English hospitals are outperforming those in Scotland and Wales

Over five years on from the height of the COVID-19 pandemic, and despite some recent improvements, hospital services in England remain in a poor state. Statutory performance targets are far from being achieved, whilst productivity remains lower than pre-pandemic. International comparisons can often cast the performance of English hospitals in an unflattering light.

However, things look quite different when we consider the two health systems most comparable to England’s: namely, the NHS in Wales and Scotland. Health has been devolved since 1999, and both nations operate a similar model in similar conditions. Yet, on many measures, hospitals in England are performing better, and have recovered more quickly from the pandemic.

In the run up to elections in Scotland and Wales in May, we have recently published new IFS analysis on NHS hospital performance in both nations. Here, we consider the implications for services in England.

Take first elective waiting lists. All three countries saw a sharp rise in the backlog for elective care during the pandemic, and all three subsequently made reducing waiting times a key policy focus. In England, progress has been slower than many had hoped: ‘elective recovery’ targets have been repeatedly missed, and 2% of patients were still waiting more than a year for treatment in December 2025, nine months after these waits were originally intended to be eliminated. But in Wales, where statistics are most comparable to England, nearly 20% of patients have been waiting more than a year for treatment, and the median waiting time is more than 40% longer than in England. In Scotland, waiting times are measured differently, but 9% of patients are waiting longer than a year for elective activity, compared with 1% in 2019.

Or consider volumes of hospital activity, where we see large differences in post-pandemic recovery. Whilst England has repeatedly set and missed targets to increase levels of hospital activity, English hospitals are now consistently carrying out more outpatient appointments and hospital admissions than in 2019. The same is not true elsewhere. Scottish hospitals are still delivering less activity than in 2019. Welsh hospitals are carrying out many more outpatient appointments, but have only recently seen hospital admissions reach pre-pandemic levels.

This is not a result of higher NHS spending in England. Headline spending per person is higher in Wales and Scotland. Even after adjusting for differences in age structure, spending per person is higher in Wales, and similar in Scotland. All three governments have also significantly increased both spending and staffing levels since the start of the pandemic: England has increased staffing by 25% since 2019, Wales by 24% and Scotland by 14%. 

These statistics suggest that Wales and Scotland, like England, have a hospital productivity problem. In all three nations, funding and staffing have increased much faster than the amount of hospital care delivered since the start of the pandemic. This suggests that English hospitals’ productivity challenges are far from unique, and are therefore likely to be primarily driven by changes that have affected similar healthcare systems since the pandemic, rather than just England-specific factors. But unlike in England, Wales and Scotland lack detailed measurement of productivity, making it hard to draw firm conclusions. The clear focus on measuring and improving productivity has been a welcome policy decision that has set England apart in recent years.

Not all services are performing better in England. A&E departments in Scotland, for example, have long had the best waiting times in Great Britain, a trend that has continued even as all three nations have seen deteriorations since the pandemic. More recently, this could reflect the overwhelming focus from the UK government on improving elective performance in England.

But, in general, it seems that struggling English hospitals are still delivering better services than elsewhere in Great Britain. Some of the reasons for this are longstanding. Populations in Scotland and Wales are older, more sparsely populated, and on average in worse health than those in England. Some additional health spending in Scotland and Wales goes on things that England does not provide, such as universal free prescriptions and more generous coverage of dental treatment. Yet some of the most striking differences in performance have opened up over the last six years, a period in which all three nations have faced a very similar set of challenges. 

These comparisons do not imply that English hospitals have had an exemplary post-pandemic recovery, or that there are not areas which need to see further progress. But those rightly pessimistic about the state of the English NHS should note that, compared to our closest neighbouring healthcare systems – both of which spend more per person – performance looks better overall.

This article was first published in Health Service Journal, and is reproduced here with kind permission.