Ten years on: what devolution has meant for the NHS

The calendar for UK devolution began in 1997 when the newly elected Labour government produced its promised white paper on the subject. But it was not until two years later that the Scottish Parliament and Welsh and Northern Ireland Assemblies assumed their formal powers.

Northern Ireland’s unique political situation meant devolution was initially short lived and then enormously complex, while the government’s intention to pursue English devolution fell off the political map when such a scheme was rejected in the North East in 2004.

And although the devolved countries were quick to use their new powers to restructure their health systems, some commentators argue that in terms of the health service, there has been as much devolution in England as in the other three UK countries.

Evolving goals

In contrast to the devolved countries, it is greater freedoms for foundation trusts and local commissioners that have shifted power away from the centre in England. And unlike in Scotland, Northern Ireland and Wales, the focus of the English service has changed frequently to concentrate on at first standards, then targets and governance, followed by competition and choice, with the focus now being on the patient experience and quality.

Marking the 60th anniversary of the NHS last year, former NHS Confederation chief executive Gill Morgan suggested the NHS in England is now about contestability driving improvement and greater choice, while Scotland’s system is “collectivist”, with very little competition.

The key feature of the system in Northern Ireland meanwhile is greater integration between health and social care, while Wales is widely believed to enjoy a better working relationship between health and local authorities than is commonly enjoyed in much of the UK.

But there is one common thread between the health services in the three devolved countries: a reluctance to comment on how well they think they are doing.

All three are much smaller countries than England and two are right in the middle of major reorganisations, leaving managers worried about what will happen if they raise their heads above the parapet.

Because of the nature of devolution, health policy is one of the predominant areas where powers have been transferred to the assembly governments. The consequent sensitivity of the debate means managers are loath to be seen to be criticising, or even praising, the effects of one particular policy. Even external observers are wary of taking too strong a view on any individual country’s policy.

NHS Confederation deputy policy director Jo Webber says: “Overall, we take the view that there is a single NHS, albeit one with four different systems. Some of the focus is a bit different in the different countries, but they are all aiming for the same end point.

“It’s almost like a real time experiment. Hopefully there will be learning available, particularly where some parts of the agenda have been introduced earlier in different countries”

“Some of the outcomes are variable, but you have to remember that not everyone is starting at the same point, and all the administrations are using the best available evidence to support the service in their own situation.”

With the patchwork nature of the health service across the UK still under development, it is too early to say which systems, and which parts of those systems, have “worked”. In time, both the advantages and disadvantages of the respective services will be able to be analysed.

“It’s almost like a real time experiment. Hopefully there will be learning available, particularly where some parts of the agenda have been introduced earlier in different countries,” says Ms Webber.

Scotland

In April, think tank Reform Scotland criticised Scotland’s centrally controlled NHS, claiming the service was not providing value for money. It suggested handing the commissioning role to health boards and making hospitals and other care providers independent of the boards to reintroduce the purchaser-provider split. The Conservatives, very much a minority party in Scotland, broadly welcomed the report’s objectives, but it caused more of a furore than might be expected, perhaps because it enabled headline writers to focus on the allegation that the NHS in Scotland is “worse” than it is in England.

Scottish managers are reticent to comment for fear of being seen to cast in their lot with one party or another.

“Even if we said one particular area of policy brought in since devolution was a particular success, if that were to change, we’d be in a difficult position,” says one.

Immediately after devolution, the Scottish white paper Designed to Care softened some of the market dynamics in the NHS there, reducing the number of trusts and introducing managed clinical networks.

In 2003, 15 NHS boards were introduced, now reduced to 14. This reorganisation reduced the purchaser-provider split. The NHS Reform Bill 2004 abolished trusts, absorbing them into the health boards.

The Scottish government was aiming for partnership within the NHS. At the same time, it unveiled headline grabbing initiatives, such as its intention to abolish prescription charges by 2011 while parking charges at hospitals have also been scrapped, except at private finance initiative hospitals.

Scottish health secretary Nicola Sturgeon says she wants a stronger relationship between the NHS and the people it serves. Her aim, she says, is to run the Scottish NHS as a “mutual”, in which patients and the public are “co-owners”.

The Scottish government’s 2007 strategy document Better Health, Better Care develops this model, outlining how health boards and community health partnerships will work more closely with local authorities, and this will “distance NHS Scotland still further from market oriented models”, says Ms Sturgeon.

Ms Sturgeon regards hitting a series of “challenging” targets as the Scottish health service’s biggest success since devolution. At the end of last year, she says, there were just 664 patients waiting longer than 15 weeks for inpatient day case treatment in Scotland, a figure she compares with the 28,000 plus patients in England still waiting for more than 15 weeks for such treatment in February. But she also argues comparisons between the different systems will become increasingly difficult to make as they diverge further.

