Published: 04/03/2004, Volume II4, No. 5895 Page 18 19

The NHS is a single entity in name only, as England, Scotland, Wales and Northern Ireland each produce their own version of a 'national' health service

In 1948, nobody questioned what the national in National Health Service meant. It meant Britain. And in 2004, fewer and fewer people are questioning what nation it means now. Four separate ones: England, Northern Ireland, Scotland, and Wales.

As discussed in the new University College London report Four Way Bet: how devolution has led to four different models for the NHS, the four health systems of the UK are rapidly diverging, as often as not without noticing. They are identifying different problems, dealing with them differently, and having different internal debates.With each day that passes, their little decisions cumulate into increasingly different models of, and visions for, the NHS.

In England, the flurry of announcements about the NHS from the government can hide what is happening - especially for those working overtime to respond to them.

After seven years of reorganisations, targetitis, mergers, inspections, and media-friendly initiatives, it is startling to look back and realise that the government has laid down the basis of a very distinct, and new, NHS.

Patient choice, diversity, commissioning under the new tariff, and the post-1997 regulatory apparatus will turn the NHS into a highly regulated market - at least on paper - and will try to reinvent professionals into something like parts of the private sector.

If England feels like the most radical, that is because it is.

Scotland has gone in a different direction, showing more faith in professionals and less faith in either markets or management.

Legislation now making its way through the Scottish Parliament abolishes trusts, the bedrock of the market, in order to run the system essentially as 15 large organisations with professional networks in a key role.

If it works, Scotland will have enlisted professionals on the side of necessary decisions and rationing.

We should not expect less from the distinct policy networks of Scotland or England. In Scotland, high status, articulate, medical elites play a dominant role in shaping policy and setting agendas, and put professional concerns and ideas high up the list. England's market agenda seems feasible and desirable because it is conceived and advocated by its think-tanks, students of management, civil servants, and special advisers.

Many English policymakers have spent their whole careers experimenting with marketbased public policy.

On one side of Gretna, the conversation is about clinical networks and science. On the other, it is about patient choice and consumerism. And over Offa's Dyke, it is scarcely the same debate at all.

Wales has adopted its own distinctive trajectory. It opted to reorganise its system so that commissioning is integrated with local government. It could adopt its localist strategy because politics abhors a vacuum. In Wales, since devolution, the space occupied in England and Scotland by medical and managerial leaders is occupied by those who are hopelessly marginal to health policy elsewhere - local government, the unions, and public health advocates. Their arguments and policy ideas have put Wales on a very different course.

Wales suffers from two problems that mean it is most likely to change.

One is obvious - losers everywhere complain, but in Wales the 'losers' are articulate groups used to being at the centre of policy, such as acute trust managers and consultants. The other is that Welsh health strategy which focuses on population health, local delivery, and wider determinants of health, will take time to show the most important benefits, but the considerable costs are visible today. The hasty reorganisation of Welsh health services last year put intolerable stress on policy and administrative capacity.

Last but not least, Northern Ireland has not had much devolution.And when it has devolved its politics are still not about health policy - at best, they are about local hospitals. That means that the premium in Northern Ireland is on hiring people who can keep the system running in complex circumstances and leaving them alone - producing both policy standstill and considerable local divergence.

So each country is on a clear trajectory. The policy advocates of England, Northern Ireland, Scotland, and Wales each identify different problems and suggest different solutions. Ideas are fervently expressed in some places that would be laughed out of the room in others.

We should expect to see more markets in England, more professionalism in Scotland, more localism and crisis talk in Wales, and more low-key local divergence in Northern Ireland.

Where can this go? In policy terms, all four trajectories might be sustainable. Not only might there be no such thing as the right trajectory. There is also little in any political system driving them towards it. Just imagine English policymakers deciding that markets did not work and following Scotland in abolishing trusts, or deciding Wales had it right and integrating local government with the NHS.

Policy failure can matter, though.Wales is the most likely to change radically since opponents of its localism are increasingly vocal, acute care is in serious political trouble, and both the Welsh Assembly and the management cadre are fighting to keep their heads above water.

More important for the future is that the four trajectories are already producing differences in priorities that affect patients.

They are systematically encoding different values, whether it is in free prescriptions for youth in Wales, personal care for the elderly in Scotland or patient choice in England.We simply do not know whether the public will notice this - or not; and accept this - or not.

If politicians seize on differences, they could decide to fight for more of the UK cash or intervene in each other's policies.

A crisis could erupt in intergovernmental relations caused by health policy which has serious consequences for health policy. And the health policy community, hugely uninterested in intergovernmental finance and relations, might well be among the last to know.

The simplest way to destabilise would be a review of the Barnett formula, which funds the devolved budgets on a higher per-capita basis than England.

But that is not all. If one government sets out to embarrass or undermine another, there are many ways to do it. And governments will eventually set out to do so. Labour cannot continue to be the biggest party in England, Scotland and Wales forever, and when politicians no longer share party loyalties there will be conflicts that could impinge directly on the way health services work.

Finally, if the referendums on elected regional assemblies in north England succeed, we will have more devolved governments.

English regional assemblies will have no serious health role - with one exception. Regions are governments looking for policies.

Public health, in England, is a set of policies looking for a government. So regional advocates and public health share a strong elective affinity that could make regionalism a boon for England's public health advocates.

The key point is that many of us underestimate devolution.

Devolution guarantees divergence because different democratic political systems are going to listen to the different voices in their different societies.

Whatever else could be the point of it? The technocratic discourse of health services should not obscure the fact that there are different values, priorities, and politics at stake.

Health politics is about more than tricks to cut waiting lists.

And that, as much as policy experimentation, is why divergence since devolution happened and matters.

Dr Scott Greer is research fellow at University College London's constitution unit and author of the report Four Way Bet: how devolution has led to four different models for the NHS, and the forthcoming book Territorial Politics and Health Policy.