“If a minister from England asked you about breaking the English NHS into regions, what would you say?” I asked this of a senior official in the Andalucian ministry of health. “Break it up. No question. You can’t manage a system for more than 10 million people well.”
Spain has made this transition. In the days before democracy came in the 80s, Spain was very centralised. With democracy came regionalisation. Initially the proposal was to create parliaments in just some regions—Catalonia, Galicia, and the Basque Country. But Andalucia wanted it for all regions, and that’s what happened. There are now 17 regions each with its own parliament, president, health system, and much more.
At the same time Spain also moved from a social insurance system to a health system funded from taxation. Spaniards do pay regional as well as national tax, but it’s all collected centrally and distributed. The formula for health system funding is based on population, deprivation, age structure, and geographical density. The distribution of funds creates squabbles but, it seems, not much more. Despite some of the regions having their own languages, Spain seems very far from breaking up. “Regions have enough autonomy,” says the official.
Regions have to provide a certain minimal health service, but they can chose to spend more and how to organise their system. Spain is thus a living laboratory for health systems with each region watching the others for useful innovations. For example, a requirement to allow patients to record living wills began in Catalonia and spread rapidly to other regions. Andalucia prides itself on a publicly funded, publicly provided system, while Valencia has experimented with a public-private mix. Unfortunately, as in the UK, data systems do not allow full comparison of inputs and outputs, but the country is working to fix that.
A Swedish study showed Spain to have the second most efficient health system in Europe (after Finland), something that the official puts down to strong primary care, salaried doctors, an integrated system, universal coverage, funding from taxation, and low administrative costs. There are no administrators between the ministry and the hospitals and clinics serving 8.5 million people. And drugs are purchased nationally—so that Spain can use its full purchasing power.
Spain also has nothing like the variation in life expectancy that Britain has, and despite the regional structure there seems to be less variation in the processes of the system; and there aren’t big complaints about services being available in one region but not in another.
The Spanish official is not alone in thinking that the English NHS should be broken up. Many of my Scottish and Welsh friends think the same, and I’ve heard private sector people argue that it’s impossible to run a good health system for 50 million people even if there is a half-hearted attempt at a quasi-market.
But the crucial difference between the Spanish and English regions is that Spaniards identify strongly with their regions in a way that the English do not. John Prescott proposed regional parliaments and was rebuffed. And the regional parliaments are very much part of the Spanish system. There has to be a strong system of democratic accountability for the system.
So perhaps despite the unequivocal advice of the Andalucian official we need to stick with a national NHS in England for now, but I do believe that a regional system, particularly one that allowed detailed comparisons, could be better than our current one.