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Devolution and health policy: A map of divergence within the NHS - 1st annual update
April 2007
The implications of a map of divergence under devolution
This paper has so far concentrated on detailing some of the political, philosophical and policy differences that account for divergence in the NHS. This section draws out some implications for UK doctors.
Health policy in the UK differs according to two dimensions: ‘left-right’ and ‘unionist-nationalist’. In England, the political challenge to government has come mainly from the right whereas in other nations it tends to be from the left. Outside England, there is perhaps greater consensus on left-right issues and little appetite for market orientated solutions. Devolution continues to have little bearing on English consciousness. There remain unresolved tensions in the UK government operating on an England only basis where there is a requirement to perform UK wide functions and maintain quasifederal responsibility. Figure 1 illustrates that the political context guides the operational focus of the health system toward different ends. This model implies that doctors in the UK face different incentive structures and working environments.
The arrows are intended to show the general direction of policy in different countries. England is to the right of other systems, and moving further in that direction. UK structures are employed to manage the English health system, but not that of others. Scotland is showing some movement to the right in permitting some mix in provision but it is also becoming more nationalist therefore forging its own unique policy direction. Wales and Northern Ireland are each developing more local policies.
The unionist-nationalist dimension has become an important dynamic during devolution. While Northern Ireland is the most unionist governed by direct rule, it has not followed the English agenda. England itself has become more introverted and a key implication of is that there is very little explicit UK focus on health policy.
Relating to four political systems and policy communities
The fracturing of political and the policy communities have four key implications for doctors:
- With no UK focus for health policy, UK-wide institutions have no choice but to represent and pursue medical interests in four administrations. Both the broad direction and particular detail of policy is increasingly nationally driven.
- Administrations have developed different characteristics, requiring different relationships. England has continued the formal Westminster process of access to politicians, but outside England political villages are smaller and relationships with government less formal and adversarial. Political villages afford more influence, which could be further capitalised upon.
- Relationships with key agencies need to be reviewed. Administrations have set up a number of agencies and regulators that are crucial determinants of doctors working environment. Given the importance of the policy community in influencing political direction there is a need to review relationships with the policy communities in each country and consider how these could be further developed.
- Policy is becoming as important as negotiations in promoting medical interests. Doctors have in the past, gauged their representational efforts according to access to ministers, senior civil servants and the influence of negotiations.
Positioning the BMA in relation to four strategic directions
Policymakers across the UK have established a direction of travel, but are not clear about the precise mechanics of implementation. Policymakers are dependent on doctors to play a leading role in the process. In England, for example, practice based commissioning depends upon innovation from GPs. In Scotland, as in England, moving services to community settings will require new ways of working across primary and secondary care.
Different strategic directions will necessitate different ways of approaching policy. In England, the BMA will need to ensure responsiveness for members in the quasi-market and understand how choice and PbR affects the quality of care and ways doctors work. While doctors are broadly supportive of the main policy goals, there are some questions about how they will be achieved. In Scotland, there is debate with the medical profession in reconfiguration and on-going debate about levels of provision. In Wales, the BMA initiated debate which led to the publication of ‘Designed for Life’ and is seeking to move the debate further with the publication of ‘Informing the NHS recovery’. More so than Scotland, doctors have been kept at the margins of reform. In Northern Ireland, the BMA will be looking to engender and focus a debate on the aims and trajectory of health policy.
The contours of debate will vary between counties, and consequently doctors will relate to the discussion in different ways, but the headline issues are remarkably similar. Devolution has produced a natural policy experiment and, as identified by Greer, there are four ‘different bets’ on how to best achieve some common aims.
There is potential for doctors to differ in their approach to different issues. For example, the BMA recognises the political consensus on the reform agenda in England, which involves mixed provision and larger roles for the private sector. This scenario may not however be one that other countries wish to see.
Different working environments for doctors
Comparing the strategic direction and organisational context, it is worth asking, to what extent the NHS remains a national health service when it is no longer directed at the UK level and has become four national health services.
There are implications for the way that doctors are represented in policy debates. The consequences of different policy directions in terms of working environments are potentially far-reaching. Reforms mean that English doctors may not be as NHS focused in the future. There may be a wider choice of employers in England and competition in England may create a turbulent employment environment. In addition, the move to create more services outside of hospitals could see hospital doctors directly contract with commissioners. For example, some doctors are forming limited liability partnerships in order to directly contract for services.
In England, as organisations develop more autonomy, there may be a more localised approach to incentives and contracts. Changing incentive structures in one UK country will invariably impact on others. Initiatives like practice-based commissioning will be closely observed in regard to effectiveness and changing service patterns. To date there has been little divergence in the way doctors are paid. Differences are, however, emerging and there is potential for more change as nations try to align incentives toward central objectives.
The consultant and GP contracts have resulted in some variations in terms and conditions for hospital doctors. Coupled with different directions for policy, there is potential for the devolved administrations to seek to steer job plans towards different aims, meaning, in time, there could be quite different ways of working. For example, this potential is stronger in primary care where the Global Income Guarantee is calculated centrally and sent to the four countries and then on to PCOs for distribution. These monies may be linked to payment mechanisms in different ways, as countries pursue differing priorities [go to
note 29].
Across the countries there is likely to be interest in productivity in the future. England is likely to maintain its focus on incentives and more transparent financial flows. Scotland and England may employ incentives in different ways to encourage GPs to develop more community services. Inevitably, there will be comparison between the different approaches that have been taken across the UK and it may be difficult for countries to sustain different directions. Scottish doctors are already participating in workforce performance and effectiveness meetings to look at productivity measures; it is likely that workforce design will become increasingly important in developments to the structure of service delivery. Across the UK, a key objective is to redesign services by working differently across primary and secondary care which will inevitably have an impact on skill-mix. Engaging healthcare professionals from both primary and secondary care will be key to fulfilling this policy objective.
Developing a local view within a UK focus for medicine
With radical change on the agenda for England and on the horizon in Scotland, Wales and Northern Ireland, doctors have been unable to avoid debate about how to change services. There are opportunities for doctors to take the lead in how policy should be shaped, but because of the different organisational contexts, some key issues may be approached variously. These range from pensions to the handling of patient complaints. In England, for example, even the most senior of policy analysts are not clear about how different parts fit together and it is likely that reform will be increasingly shaped at a local level. The precise configuration of PbR, choice and plurality is likely to vary between areas.
The BMA will need to develop a picture of change, while maintaining a UK focus on policy. It will be important to recognise difference and that different approaches may be required in each of the UK, and in different regions. The broader UK focus could be provided by focusing on the overarching policy objectives, such as changing relationships across primary and secondary care, patient care and case management initiatives, changes in commissioning and the ultimate goal of UK systems: service redesign.
There are opportunities for the Association to capitalise on devolution by drawing on best practice initiatives in different countries, and pressing for national implementation. The BMA has an important policy role by filling the vacuum of a UK policy perspective. For some UK issues, the bodies in each country do not clearly overlap. The BMA needs to raise questions about linkages between these groups.