Ties that bind

Published: 16/05/2002, Volume II2, No. 5805 Page 27

The Commons recently witnessed health secretary Alan Milburn dig himself a hole when he said, 'I do not do Wales... However, I occasionally like to do people from Wales.' I do not want to sound like a whingeing Welsh windbag, and I know (because my English colleagues often remind me) that Wales is not much larger than an English strategic health authority. But it has high levels of socio-economic deprivation, rural communities and the impact of the decline of heavy industry to contend with, and perhaps it is time the health secretary got round to 'doing'Wales - along with Scotland and Northern Ireland.

The history of Wales has been tied in with the fate of England for many centuries. The Welsh Act of Union of 1536 predated Scotland's, and in contrast to Scotland we did not retain our own legal system.

Unlike its Scottish Office counterpart, the Welsh Office was formed only in 1969. This, combined with the proximity of Cardiff to London, led to a view that while the Welsh Office had responsibility for health, Welsh health policy amounted to little more than deleting the words 'Department of Health' and inserting 'Welsh Office'. Nor could it be said that the role of secretary of state for Wales was the most coveted - particularly among Conservative politicians.

But Wales has had, even before devolution, different structures and policies from those in England. It was the Welsh health planning forum which pioneered the concept of health gain, and the All Wales strategies on mental health and, as it was called in the 1980s, 'mental handicap' are particularly noteworthy Welsh policy initiatives.

Devolution brought with it the potential for Wales, along with Scotland and Northern Ireland, to develop distinctive policy solutions yet further.

There is much debate about how far this has been achieved. Inevitably, new institutions such as the Welsh Assembly operate on a steep learning curve for civil servants and politicians alike. It will take time for the Assembly to mature and for it to be seen as a home for the brightest and the best in Welsh political and administrative life. And the Assembly was initially hamstrung, as Welsh Labour was the largest political party yet did not have a working majority. The creation of the Liberal Democrat-Labour coalition has allowed for more - and speedier - policy making. Equally, the fact that both Westminster and the Welsh government are Labour controlled has impacted on notions of distinctive policy-making and indeed may also have resulted in pressure placed on Welsh Labour to follow the New Labour UK party line.

Health and social services form the largest part of the budget of the Welsh Assembly and are consequently a source of major political attention.

To date, the achievements of the Assembly in this area may appear tokenistic... extending free prescriptions and eye care, freezing prescription charges and the appointment of a children's commissioner. In addition, Wales has its own national plan, Improving Health in Wales.While its inception may owe something to the NHS plan, it takes a somewhat different path to its English counterpart.

And this takes us to the major challenge of the devolution of Welsh health policy. There is a delicate balancing act in seeking to find distinctive Welsh solutions, yet learning and drawing from experience in the rest of the UK.

While the concept of a 'national' health service seems likely to be eroded as differing arrangements emerge as a result of devolution, this presents us with a unique opportunity to learn and evaluate differing policy and structural solutions to what are similar issues and problems elsewhere. But the spectre of central control over health policy by Westminster still looms large.

The Welsh Assembly, unlike the Scottish Parliament, cannot enact primary legislation and has to pass Welsh legislation through the UK Parliament or, as is currently the case, 'piggy-back' onto English health legislation, with all the problems that poses. Nor does the Welsh Assembly have tax-varying powers. This limits the potential to take the sort of radical steps Scotland has proposed for personal care of elderly people.

It is funding that ultimately ties Welsh health policy into Westminster. The future funding of the NHS remains the domain of the UK government, and the tentacles of the Treasury can be seen to reach even into specific areas of policy-making itself.

So while it seems unlikely that Wales has the stomach for the development of the private finance initiative and public-private partnerships, Treasury rules may nonetheless force us down this route. It is debatable how far devolved health policy will, in the final analysis, be determined by UK fiscal policy, and whether Welsh policy makers will ultimately be 'done over' by their Westminster counterparts.

Professor Siobhan McClelland is head of research, Centre for Health Leadership Wales.