Devolution and health policy: A map of divergence within the NHS - 1st annual update
April 2007
The political context
Health policy is fundamental to the interests of individuals and society as a whole and involves high economic stakes. Health policy is considered a volatile area for any political system [go to note 8] and the political context is a crucial determinant of health policy. Within health policy commentators have noted the limited commonality between the three Labour administrations in London and Cardiff and in Edinburgh (where Liberal Democrats share power). It is observed that each nation is fundamentally trying to reorganise services but is going about it in very different ways.
One of the earliest and most important changes since devolution has been the narrowing focus of UK politicians and the Department of Health to an anglo-centric approach. This has increased over time and reflects and fuels an acceleration of policy differences.
England
The House of Commons, its Health Select Committee and Department of Health are each primarily focused on England. Since the election of David Cameron, the Conservative leadership has swung behind the Blair agenda for radical reform: mixed provision, competition for patients (and tariff payments) and a service that remains free at the point of use. There has been a growing internal challenge from the left, which is uncomfortable with the direction of health policy, particularly decisions to award contracts to private providers and the use of competition to ‘shake-up’ service provision.
The current policy direction has resulted in considerable change at a local level, due to more autonomous foundation trusts, varying commissioning models with central administration playing a slightly different role in regulating health care, and an agenda to reconfigure services. Politicians have argued over the rights and wrongs of allowing private providers to deliver NHS care, the theory of competition and patient choice. It is becoming clear that the developing plurality agenda and burgeoning healthcare market in England are creating a context in which sections of the medical workforce will increasingly seek to explore new ways of providing care to NHS patients. Greer, identified the role of the market, he believed that the aims are to design the NHS as machine that will go by itself, ‘mechanically taking hard decisions about services and process, via the market’ and that this can proceed without political intervention [go to note 9]. The speed of change in the English health system has been cause for concern, the lack of evaluation and local implementation of centrally developed policies in what has been described as a continuous cycle of change has been criticised.
It is suggested that the Blair government will want the period of turmoil brought by service change to be complete by the time of the next election. As we approach May 2007 the extent of the current government achievements in the health service appears clouded by on going tensions of funding and reconfiguration. It is doubtful whether the most recent wave of changes will be achieved.
Scotland
The Scottish Parliament has full legislative power for health in Scotland, except for professional regulation and abortion. Although Scotland has the power to raise a small amount of taxes it has yet to use it. Funding comes from HM Treasury via the Barnett formula and is allocated by the Scottish finance minister. The political structures are in place to operate independently of Westminster: the Minister for Health and Community Care is accountable to the Scottish Parliament for the running of the NHS; the Parliamentary Committee can call to account the Scottish Executive Health Department’s Chief Executive and the chairs of all the NHS boards.
As in England, a key aim of policy is to reconfigure services and with this tensions have arisen. The aim is to centralise specialist services while increasing the capacity for other services to be delivered in the community. Unlike England, there has been wide consultation over service reconfiguration resulting in plans to make the best use of limited resources by concentrating specialist services in fewer acute centres and providing more care outside hospital settings. A key difference with England is the Executive’s plan to redesign services, a policy approach generally supported by the profession. Although Scottish policy has a clear direction, when institutions are under threat and begin to close it is likely that Scottish ministers will reignite debate. Increasingly there is evidence of small political parties set up with the aim of defending the NHS or campaigning on local issues, for example the NHSFirst party and the Scottish National Party (Save Monklands Hospital) [go to note 10]. The implications of elected members of such parties in Scottish Parliament are small but not insignificant.
The main pressure for the government comes from the left, but control over government may change in the elections next year. Recent by-elections have resulted in a move away from Labour towards the Liberal Democrats and SNP, which may have implications for a more devolved health service in government elections.
Northern Ireland
Since 2002, the Northern Ireland Assembly and Executive have been suspended and responsibility for Health and Personal Social Services (HPSS) has rested with the Northern Ireland Office (NIO). The NIO comprises of ministers who direct and manage the Northern Ireland Departments, and support the Secretary of State. The Department for Health, Social Services and Public Safety however is not the sole responsibility for the direct rule minister, who usually has multiple portfolios. The agreement set up the structures for a North-South Ministerial Council to identify and work on issues of mutual interest between Northern Ireland and the Republic of Ireland. Accident and Emergency services is one of the health related areas identified for cross-border co-operation.
During the lifetime of the Northern Ireland Assembly reform of health services has been on the agenda, but little has happened. There were a number of consultations on reform and reconfiguration of health services however Northern Ireland politicians have been reluctant to make decisions on the grounds of sectarian divisions or making a necessary but unpopular decision that would lose votes for themselves and their party at the next election. Health policy during this time was therefore full of consultations and very few decisions.
The Review of Public Administration (RPA), which commenced in 2002, signalled significant reform in Northern Ireland. The RPA remit covered the delivery of services across health, housing, education and local government sectors in Northern Ireland. In November 2005 Direct Rule Ministers delivered decisions on how the RPA would be implemented.
While Northern Ireland HPSS has been described as having a ‘permissive managerialism’ model, the recent decisions on reform by Direct Rule Ministers is resulting in a period of accelerated reform, while being open to consultation in the beginning is losing the transparency it needs to continue to hold the confidence of the medical profession.
Reform is taking place while Northern Ireland continues to have 1 in 8 of its population on a HPSS waiting list. There are a number of new initiatives to reduce waiting lists such as Integrated Clinical Assessment and Treatment Services (ICATS), the building of Health and Care Centres under the Primary and Community Care Infrastructure programme (PCCI) and the introduction of Locality Based Commissioning.
Wales
The National Assembly for Wales assumed the powers of the former Welsh Office. In 2006 the Government of Wales Act formalised the legislative/executive split between the National Assembly for Wales and the Welsh Assembly Government.
The Health and Social Care (Wales) Act 2003 provided for a range of powers to take forward policies in NHS healthcare, social services, dental and medical services. Much more so than in England or Scotland, policy is concerned with health rather than healthcare and there is greater emphasis on public health. Political rhetoric has been directed against the causes of ill-health in society with less attention played to the management of the system.
The policies reflect the political philosophy of the Labour administration. The first Minister, Rhodri Morgan, has talked of creating ‘21st century socialism’ if elected in the May 2007 elections [go to note 11]. His comments echo those made in 2003 when he set out his ‘clear red water’ strategy to separate English
politics from those in Wales effectively opting out of the controversial market driven Blarite reforms. Post devolution NHS Wales has seen little, if any, significant input from the private sector. This is in contrast to England which is moving towards greater involvement of the private sector in the delivery of healthcare services. The Welsh Assembly has, so far, rejected this model of providing services through increased competition.
As in Scotland, there are differences in health strategies, for example the mental health strategy has been significantly different to that in England (and Scotland). Other significant examples include free prescriptions for all by 2007 (85 per cent are already covered), free breakfast for primary school children, a Children’s Commissioner, and the retention of Community Health Councils. These moves are articulated as taking a more integrated approach to health policy but provide debate around access to services from the NHS for those in the ‘border’ geographical areas between England and Wales.