Devolution and health policy: A map of divergence within the NHS - 1st annual update
April 2007
Strategic direction
At the point of devolution, national decision-makers inherited similar problems. All, except Northern Ireland, made an immediate move away from the internal market and a political will to increase resources, although this was delayed for the first two years because of the commitment Labour made to Conservative spending plans. Spending in the NHS has been at record levels with an average of 7 per cent. In 2007 a return to spending levels slightly above inflation will occur, the impact of funding limits are being seen in England with NHS trust deficits, redundancies and resource restrictions.
Each of the devolved nations has its own political dynamic and policy communities that point health policy in quite different strategic directions. Greer has given labels to these distinct approaches (table 2). English policy is characterised by markets and management, Scottish by a new-professionalism, focusing on networked clinical management. Welsh policy is described as primarily ‘localist’ while Northern Ireland is labelled ‘permissive managerialism’ – though, as noted above, this is beginning to change. It is worth noting that as the least changed of the four systems, Northern Ireland is consequently quite different.
Table 2 - Distinct approaches to health policy in the four nations (adapted from Greer [go to note 12])
|
England |
Northern Ireland |
Scotland |
Wales |
Organisation |
Market localism |
Staus quo |
Hierarchical regionalism |
Localism |
New public health |
Largely verbal (obstructed |
Largely verbal (not |
Fairly strong commitment |
Strong commitment |
Expansion of the welfare |
None |
None |
Long term care |
Free prescription charges |
England
The NHS Plan [go to note 13] claimed to be the most fundamental and far reaching reform of the NHS since 1948. It was issued in 2000 and at least two other reforms have been described in the same terms since. New Labour came to power committed to abolishing the internal market, but has now revisited this way of delivering healthcare. Policy initiatives, collectively known as ‘system reform’, support the development of a market with a mixture of private and public providers. The language of English policy includes ‘informed consumers’, ‘incentives’, ‘competition’ and ‘responsiveness’, words that tend not to appear in dialogue from other nations.
The English approach reflects a dominant political view that the NHS is a self-serving institution. Policy aims to expose the NHS to patient pressure by forcing providers to compete for referrals, based on the view that a more responsive, ‘patient centred’ service will result. Policy priorities now include developing more points of treatment and better information to judge services, which will both aid consumer-style choice. A movement towards community hospitals has also resulted with the Health Secretary welcoming bed closures as a ‘healthy sign for the NHS’ [go to note 14]. In February 2007 the government also re-launched their previous focus on waiting times with a commitment to ‘focus all NHS staff’ on waiting times with no patient waiting more than 18 months by 2008 [go to note 15].
The English health policy community is unique is nurturing many more pro-market, pro-management ideas than any other in the UK. There are numerous think-tanks, academic departments and professional bodies creating a whirlwind of debate. The main body of the policy community is generally supportive of the direction of change. There are, however, different views on the depth and speed with which observers believe the latest version of the reform agenda should be progressed.
Scotland
The Scottish health-policy community is based on medical and professional elites which includes three Royal Colleges, and five university medical centres. Policy-makers and healthcare professionals appear to have a closer professional relationship in the development of health policy which is often lacking elsewhere. The last five years have seen Scotland take significant steps toward the distinctive policy it now espouses, a direction which has been influenced by its policy community. The strategic direction has been developed by senior doctors, Sir David Carter, and latterly, Professor David Kerr. More recently
Dr Kevin Woods, chief executive of NHS Scotland, has taken forward policy development. Other contributors in the policy community have been critical of the policy agenda of the Scottish Executive.
The priority of Scottish policy is to create an integrated health system with close connections between different components, an approach more likened to single system working. The aim is to develop care pathways by building on clinical networks between specialist acute services and primary care. Kerrs report ‘Building a Health Service Fit for the future’ [go to note 16] and the Scottish Executive’s response ‘Delivering for Health’ [go to note17] have resulted in joint working, both between boards through local planning and locally, where the principle vehicle has been Community Health Partnerships, working also with local authorities.
Scotland is seeking to centralise the most complex high-end services and move care out into the community – even beyond district general hospitals to community treatment centres and the primary care sector. Greer says that the move toward more community provision ‘clearly stems from both the solid political bases of Scotland’s health service organisation and the fearsome political consequences of the hospital closures that would be required without new thinking about service delivery’ [go to note 18]. For example, the remote and rural lobby in Scotland has been vocal and has influenced health policy successfully as evidenced by the establishment of rural district general hospitals.
Northern Ireland
A lack of change in Northern Ireland has led to the internal market continuing much longer in Northern Ireland than elsewhere. This has been exacerbated by a lack of interest in health policy in the local politics of Northern Ireland which reduced any incentives to develop or implement policies. Even in this unique political context policy differences have emerged. Legislation differs with respect to mental health and death certification. There have been no foundation hospitals, NHS Direct, PMS or Primary Care Trusts.
The review of public administration is changing the shape and number of acute trusts and boards and there will be new commissioning structures. This future direction has elements of Scottish redesign, Welsh localism, and English emphasis on devolved commissioning.
Wales
Like Northern Ireland, Wales is changing its strategic direction. The policy community is different in Wales to that in England or Scotland.
A crisis in services prompted an attempt to develop a policy community. Recently there were discussions to develop a ‘health academy’ which received some support. The BMA has been involved in discussions with the NHS Confederation and the RCN to focus on solutions to Welsh problems. A number of stakeholders including the medical profession have been brought together by government to ensure close working relationships result.
At the outset of devolution, the Welsh Assembly has sought to closely align the NHS with local authorities. Local Health Boards were established to plan and commission services, while an all Wales body commissioned specialist hospital services. Wales has sought to change the health agenda considerably since devolution. There has been a shifted focus away from maximum productivity towards changing the social determinants of health and integrating democratic politics and community to the heath system. The public health agenda is prominent and there is an emphasis on preventing ill health and reducing health inequalities in policy. Policymakers have adjusted the way resources are allocated in the NHS to take account of the needs of disadvantaged areas and created an ‘inequalities in health fund’.
There is recognition of the need for greater engagement with the profession in the development of policy solutions. In 2004, BMA representatives, Tony Calland and Richard Lewis called for a root and branch solution, seeking to lead a debate on the redesign of services. The recent strategic plan, ‘Designed for Life’, is considered to be the first step in changing services and in 2006 resulted in the development of the BMA’s ‘Informing NHS recovery [go to note 19]’ document which sets out the key values and principles to help shape and inform the future of NHS Wales for the benefit of patients and staff.