health systems: Can we still talk of a 'national' health service when the systems in England and Scotland are moving further and further apart? John Deffenbaugh investigates

Published: 16/05/2002, Volume II2, No. 5805 Page 28 29

The 'national' in NHS is evaporating and few people are aware of the radical reshaping of the service through different models of delivery in England and Scotland. As recently as a decade ago, NHS white papers were written for the UK, albeit with a 'tartan' Scottish section.Working for Patients set the template for a UK-wide model around the 'internal market'. This began to shift with the change of government in 1997.

The New NHS was written for England, and Designed to Care for Scotland - perhaps the titles were an early pointer to what was to come.

The common denominator was the abolition of the internal market.However, different structures were beginning to emerge, particularly for primary care - primary care groups and trusts in England with commissioning powers, local healthcare co-operatives in Scotland with no such powers.

The divergence has continued, even accelerated.

The NHS in England flirted with the end of the internal market when Labour came to power. It was always thought to be more rhetoric than substance, and events have reinforced this perception. GPs with purchasing power and trusts in mergers and acquisitions still have the ring of 'business speak'.

Maybe it is the size of the task. A£48bn business run within a bureaucratic framework is very difficult to change. The government had hoped for short-term success with minimum investment, but some of the people who said that the Conservatives got it wrong were ignored again.

The NHS plan was good enough for re-election, and the jury is out on whether or not it will bring long-term change. Governments have tried, and failed, to turn the NHS around, and the current one appears to have now recognised the magnitude of the challenge. Size may be the stumbling block. The armed forces have a budget of£23bn, but possess a command-and-control ethos not found in the NHS.

Hence health secretary Alan Milburn's frustration at the pace of change, and his speech to the New Health Network in January this year on 'redefining the NHS'. These proposals must be seen in the context of other government 'modernisation' proposals in England, in areas such as education, housing and prisons. They represent a shift to the right that the Conservatives could only dream about.Who thought in 1997 that a Labour government would be promoting so assertively the concept of 'public service entrepreneurs'? Is this not another way of describing GPs?

The tortuous logic proposing the 'franchising system' and 'foundation hospitals' tries to distance itself from 'self-governing trusts'. The difference is not obvious. Political expediency aside, this emperor may have no clothes.

The overall perception of the NHS in England is that It is back to 'winners' and 'losers'. The stargrading system drives home the reality, with performance mechanisms designed to support the good, and weed out the bad.

It is going to be difficult to take a whole-system perspective among these competing interests. The strategic health authorities will have their work cut out, and the PCTs as both poachers and gamekeepers will find themselves in the same contradictory position as the old fundholders.

And for the leaders of this new movement, we are back to 'hero' leadership.Managers who have three stars will have a chance to earn more. This will be some challenge - ask the 'superheads'who fell by the wayside in the teaching profession. 'Super anything' should come with a performance warning.

The reality is that the stars come from many factors - process, staff, infrastructure, culture.A franchise manager can make some progress, but success is not immediately transferable. It is not vested solely in one individual or team. It will take time to change, and We are talking about changes to attitudes and behaviour more than structures. So, look north for a different - and increasingly divergent - approach.

The impact of devolution is emerging in the NHS in Scotland. Designed to Care in 1997 heralded the end of the internal market. The Scottish equivalent of the NHS plan in England - Our National Health - announced the end of trusts as we have known them.

Some call this a more 'democratic' approach; others describe it as harking back to the days of 'consensus management' in the 1970s.

Scottish ministers found that the interregnum between gaining office and making the step-change in investment did not bring about the desired change in attitude.

As in England, the language was still 'them and us', and some of the behaviour was more internal market than under the Conservatives.

While in England a rigid regime weeds out the underperformers, the Scots have gone in the opposite direction - making performance an issue of 'corporate accountability'. One falls, you all fall. Partnership is the mantra, and it permeates everything. Internally, there is partnership at corporate level, and with staff, externally, to joint working, management and funding with social services to deliver elderly care services.However, it does not extend (yet) to partnership with the private sector to the extent proposed in England.

Terminology like 'franchising' is not even on the radar screen in Scotland. The system is much smaller and more manageable, and the leverage applied by the Scottish Parliament focuses minds on working together on a 'whole-system' basis.

Certainly, something radical will be required to bring about long-term health improvement to rid Scotland of the 'sick man of Europe' label.

As in England, behaviour gets in the way.

A democratic approach requires decision-makers to take an altruistic view. But the reason the internal market appealed was because it allowed natural behaviour - 'win-lose' instead of 'win-win' - to come to the fore. The jury is out in Scotland as to whether the new NHS boards, based around corporate accountability for whole systems, will deliver the step change required. The current review of NHS Scotland could bring even more radical steps to achieve leverage in health improvement and behaviour change.

There is divergence, but it goes largely unnoticed.

So are there practical implications?

The first concerns 'whole-system' thinking and acting. This was a major failing of the internal market, and there is a lot of catching up to do.Who is going to set the vision to bring about generational change in health improvement, and make serious inroads into acute care demand?

Management thinking and acting is around an implicit 'them and us' attitude; the language is also not conducive to whole-system working. This is where SHAs will come into their own. Their role can be to provide 'vision', encourage compromise and reward appropriate behaviour.

The opposite is true in Scotland.Whole systems have been established - 15 of them - but they are too small for some decision making.

Regionalisation may hold the key, but which regions, and what size do they have to be to work? If real value is to be obtained, then there will need to be co-terminosity with councils and economic development agencies. This is one of the challenges for the team heading the review on NHS Scotland.

The second implication concerns the 'partnership' agenda. In England this has focused on the private sector; in Scotland on councils and the voluntary sector. The driver in partnership-working in England is getting the best output - separating the purchaser from the provider - with less concern on who provides the output.

Hence, public service entrepreneurs mirror their private sector counterparts. This is language more reminiscent of the Conservatives, and brings a degree of discomfort to many public sector managers.

Scotland, on the other hand, has remained more wedded to the dogma, driven by the process as much as the output.Hence, the emphasis on collective accountability, bringing councils into the NHS boardroom. The approach to the care of elderly people is a good example - much of this is transferring to councils, with the NHS in a support role. The approach in England is pragmatic, while Scotland scores with a process that could bring about sustainable, long-term change.

The third practical implication is in the area of staff involvement.Who is going to change the way care is delivered to maximise the new investment?

This is a theme pushed by Nicholas Timmins of the Financial Times, who has observed that 'the best route to improving the NHS lies in reforming the way it delivers care, rather than in changing the way it is funded'.

1The need to change NHS culture and behaviour comes to the fore.

The re-emergence of the internal market in England offers pluses and minuses. There may be greater incentives to change, but the downside could be inequity in the outcome. Scotland is encouraging a uniform approach that could go one of two ways - whole-system change through tapping into the body politic of the NHS, or grinding into the sand around the process rather than the result.

Whichever approach is adopted, staff involvement is here to stay. On both sides of the border, the challenge will be to tap into the contribution of all staff, but particularly those who can have a major impact on service redesign and demand management.

The NHS in England and Scotland is being led in different directions by both ministers and managers. It is too early to tell which will provide the better long-term result. l John Deffenbaugh is a director of Frontline Consultants.


1Timmins N. The hidden trade-offs of healthcare funding. Financial Times, 25 February 2002, p19.

Key points

The differences between the English and Scottish health systems are becoming increasingly wide.

The star-grading system in England has led to a winners and losers model, whereas Scotland has gone for a more collective approach.

England has emphasised partnership with the private sector, Scotland with the voluntary sector and councils.

Both systems will rely increasingly on staff involvement.