Secretary she used existing legislative powers to place the NHS on an "emergency footing" on March 17 2020 which meant that "decision-making at board level was superseded by my decisions".

This resulted in a "consistency" which meant that elective treatment and cancer screening programmes were paused at the same time nationally, with all boards were expected to prioritise cancer care and urgent admissions alongside Covid.

Mr Yousaf also defended the Scottish structure, arguing that an overarching entity such as NHS England is "effectively adding another layer of bureaucracy with little in return".

He added: "Not only do you get little in return, I think the worry is that the direct relationship between Cabinet Secretary for Health and chairs and chief executives is diluted [and] it could allow a Cabinet Secretary to feel like, in some respects, they're somewhat off the hook, when they should never be off the hook."

Scotland's and England's NHS systems diverged significantly after devolution (Image: DerekMcArthur/Newsquest)

No competition

In her evidence, Ms Freeman also referenced NHS England's internal market - a system abolished in Scotland in 2004 - noting that "whilst we have individual boards, they do not compete with each other for funds or in terms of their performance".

NHS Scotland is structured "to operate as a single unit, where the board's discretion...is to apply the national [Scottish Government] strategy to local circumstances".

There is plenty to criticise in England's internal market - most commonly that it turns hospital trusts "into businesses" and that administrative costs are wasteful. 

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The idea is that trusts have more freedom to develop their own strategies, patients have more choice where they are treated, and money "follows the patient". 

Trusts are incentivised to innovate because the best-performing trusts (for example, in terms of reducing waiting list backlogs) will be financially rewarded, whereas boards in Scotland tend to have a fixed budget based on funding allocation formulae such as NRAC which is weighted to factors such as population size and demographics. 

While the Scottish Government announced an extra £300 million to tackle waiting list backlogs over three years, just £30m has been awarded to health boards in the first eight months based on the extra work they agreed to take on. No more money will be handed out until that work has been completed. 

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And while Scotland has launched just two brand new National Treatment Centres (Highland and Fife) plus an expanded Golden Jubilee, trusts in England have created 90 new dedicated elective surgical hubs since Covid - taking the total to 108, with 26 more due to go live in 2025.

This may go some way to explaining why there are 2,703 people on NHS England lists who have been waiting over 18 months for a planned operation, compared to 17,731 in Scotland.