“For example, our focus on shifting the balance of care towards outpatient, primary and community care means more patients in Scotland can be treated for less complex procedures without an acute setting and nearer to home,” she says. “This impacts on [our] average length of hospital stay by increasing it relative to the English average.”

NHS Highland board chair Gary Coutts says an acknowledgement that several rural communities need different types of hospitals “has drawn a line in the sand over a perceived threat to these hospitals which has dominated our relationship with communities served by them for years and is allowing us to develop them in a much calmer environment”.

The lack of a purchaser-provider split, with unified health boards planning, commissioning and providing the range of healthcare in Scotland, is the biggest obvious structural difference between the health services in England and Scotland.

Ms Sturgeon says the integrated model in Scotland enables “a simpler context for financial flows within the system”, with managed clinical networks serving as “Scotland’s unique service delivery vehicle”.

Wales

Founded by Welshman Aneurin Bevan, the NHS is as close to Welsh hearts as rugby union and close harmony singing.

The biggest post devolution structural change so far was prompted by the 2001 publication of Improving Health in Wales, which replaced health authorities in 2003 with 22 local health boards.

Twelve regional trusts, each matching local authority areas, were made responsible for primary, secondary and mental healthcare, while one national trust, Health Commission Wales, an executive agency of the Welsh Assembly government, commissioned and funded tertiary care. A single national Welsh Ambulance Service was created while a Health and Social Care department with three regional offices was responsible for performance management.

Then, last year, Welsh health minister Edwina Hart unveiled bold proposals to wipe out the internal market completely. Instead the NHS in Wales will be run through seven autonomous local health boards. A National Advisory Board, chaired by the health minister, and a performance monitoring delivery board will be created. A “unified public health organisation” will have executive responsibility for public health through the local health boards.

With their chairs and six chief executives already announced, shadow boards are due to start work in July and the boards to begin work on 1 October.

Although free prescriptions, introduced in 2007, and free hospital parking, due in 2011, might be expected to resonate most strongly with the public, Welsh NHS Confederation director Mike Ponton says structural overhauls hit the headlines. Intended as a blueprint for shifting care into the community, the 2005 publication of the 10 year strategy Designed for Life generated the biggest rumpus since devolution.

“It caused a phenomenal debate,” says Mr Ponton. “Wales is such a goldfish bowl. I don’t know what the press would do without the NHS - everything we do is a story. “

This focus and fear over the forthcoming shake-up means managers simply refuse to talk about the effects of devolution.

Mr Ponton though believes the end of separating purchasers and providers was always likely in Wales, because it is too small a country to have the flexibility to respond to market forces.

Even before devolution, public health was a focus and managers needed the strength to meet that. Commissioning was always about planning in Wales and meeting need, rather than competition, he adds, while plurality of provision was never really an issue, again mainly because of size and because there was no private health service to speak of.

“Obviously the principles of the marketplace, pushing up quality and reducing costs, were something we wanted to aim for, but there were never going to be those aggressive market forces that there might be in other places,” he says.

A spokesman for the Welsh Assembly says it has strengthened local analysis and action, and moved “decisively” to eliminate the market from the NHS.

The 2003 reorganisation improved joint working, strengthened the relationships with primary care and improved the focus on local health improvement. He adds the new system will give staff and managers greater access to senior officials and ministers and offer them a greater role in forming policy and improving care.

Northern Ireland

Funding for health and social services in Northern Ireland amounts to 40 per cent of the devolved government’s budget, making it a huge player in the country’s politics.

The general view among the service in Northern Ireland is that health minister Michael McGimpsey is doing a good job. But a senior source says that for NHS managers to comment on health policy is a step too far, because of the necessarily close relationships that have developed.

As in Wales, the Assembly minister has taken an increasingly hands-on role, while a recent reorganisation meant a number of senior managers lost their jobs.

The country initially had limited plans to reconfigure services because of the suspension of the Northern Ireland Assembly and executive and transfer of powers back to the Northern Ireland Office. But in 2002 the Northern Ireland secretary launched an all-encompassing review of public administration, published three years later.

The reorganisation of Northern Ireland’s health and social services, announced later that year, reduced the number of health and social services trusts from 19 to six, including a national ambulance service.

On 1 April this year its four health and social services boards were replaced with a single Health and Social Care Board for Northern Ireland, responsible for commissioning and performance. It includes five local commissioning groups that mirror the five regional trusts. The overhaul also introduced a new Public Health Agency and Business Service Organisation.