Devolution and health policy: A map of divergence within the NHS - 1st annual update
April 2007
Views of professionals
Professional regulation remains a UK wide issue. Within the UK there are many different philosophical and organisational approaches to the role and function of healthcare professionals. Whether this remains will be influenced by the extent to which regulation is seen as an area that disables the implementation of national policy.
Regulation of the healthcare profession is UK wide with professionals in each nation adhering to the same framework. The Department of Health white paper on regulation [go to note 24] has been cautiously welcomed. Publication of further change to the system by the Chief Medical Officer has acknowledged difference between the devolved nations and central administration and the need to recognise these differences. There has been a better appreciation of the different ways in which doctors’ work, though the BMA believes this is still inadequate and does not fully appreciate the direction of travel within policy towards specialist care being increasingly provided outside hospitals. There is also concern about the policy implications for the proposals on a national level which are still to be worked through. Elements of the proposed regulatory framework are vague and, if the framework is negotiated at the local level will see different settlements in different nations. This may have implications through disparities in the framework and therefore difference in cross boarder regulation.
Further differences are also seen at the national level in other areas. The recent implementation of the DDRB recommendations for doctors by Scotland in full contrasted with the staged implementation in England and resulted in different pay structures. The application system for junior doctors is a further example of different professional views in the nations. The Medical Training Application System (MTAS) was supported in Scotland by close working between politicians and representatives of the medical profession (SJDC) and has been implemented reasonably successfully however, in England, the medical profession challenged the process and outcome and have disengaged from the review process [go to note 25]. 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.
In every country, those running the system would wish doctors to work differently and in line with different visions for health systems. Attention is being drawn to doctors incomes due to spiralling costs which have been blamed on the new GMS contract and the new consultant contract. Attention is also being drawn to long waiting lists which the media is suggesting is partially blamed on doctors not working enough in the public sector. Across the UK, there are different views of doctors with the biggest contrast being between Scotland and England.
England
In line with a move to patient choice, competition and market levers, there is greater emphasis on incentives as a way of changing the behaviour of doctors.
Julian Le Grand, the former advisor on health policy to the prime minister, has written widely on incentives. His view is that policy has historically seen doctors as ‘knights’, valiant defenders of patient interest and promoters of altruism. Policy has floundered on this assumption and policymakers need to understand doctors as ‘knaves’ who are, in part, motivated by their own self-interest.
The working environment in England could change further with the development of a greater number of potential employers from different sectors and opportunities to undertake extra work in treatment centres or in PCT commissioned clinics. Some doctors are moving to form collaborations which can bid for NHS work. There is some concern that payment-by-results encourages acute centres to undertake more procedures and costs more. To counter this, GPs are being given incentives to provide care in local settings in order to provide less costly treatments and care in community settings. This is likely to lead to tensions between primary and secondary care.
Scotland
In Scotland, doctors were seen more as more ‘knightly’, primarily concerned with the quality of the system rather than their own position in it. The policy agenda has been shaped by senior medics and doctors are seen as central to developing the policy agenda.
The Royal Colleges in Scotland and the BMA have, in general terms, supported the reconfiguration agenda. More than two years ago, the BMA briefed members of the Scottish parliament that ‘the BMA believes that now is the time to hold a rational and sensible debate on this matter which reflects not only public concerns but also the important issue of safety and quality of health services for the people of Scotland’ [go to note 26]. Since that time the BMA has sought to promote the interests of Scottish doctors through regular parliamentary briefings and recently with its manifesto which considers issues affecting public health, NHS reform and the medical workforce [go to note 27].
Northern Ireland
In Northern Ireland instead of being seen as either a ‘knight’ or a ‘knave’ (see 7.1 and 7.2), the status of doctors could be described as ‘squire’ [go to note 28]. Whilst doctors have input into policy formation, their advice has usually been ignored because the status quo must be maintained. Doctors are not seen as resistant to change as a ‘knave’ is, as government policy is ‘no change’, nor are they seen as a ‘knight’ as they do not have the power to force change. Northern Ireland could go either way in the next few years.
The roll out of the GMS and consultant contracts has also changed the relationship between doctors and the NHS in Northern Ireland. There are those within the health service who view the associated costs as a drain on limited resources (the money for the two new contracts had to come from within the existing HPSS budget). The change in attitude has caused GPs and consultants to feel frustrated, not at the contracts but on their implementation. For example with regard to the implementation of the consultant contract there are problems with job planning, facilitation, guidance documents, the number of Programmed Activities, lack of training for managers and non-implementation of appeal panel decisions.