Devolution and health policy: A map of divergence within the NHS - 1st annual update
April 2007
1. Introduction
This report provides a broad overview of changes in the NHS since devolution, focusing on doctors working environment. It draws on academic accounts of the impact of devolution, policy analysis of divergence and the views of BMA representatives across the UK. After outlining key areas of divergence, the report considers their implications for UK doctors and makes recommendations for the BMA. Appendix 1 details the regulatory and legislative differences between the nations and appendix 2 summarises key areas of divergence. Changes in political leadership, which may occur through elections for representatives of the Scottish Parliament, Northern Ireland Assembly and National Assembly for Wales in May 2007 and local elections in England and Scotland, are acknowledged.
The United Kingdom (UK) [go to note 3] has always had different policy processes because of separate administrative structures in the four nations. The creation of national Assemblies for Wales and Northern Ireland and a Parliament for Scotland has accelerated the extent of these differences by bringing greater political autonomy across a range of competencies as well as providing new opportunities for nations to pursue different priorities [go to note 4]. Difference between the nations has been shaped by difference at the national level in the delivery of political agendas to constituencies (table 1).
Table 1 - Institutions managing UK policy and areas of devolved government (adapted from P Norton ‘Tackling the devolution bug’ King Hall
paper no. 6 London 1998)
|
UK |
England |
Scotland |
Northern Ireland |
Wales |
Parliament |
House of Commons |
None though English affairs dominate the |
Scottish Parliament – |
Northern Ireland Assembly – |
National Assembly |
Population |
59 million |
48 million |
5.1 million |
1.64 million |
2.9 million |
Transfer of powers |
The policy areas listed to |
Addressed through the |
Agriculture, fisheries, |
Agriculture and rural |
Agriculture; Economic |
At the point of devolution, commentators believed there would be little impact on health policy. The first analysis of the impact of devolution on health in the UK ‘devolution and health’ noted that structures allowed for ‘differences of approach’ but that there were ‘differences of emphasis at the margin’. The authors went on to suggest that ‘this judgement might be wrong, however, because it may assume more commonality [across Labour administrations] than actually exists, and it may underestimate the political dynamic of devolution’ [go to note 5]. By 2001, the same authors’ annual report, monitoring the impact of devolution, noted that Richmond House was ‘seen much more clearly as pursuing an English agenda’ and the devolved administrations were working to prevent ‘distorting their own plans and priorities’ [go to note 6].
By 2004, the authors had come to the view that devolution had led to radical differences. These were set out in a report Four Way Bet: how devolution has led to four different models for the NHS [go to note 7]. The paper outlined distinct policy approaches to create more efficient and effective health services and provided an overview of change in the UK since the Welsh and Northern Ireland Assemblies and the Scottish Parliament took responsibility for health.
Despite the changes that have occurred since devolution little attention has been drawn to the consequences of divergent policy for the professionals working within the health system and the patients that use it. This is perhaps because devolution is often seen as an event rather than the ongoing process with divergence occurring over time.