devolution

Does the self-governing, legislatively independent Isle of Man offer lessons about the future for health services in post-devolution Wales and Scotland?

Geoff Newbery thinks so

Constitutionally, the Isle of Man is a self-governing Crown dependency and part of the British Isles - but not part of the UK. Its legislative independence is exemplified by the claim that its parliament, the Tynwald, is the oldest in the world in continuous existence.

The island, with a population of 70,000, enjoys a high degree of autonomy, including its own legal system and judiciary, and a legislative competence that does not derive from Westminster. It controls personal and corporate taxation, together with the decisions on how to commit the resulting revenues, a key issue in shaping public services. The health budget is£62m, with£11m for social services.

Because of the island's physical isolation, the hospital services provided for the Manx population are significantly greater than those for the average 70,000 population. It has three hospitals with a total of 525 beds. But from a patient's viewpoint, the Manx NHS looks indistinguishable from the UK's. Like its larger neighbour, it is tax-based and, apart from certain charges, free at the point of delivery. Primary care is provided by the same group of independent contractors with similar methods of working. The island has 44 GPs. There may be minor variations, such as a lower prescription charge -£2.40 per item - but not fundamental differences.

Of more significance is the government's revenue freedom to keep pay levels for nurses above those in the UK. It helps to have a thriving economic base.

The differences start to emerge when the structures for service delivery are compared. One key point is the absence of the structural change that has convulsed the NHS in the UK since 1990. The island has used its independence from Westminster to opt not to enact the Conservative or, for that matter, the Labour health reforms. Purchaser-provider split, fundholding and primary care groups do not form part of the health service vocabulary.

It remains to be seen whether clinical freedom will remain insulated from the impact of the National Institute for Clinical Excellence and Commission for Health Improvement, but developments related to clinical standards may be harder to ignore. The Manx NHS model is akin to that of the UK in the late 1980s, characterised by direct management and with a primary care sector untouched by fundholding.

This has meant some of the reforms' benefits, such as the service and practice changes that fundholding stimulated, or the improvements in management information, are absent. It has seen the creation of a Department of Health and Social Security that includes social services, putting in place a structural solution to the perceived divergence of service delivery that is generating so much debate in the UK.

This may not appear so relevant to the immediate devolution issues, but it may have significance for the next stage of development - English regionalism. The degree of independence that the proposed constitutional changes allow - both now and in the future - may well be crucial in determining the shape of health service provision.

Most members of the Tynwald sit as independents. This virtual absence of party politics means there is no parallel to the UK pattern of government by a party with policies it wishes to see implemented within a constitutional timescale. The Manx policy of consensus is undoubtedly made easier by the opportunity to mirror legislative developments on the mainland, but it also gives more responsibility for detailed policy development to the managers responsible for delivering the service.

The Manx experience suggests that devolution, by itself, does not spell the end of the NHS. The basic principles are alive and well. Political change may bring changes in service delivery, but support for those deeply ingrained basic principles remains unaffected.

Devolution creates the possibility of a different political culture emerging. The degree of change in this culture will create the opportunity for different styles and structures of service delivery beyond the variations already introduced by the recent white papers for England, Scotland and Wales. And it seems likely that Scotland, with the greater delegation of power and a stronger nationalist element to its politics, will see the greater divergence over the next few years.