Devolution and health policy: A map of divergence within the NHS - 1st annual update
April 2007
Organisational environment
Since 1997 structures in England have changed on average every 18 months. There is a movement towards acute services being streamlined, more services delivered in community or non-specialist settings and greater emphasis should be placed on anticipatory or preventative interventions.
The four UK health systems all face similar challenges in achieving this aim and have adopted different approaches to deal with them. It is reasonable to suggest that divergence in policy is a result of the acknowledgement of differences both within organisational structures and the way in which healthcare is delivered in each nation. 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 choosing to focus on single system working and regional and central planning, Community Health Partnerships have also initiated closer working between primary and secondary care professionals at the local level. In Northern Ireland the rationalisation programme has focused on reducing hospital trusts, reconfiguration is beginning to be implemented and commissioning models being developed.
The extent of change in Northern Ireland continues to be influenced by political processes such as the reintroduction of the Northern Ireland Assembly. In Wales similar political barriers to service change exist perpetuated by the continuing strength of healthcare providers. It is unlikely that significant delivery of the reconfiguration agenda will take place on a national level before the May 2007 elections however inevitable campaigning in the press will occur on issues of public interest such as the closure of local hospitals.
England
Change has been a common term in the NHS over the past decade. There have been a significant number of ‘reforms’ and changes in the way healthcare is delivered.
The headline change since devolution was the introduction of competition, which went beyond the internal market of the early nineties due to acceptance of the independent sector in care provision. In 2002 the government anticipated 15 per cent of elective surgical procedures and an increasing number of diagnostic procedures may be delivered by the private sector by 2008 [go to note 20]. It is not known how much service provision is delivered by the private sector, what is known is that there have been varying degrees of success in the roll out of independent sector treatment centres.
There are signs that the NHS will place much more emphasis on commissioning. This is seen as a tool to manage the market, move decision making closer to clinicians and to move outpatient care from hospitals and into the community. In England, the line between public and private is becoming increasingly blurred in relation to the provision, management and commissioning of health services. For example, patient choice has been a big issue for government however there is increasing evidence of both over and under capacity in relation to the conflict between private and NHS providers of care, both who are fulfilling contractual arrangements with PCTs. The theory behind the move to a competitive environment reflects a view that organisations are not responsive to their users. By encouraging competition between providers, each will be paid a tariff for each procedure they perform meaning that hospitals will face incentives to make services more attractive to patients.
This change may have significant repercussions for NHS hospitals. Whole hospitals could be destabilised. Either an entire institution will transfer to a new management, possibly in the private sector, but more likely, the departments within a hospital will cease to be viable. If departments do not attract enough patients (and money) to pay for the overheads, opportunities to cross-subsidise departments may also be limited. Some hospitals have been awarded greater autonomy to determine organisational strategy in a market. In previous years, a hospital deficit was met by any surplus in region. Now hospitals will be liable for their own debt and could go out of business, although in practice this is more likely to mean a takeover of management.
Policy in England is designed to cause ‘creative discomfort’ based on a view that new incentives in the system will force innovation and improvement. The government has yet to define ‘market failure’ but it is likely it will lead to a change of management. It is already the case that doctors stay within institutions longer than managers, but this tendency may be increased. Market failure could also lead to private firms being awarded contracts to manage public facilities. This could lead to quite different relationships between doctors and employers. In the face of an ongoing government review, and changing policy, there is some uncertainty about the future of regulation (see section 7).
Scotland
Scotland places more emphasis on regional and central planning which is a key difference between Scotland and England. There are 14 NHS Boards in Scotland (11 mainland and three island boards), to manage local health care organisations, give strategic direction and provide clinical governance. A recent reduction in the number of mainland boards from 12 to 11 may be a move towards a wider reduction in the number of bodies tasked with providing and delivering healthcare in Scotland. The boards have representation from medical professionals, through managed clinical networks.
Scotland has shaped its organisational environment in almost the opposite direction to England. The purchaser-provider split has been dismantled and trusts have been dissolved and both are now part of boards and within a ‘single-system’. The NHS Reform (Scotland) Act 2004 gave a legislative framework to organisational and management changes and continued to enforce the new professionalism model.
On a smaller scale to England, Scotland has used private sector capacity. The involvement of the private sector appears to be part of a transition process by supporting acute care and managing waiting lists while secondary and primary sectors are reconfigured. In England, private providers were set to become a permanent part of the landscape, for Scotland however there is no real policy drive for this area of healthcare delivery reflecting the focus on planning for the health needs of the population rather than focusing on competition as is the case for England.
In Scotland the focus is currently on the use of networks and partnerships. Existing and new primary and secondary care organisations are working together with allied professions to deliver the service. In England the focus is on market forces and associated financial incentives to provide efficient services through competition and a separation of commissioning and provision. Scotland is aiming to forge united health systems breaking down these structural barriers.
Northern Ireland
The Northern Ireland health service is unusual because it integrates health and social care in a single structure rather than the fragmented structures in the other UK nations. The Department of Health, Social Services and Public Safety is responsible for the overall planning and regulation of the health service.
The recent review of public administration has important implications for health as well as other services in Northern Ireland. The changes to organisational structures in Wales, as announced in 2005, sought to:
- Reduce the number of local authorities from 26 to 7
- Reduce the number of non-departmental public bodies from 154 to 75
- Merge the four health and social service councils into one regional patient client council
- Merge the four health and social services boards into one regional health and social services authority with outlying offices
- The health and social services authority will oversee local commissioning groups in each of the 7 new local authority areas
- Reduce the number of health and social service trusts from 18 to 5
Direct rule ministers have generally been comfortable with the ‘permissive managerialism’ arrangement in the past. However, with the perceived likelihood of a new labour leadership in 2007 the issue of fiscal efficiency has been raised in Northern Ireland due to the reform proposed needing financial justification. The stated aim of the review of public administration is to eliminate bureaucracy and release more resources for frontline patient care. Whether the funds released from reducing bureaucracy will be spent on patient care remains to be seen and will largely depend on the mechanisms for identifying and releasing such funds.
Shaun Woodward was the first health minister to explore the issue of reform in health (11 May 2005 to 5 May 2006) and was involved with the decisions based on the RPA. Paul Goggins, the present Direct Rule Minister is continuing to oversee reform happen, with the reform of all health organisational a structure is to be completed by April 2008.
Wales
In Wales, there is a considerable emphasis on local NHS bodies and local authorities working together to meet local needs. The onus on localism means that there are fewer opportunities to focus on all-Wales healthcare.
In Wales there are 22 local health boards in each of the local authority areas. The boards are responsible for commissioning primary care. Secondary care is commissioned by local health boards and delivered by NHS Trusts and, when it comes to specialist services, through Health Commission Wales. There are 14 NHS Trusts in Wales and they manage about 135 hospitals.
NHS Wales, the executive department that manages the NHS, has continued to operate on a similar basis as it did pre-devolution however there is no longer a reliance on political direction form the centre. Power is concentrated into local health boards who focus on local issues. This has resulted in less capacity to make decisions for Wales. The fragmented nature of localism has also limited the power of health boards to shape large and powerful acute trusts.
Wales has less input from the private sector than other devolved nations. The private sector is unlikely to play a role in the delivery of NHS services. Although there seems to be some recognition of the need to change there is no clear organisational plan to do this. The private sector has not been on the agenda within Wales and has been distinctly missing from coalition government negotiations.