Intended for healthcare professionals

Feature Data Briefing

What’s happening to NHS spending across the UK?

BMJ 2011; 342 doi: (Published 24 May 2011) Cite this as: BMJ 2011;342:d2982
  1. John Appleby, chief economist
  1. 1King’s Fund, London, UK
  1. j.appleby{at}

England has traditionally lost out in the per capita health spend across all UK countries, but John Appleby finds it is faring better in the current economic climate

In much of the discussion and debate about healthcare spending and reform, the “N” in NHS seems often to stand for England. And yet, of course, around 10 million people in the UK (equivalent to the population of Portugal or Greece) do not live in England or (generally) use its healthcare services. For those of us who do live in England and consume English based media, not noting the existence of such English bias may itself be an example of English bias (or plain ignorance).

Apart from confusing England for the UK, there is also a problem with treating the UK as the UK. The Organisation for Economic Cooperation and Development (OECD), for example, treats the NHS as a UK-wide organisation for the purposes of collecting health statistics. Devolution means that this aggregation makes less sense than it once did. This is not just an issue for the UK. Many countries—Spain, Italy, Germany—have forms of devolved administrative, political, and policy arrangements in healthcare (and other areas) that can make aggregation at a national level if not wrong, at least potentially misleading.

What territorial unit of analysis makes sense depends on the question and the topic. To take one (albeit absurd) example, FIFA’s rankings of international football teams do not contain a UK team ranking based on a composite of the four UK countries’ match results. But how much sense does it make, for instance, to combine NHS spending into one aggregate number?

But given the political arguments about whether the NHS has received a real increase in funding over the next four years as the government claim, it is important to be clear about which NHS is being protected (or not). Certainly planned health spending in Northern Ireland is not going up in real terms—it will be cut by around 2.2% by 2014-5 (fig 1).1 2 And in Scotland, NHS spending will be cut in real terms by around 3.3% this year (with no plans yet made for spending in subsequent years).3


Fig 1 Change in real NHS spending, 2011-51 2 3 4 5

Despite these cuts, the NHS has done quite well compared with other areas of spending in Northern Ireland and Scotland. But in Wales, the NHS is set for a real budget cut of nearly 11% over three years.4 As for the NHS in England (for which the political pledge was made) it looks as if real spending will be around 0.9% lower in 2014-5 than in 2010-1.5 For the UK NHS as a whole funding will be cut in real terms by 2014-5.

NHS spending in England dominates UK spending of course—spending in the South West region alone is equivalent to that of Wales and Northern Ireland combined, and London’s healthcare spending is equivalent to that of Wales and Scotland combined (fig 2). But traditionally, spending per head in England has been lower than in all other parts of the UK (fig 3). On average, over the past seven years NHS spending per head in Scotland has been around 15% higher than in England—equivalent to a financial gap of over £15bn—or the annual budget of London’s entire NHS.6


Fig 2 NHS spending for 2008-9 broken by country and region


Fig 3 Changes in NHS spending per head, 2002-10


Cite this as: BMJ 2011;342:d2982


  • Competing interests: The author has completed the unified competing interest form at (available on request from him) and declares no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; not externally peer reviewed.