Will devolution mean an end to a truly national health service? Paul Jervis and Robert Hazell examine the possibilities

Will we still have a national health service in a few years' time? Given a government pledged to 'renew the NHS as a genuinely national service' this may seem an odd question. But, as the health services of England, Scotland and Wales implement the proposals in the recently issued white and green papers, devolution is adding a new dimension.

The Nuffield Trust commissioned a report to explore the issues for the UK health service, and for the health services in Scotland, Wales and England, that may result from political devolution to Scotland and Wales. The report drew on official publications and interviews with representatives of central and local government, health service professionals and managers, academics and others who make or influence policy. It also drew on discussions at a series of seminars held in Cardiff, Glasgow, Leeds, and London between September 1997 and March 1998.1 Northern Ireland was not included in the initial phase of the investigation.

Although a complex and interrelated set of changes have begun, the investigation suggested that it is too early to forecast how much divergence will appear in time between the four health services within the UK. Those who expect few differences to appear may be wrong. For several reasons, the white and green papers may not provide a reliable guide to the amount of divergence in future.

The various white and green papers were developed under the current system of administrative devolution to Scotland and Wales. Both countries have considerable freedom to develop their own health policies. Their health services are run by the Scottish Office and Welsh Office, not by the Department of Health in London. Nevertheless, policies for health have been broadly the same in all three countries. Since Scotland and Wales have introduced more differences so far, some argue that there will be little difference in future, particularly while the same political party is in power in each country.

But political devolution may bring changes. With its advent, the Scottish parliament will have significant law-making powers, which will include health generally, the education and training of health professionals and the terms and conditions of service of NHS staff and GPs. The parliament will also have power to vary the basic rate of income tax by up to 3 per cent although, even if it is used, this would only raise around£450m of revenue compared with a total expenditure of£14bn.

The Welsh assembly will not have law-making powers, or the power to raise additional revenue, but it will allocate the£7bn budget currently assigned to the Welsh Office, set policies and standards for public services in Wales, and make orders and regulation through secondary legislation within the overall legislative framework laid down by Westminster.

More important than the legislative position is the fact that devolution will bring health policy under the democratic control of the directly elected Scottish parliament and Welsh assembly. These will have a crucial role in shaping their nations' responses to the health agenda. The traditional culture in both Scotland and Wales is strongly communitarian, and devolution is seen as a chance to reassert this. Health will provide a highly visible test of whether this can be done. Together with education, it is likely to be one of the key policy areas in which the parliament and assembly exercise their new freedoms. As one Scottish health professional commented: 'Devolution doesn't mean anything unless you do things differently - otherwise why have it?'

The new freedoms may have a down side. Many fear that members of the Scottish parliament and Welsh assembly may wish to interfere in tactical issues of service delivery rather than exercising strategic leadership. An overemphasis on audit and scrutiny could be counter-productive.

The most important single factor which might lead to the development of the appropriate leadership role for the new parliament and assembly will be the quality of the political cadre attracted to stand for election.

The objective, of course, is to improve each nation's health, not simply deal with the running of the health service, important though that is. Here Scotland, Wales and Northern Ireland may have an advantage over England. The 'policy villages' in these countries should make health-gain policies easier to implement, and the smaller scale of government should make it easier to achieve

co-ordination across government departments, and between national and local government.

If devolution can bring better 'joined-up government' to Scotland and Wales then there will be important lessons for England. Indeed, devolution raises some interesting questions about the place of health within the developing English regional agenda.

Health is not one of the core functions of the regional development agencies, but they will have major consultative and advisory roles in a number of non-core areas which include public health. Already, regional economic development organisations see the NHS bodies in their regions as essential partners in their activities, both for the contributions they can bring to improving the health of regional workforces, and also as major regional employers in their own right.

In London, a similar distinction between healthcare and public health is maintained. London's health service will not be one of the responsibilities of the new Greater London Authority and elected mayor. But the new authority will be able to scrutinise public services over which it does not have power, including health services for Londoners, and the mayor may decide to appoint a director of public health.

Given the popular mandate a London mayor may have, and the importance people in all regions attach to their health services, central government may find that as regionalism develops in England, it is hard to maintain the distinction between public health and healthcare services. This would pose a challenge for the English NHS.

While there is no prospect of regionally determined policies replacing the current system of national policies with local initiatives, it will be hard for the NHS in England to stand outside an increasingly dynamic regional level of policy development. English NHS managers may come under conflicting pressures - from their regional and local communities - to play a full part in responding to local concerns and priorities, and from the centre to respond to a Whitehall-controlled policy agenda and performance requirements.

