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Devolution and health policy: A map of divergence within the NHS - 1st annual update

April 2007

Summary
This report updates the overview of changes in the NHS since devolution. It draws on academic accounts of the impact of devolution and provides a policy analysis of divergence and the implications for the BMA. First published in 2006 the map of divergence is updated annually following a decision by BMA Council to devote a session each year to discussing devolution.

The UK has always had different health policy processes because of the separate administrative structures in the four nations. It was thought that devolution would have little impact in health however the creation of national assemblies for Wales and Northern Ireland and the Scottish Parliament has accelerated difference between the nations.

The 2006 report mapped the impact of devolution in each of the nations by identifying the different policy directions in each nation. Changes which have occurred since the first edition of the report suggest that each nation has continued to follow their own policy direction. England is continuing with an incentive approach using market style incentives to create a self improving system. Scotland is implementing professionally led single system working through Community Health Partnerships. Wales has introduced free prescriptions but retains emphasis on local NHS bodies and local authorities working together to meet local needs and Northern Ireland has introduced organisational rationalisation although the Assembly. Each nation has different health policies; the extent of divergence as a result of devolution is mapped in this report in five broad themes.

1. Political context
Unresolved tensions in the UK remain where government operates on an English only basis but performs UK wide functions. Increasingly there are tensions between the different levels of political influence, for example the ‘West Lothian question’ [go to note 1] remains where Scottish MPs are able to vote on
English issues at Westminster but the opposite is not true. In response to these tensions the Conservatives have proposed that non English MPs should not vote on English only matters in Westminster.

There is also a growing awareness of divergence and a narrowing of policy focus amongst UK politicians and the Department of Health. It is suggested that Westminster is representing different philosophies on health in each nation which is resulting in an anglo-centric health policy approach. Scotland, Northern Ireland and Wales however, are continuing to develop distinct national health policy approaches of their own. Policy in Wales and Scotland remains mainly from the left whereas England focus is mainly from the right.

The national and local elections in May 2007 will influence the political context in each nation and will have important implications for the direction health policy in the UK and in each nation. A non Labour administration may be elected in Scotland representing a move away from one party government on a UK level. Local elections are also likely to result in change with hospital reconfiguration becoming an increasing concern and likely to result in further localised political difference.

2. Strategic direction
Each of the devolved nations has its own political dynamic, with each associated policy community concerned with different initiatives and approaches. English policy adopts a market and management approach, Scottish policy focuses on single system working, Welsh policy a ‘localist’ approach and in Northern Ireland ‘cautious managerialism’. Each nation has distinct approaches to policy with different strategic directions. The strategic direction of each nation has in itself become politicised. Scotland’s strategic direction and policy implementation is increasingly compared more favourably than in England. The BMA’s alternative vision for English health policy proposes components of Scottish policy to support a new approach to the reform agenda. These differences have consequences for those working in the system and organisational structures.

3. Organisational environment
Since 1997 structures in England have changed on average every 18 months. More recently England has departed from a top down approach to policy and used incentives to manipulate market style responsiveness from organisations.

New commissioning models are likely to increase local autonomy which may result in the regionalisation of health systems increasingly towards the local level. Scotland has regionalised its organisational environment through creation of health boards however it has not adopted the market approach, instead Scotland has chosen to focus on single system working and regional and central planning. In Northern Ireland the rationalisation programme has focused on reducing hospital trusts; reconfiguration is beginning to be implemented and commissioning models are being developed. The extent of change in Northern Ireland continues to be influenced by political processes such as the reestablishment of the Northern Ireland Assembly. In Wales similar political barriers to service change exist, perpetuated by the continuing strength of healthcare providers.

4. Changing financial and regulatory environment
The financial arrangements for the UK NHS continue to be determined by the UK Treasury. NHS expenditure for the devolved nations is determined by a block grant. From 2008 the rate of budget growth will slow and will be allocated differently. It is likely this will result in increased financial pressures for all nations.

The current reform programme in each nation could be considered an attempt to create a service that is sustainable without increased funding. England’s competition approach is likely to raise costs by incentivising treatment and increasing the number of access points (based on payment by case). In England the development of new local financial ideas, such as localised negotiation of the Quality and Outcomes Framework (QoF) or localised unbundling of Payments by Results (PbR) may occur. It is also likely that there will be increased innovation within the emerging incentives market. Funding is a concern across the UK. The devolved nations are addressing problems through service redesign and rationalisation rather than using the English model of competition or increased involvement of the independent healthcare sector.

A further issue is the role of the UK within the European Union (EU) and the implications of devolution on national health policy. The EU recognises the UK as a single member state which in the future may lead to increased dialogue about which nation is the lead country on UK issues. There may also be implications for devolution and divergence if the EU sets standards for health, for example through EU target waiting times.

5. Views of professionals
Within the UK there are many different philosophical and organisational approaches to the role and function of healthcare professionals. Nationally the greatest contrast is between doctors in England and Scotland. England is placing emphasis on incentives as a way of changing the behaviour of doctors however Scotland is concerned with the quality of the system and diluting reliance on doctors leading service provision.

Regulation of the healthcare profession is UK wide with professionals in each nation adhering to the same framework. The publication of changes to the system by the Chief Medical Officer in England caused tensions, there has since been an acknowledgement of difference between the devolved nations and central administration and the need to recognise difference. Elements of the proposed regulatory framework are vague, if the framework is negotiated at the local level there are likely to be differences in cross boarder regulation which has implications for the workforce and service delivery.

Further differences are also seen at the national level. The recent full implementation of the DDRB recommendations for doctors in Scotland contrasted with the staged implementation in England and resulted in different pay structures within the NHS. The application system for junior doctors is a further example of different professional views within the nations. The MTAS system was supported in Scotland by close working between politicians and representatives of the medical profession (SJDC) and was implemented reasonably successfully however, in England, the medical profession challenged the process and outcome and have since disengaged from the review process [go to note 2]. A key issue for all nations is the approach to healthcare professionals in each nation, in particular the impact of change in service redesign and the implications on skill mix.

Conclusion
Since this report was first written in 2006 each of the four nations has continued to further develop their own policy direction. While policy aims are similar across the UK, each nation is evolving their own way of taking forward health policy to meet the needs of the population they serve. These aims are driven by fundamentally different philosophies to health service improvement.

The existence of divergence provides opportunities for the BMA to learn from development in each nation. There are also opportunities to call for policy changes that are working effectively in one country, region or locality.

This map of divergence will be updated annually, the 2008 report will take into account the political changes that are likely to result from the national elections in May 2007. The report will also provide an opportunity to track the extent of divergence across English regions which is will further complicate the map of divergence. The report will also consider the implications of UK regionalism for the BMA.