The devolution revolution: is further divergence in health inevitable?
As the end of the 2005-2010 Parliament approaches, and the political classes gear themselves up for the general election, each of the political parties’ health teams will be looking to prove that they have the big ideas to take the NHS forward in a period of tight public finance but escalating public expectation.
In this short series of opinion pieces, Health Mandate’s team of expert health policy consultants look at some of the big issues that will shape the political and the NHS landscape in the next parliament. Today’s piece sees Lizzie Wills examine the future of health policy in the devolved nations.
The devolution revolution: is further divergence in health inevitable?
It is one of the peculiarities of the forthcoming General Election that – though health is set to be a major election battleground – almost one in five voters will be asked to judge the relative merits of health policies which will not impact on their lives. These one in five voters are – of course – those in Scotland, Wales and Northern Ireland: the countries to which powers over healthcare delivery were devolved after Labour came to power.
Those of us in England now have health services which share the ‘NHS’ name with the health services in Scotland and Wales (though not Northern Ireland) – but over the past decade the provision of services has become increasingly divergent.
There has always been some divergence in healthcare services – the most obvious being the continued legal restrictions on abortion services in Northern Ireland – but the creation of devolved assemblies and parliaments after Labour’s election victory in 1997 was a watershed moment. Indeed, in the area of health, the devolved countries have been quick to use their acquired powers to restructure their respective health systems – shifting decisively away from the services they inherited.
In general, Scotland and Wales have spurned the ‘internal market’-type systems they inherited (as did the Labour Government in England, initially), and continued on this path even when health policy in England gravitated back towards ‘contestability’ and ‘competition’ under Health Secretaries Milburn, Reid and Hewitt.
But this is not what we will hear about in Election 2010, which is a shame, because looking objectively at the differing UK healthcare policies could potentially give us an important insight into what, genuinely, improves the health of the nation. Sadly, and instead, we will hear only two things, about drugs: (1) we will hear about “drugs which are available in Scotland but not available in England” and (2) we will hear about “Scotland having abolished prescription charges which people in England still have to pay”. These inequities are the most obvious symbol of what some mid-market papers now almost-gleefully call healthcare ‘apartheid’ (as if that word should ever be taken in vain). And they are also an elephant trap for our Prime Minister, and journalists know it: why is it, after all, that he ‘looks after his own constituents in Scotland but not in the rest of the country..’?
Next year’s elections will be when we will hear the devolved governments justifying their own market-rejecting approaches – an issue which cuts deeply into all major parties’ own market-supporting philosophies in England.
Put simply, this debate will be about whether a market in healthcare services works at all.
So what’s going on in Scotland..?
Scotland has made the greatest headway in consciously departing from market oriented models – and towards what might even be described as ‘collectivist provision’. Designed to Care, published soon after devolution, was the first shift away from the competitive dynamics of the service. This was continued by further reforms – such as the 2004 NHS Reform Bill – which abolished the ‘NHS Trusts’ so treasured in England. And the divergence has continued with the specific rejection of policies adopted in England: ‘Payment by Results’, ‘choice of provider’ and now ‘individual budgets’, and the specific retention of policies out-of-favour in England (ie targets).
A noteworthy linkage between the politics of health in Scotland and England will be the role of Professor David Kerr, as a clinical adviser to the Conservatives. Kerr was the architect of reforms to Scotland’s cancer services – many of which took a very different philosophical approach to the use of markets now being advocated by Andrew Lansley.
A slight footnote on Scotland has been its pioneering approach in the area of public health – in which policies of the other countries have often trailed in their wake. Laws to ban smoking in public places were, after all, passed first in Scotland – whilst here in England we were still discussing exemptions.
…and Wales?
Wales might have gone further, faster than Scotland in shifting away from market-based systems, had it had the powers to do so – but up until 2007 the ‘Welsh Assembly Government’ didn’t actually exist separately in law, and the ‘government’ had no independent executive power.
Once the Government of Wales Act provided the Welsh Assembly Government with these powers, however, it used them. In 2009, the NHS Wales was reorganised from 22 local health boards into seven local health boards which were given control of both the purchasing and the provision of healthcare. It was the most emphatic rejection of a ‘market’ system in favour of a ‘planned’ system in the UK to date. (Incidentally, in taking these powers, the obligation on NHS Wales to follow NICE technology appraisals was also tweaked).
It might be slightly unfair to draw parallels between the 2009 NHS Wales reorganisation and the (“calamitous”, someone said at the time) 1973 NHS reorganisation, but there are echoes in the Welsh policy of the pre-1980s NHS across the UK. Echoes insofar as funding is planned rather than ‘won’ and insofar as there is no purchaser-provider split. Watch to see whether this works.
There is a very intriguing – almost imperceptible – undercurrent running through Wales’ health policy, which is that investment in ‘health services’ has been deprioritised in favour of investment in ‘public health (ie preventative) services’. More than any other home country – a legacy, perhaps, of its industries and its politics – Wales has focused on tackling the social determinants of ill-health rather than ill-health itself. It is an interesting blueprint to examine for those seeking to establish their ‘independent public health service’ in England.
What next?
Those living in Northern Ireland must forgive us for willfully ignoring it in this article. In defence, Northern Ireland politics are rather unique – and the suspension of a devolved assesmbly between 2002 and 2007 renders a considered assessment of the direction of travel on health rather difficult, if not impossible. Indeed, the ‘NHS’ as a name isn’t really used by the health service in the country.
So – notwithstanding the willful neglect of Northern Ireland – what does the history of devolution to date tell us about how the health services in the home countries will develop? Perhaps most importantly, devolution itself not only opens up the possibility of divergent policies – but the politics of devolution (that hostility between the home nations again) itself encourages such divergence.
It is also inevitable that the divergence between the home countries will continue – put two politicians in a room and they will find something to disagree on; compare two different assemblies full of politicians and the disagreements will be never-ending.
And this is the interesting thing: devolution has effectively created a policy laboratory across the UK in which the effect of various differing policy interventions can be compared and contrasted. It is surely the case that these differing policy interventions must have an impact – otherwise health policymakers might as well just give up – but what will happen when it becomes clear (as it surely must) that a devolved government has made a policy error?
The devolved governments remain perhaps too embryonic for their differing health policies to have had a clear impact on the health of their populations. So (sorry) it is probably ‘too early to tell’ which health policies are working and which are failing. But – one day – we will know. And what happens then is anyone’s guess. The impact of devolution on health policy might not yet be, but will be in due course, fascinating.