There are a number of other problem areas. In time, differences may appear over issues such as the consultants' contract and the GPs' contract, and over aspects of regulation such as prescribing policy and relationships with the pharmaceutical industry. There will be a need to collaborate in areas such as education and training, where the number of medical schools and the output of graduates is determined by the four countries individually, but where a degree of co-ordination over supply and demand may be appropriate.

The devolution legislation also reserves a number of health policy matters for decision and action at UK level, including regulation of professions and other matters including abortion, human fertilisation and embryology, genetics and so on, 'in view of the need for a common approach'. How policy in such matters is conducted will need to take account of the Scottish and Welsh health services' desire for greater freedom and influence.

All these issues will be affected by the relationship between the DoH in Whitehall and the health services of the other countries. The DoH has responsibility for a range of England-only functions, and for others in which it has a wider role across the UK. It will need to differentiate clearly between them. Indeed, this itself is a possible source of tension after devolution.

The danger is twofold. First, that the needs of England (85 per cent of the population) may lead to structures and systems used for resolving all-UK issues that are less than ideal for Wales, Scotland and Northern Ireland; and second, the separate interests of England may at times be submerged by the UK-level agenda.

One area in which the DoH's all-UK responsibility is particularly important, and where its actions may be challenged, concerns links with international bodies such as the EU and the World Health Organisation. Post-devolution, formal representation with these will remain a matter for the UK. But there is a strong desire in Scotland, Wales and Northern Ireland to form direct health policy links with international bodies.

For each of these issues there are possible responses. For example, with international issues the other countries will be unable to change the formal mechanisms or challenge UK-level representation. There must be effective consultative machinery so UK delegations are briefed on national views, and Northern Irish, Scottish and Welsh representatives should be included. Effective communication will be crucial in creating a 'culture of inclusion' in UK policy matters.

In health, as in other policy areas, devolution requires a reconsideration of the roles of the UK 'centre' and the governments of the four countries. There are different possible relationships, 'corporate', 'collaborative' and 'federal'.

The corporate model is one based on ownership and control, with the centre determining the objectives for each of the operating units. In the collaborative model, organisations are independent bodies with full control over their strategies and resources. They may decide to collaborate, but collaboration is voluntary and reversible.

A federal model shares some of the characteristics of the first two. In this, members yield power over some issues to the 'federation', which develops at its core the competences to deal with them. What is a federal issue and what is a state issue is usually clear cut, and this model differs from the corporate one in that the federation cannot collect more power to itself unilaterally.

Legally and constitutionally the devolution relationship will be a corporate one. The government's devolution white papers emphasise the continuing sovereignty of the Westminster parliament, which will retain the power to override the devolved assemblies or to amend the terms of the devolution settlement. This runs counter to the views of many in Scotland and Wales, who might see collaborative or federal relationships as more appropriate than a corporate one between their national health services and the NHS in the UK.

What is likely to happen as devolution becomes a reality? Those who have experienced organisational separations will have noted that they are often followed by a period in which former colleagues behave in a surprisingly hostile manner. Part of the process of gaining and exercising independence involves relationships which become more adversarial as people test out their new freedoms. This was certainly the case with relationships between some health authorities and trusts after the purchaser-provider split was introduced. There is no reason to believe that the health services post-devolution will be different.

If devolution in health is to work, it must be supported by appropriate systems and structures, by a sound understanding of the roles and the relationships between the different decision-making bodies, but also by appropriate behaviours.

Development post-devolution

The way in which health services in the UK develop post-devolution will be affected as much by the style and culture adopted in the different health communities as by substantive issues of policy content or service operation. Devolution will require a different mind-set in many areas of the health services, particularly among those in the centre in Whitehall, as well as in Scotland and Wales.

The UK-wide professional bodies, too, are affected by devolution. They will need to review the ways they relate to members in England, Northern Ireland, Scotland and Wales, and the way they relate to the four countries' health services. But they can also help capture important learning, and safeguard against a fear many health professionals have expressed: that devolution may lead to the fragmentation of UK-wide policy networks. All countries would suffer from this, not least England.

So, will a national health service remain? The core values and principles which underpin the NHS in England, Scotland and Wales are unlikely to be changed by devolution. There is still likely to be a service funded from general taxation, available to all, and free at the point of delivery, in each of the four countries. But there may be more divergence in the details of policy, organisation and management than appears likely at present.