One NHS, or Many? The National Health Service under Devolution
Tony Blair once remarked that the NHS is ‘the healthcare system the world most envies’. But is there still one single NHS? As powers have been devolved to Scotland, Wales and Northern Ireland, what impact has devolution had on the NHS as a single national service? Axel Kaehne investigates.
Image © Gary Barker, http://www.garybarker.co.uk
Since 1999, devolved governments in Wales, Scotland and Northern Ireland have had powers over the organisation and budgets of the National Health Service in their jurisdictions. They can spend as much as their annual allocated block grant from the Treasury allows. They can reorganise their NHS along the lines they feel appropriate.
This quasi-federal system has serious implications for health provision. An intriguing question is whether or not devolution has lead to significant policy divergence within the NHS – does it even make sense to speak of a ‘national health service’ anymore? Three main aspects may help give some answers to this question: the way we perceive of the NHS as a public service in a mixed economy, the way the health service is organised, and how we think it can be reformed to meet future challenges.
More than one NHS?
As devolution took root, the NHS became a central pillar in the legitimising narrative of devolved governments. Administrations in Cardiff and Edinburgh frequently emphasise the difference of ‘their’ NHS to the service in England. Yet, the dilemma for politicians in devolved governments is that policy divergence in devolved areas rarely registers on the public's radar. When it does, the main point of reference remains England and the NHS is often perceived as a singular national service.
More recently, devolution has featured heavily in debates on public spending. So what does spending on health look like post-devolution? With the onset of austerity, spending in Wales, England and Scotland took different paths. The graphic on page 32 shows the expenditure in all four home nations on the NHS over the present parliament.
Healthcare expenditure, of course, is influenced by many different factors, such as deprivation levels, health needs, and access to services. The complexity of health care provision is such that directly comparing per capita spending makes little sense. It may be more useful to look at outcomes for patients to get a picture of how effectively resources are spent in bringing about improved population health. Given significant health disparities across the UK, achieving similar patient outcomes may require different patterns of resource distribution in different locations. The complexity of this argument may resist any simple political narrative. This is somewhat ironic given that the main driver of the complexity in resource distribution and organisational modelling is the simple objective of preventing a postcode lottery for patients, a popular refrain used by politicians of all strips.
In addition, the discussion about spending has been linked to concerns about the ‘privatisation’ of the NHS in England. The Health and Social Care Act (2010) in England abolished Primary Care Trusts, the commissioning centres of the NHS, and replaced them with Clinical Commissioning Groups (CCG). In effect, CCGs are GP surgeries that have grouped together to take charge of commissioning. From April 2013, they have been given the lion's share of the NHS budget in England to ‘buy’ relevant services for their patients (this may include anything from elective surgery to x-rays).
Although this re-organisation has sparked talk about privatisation of the NHS in England, the rhetorical battle over the private or public nature of the NHS actually encompasses different concerns. First, as CCGs are now the main commissioning body of NHS services the fear is that they would ‘buy’ mainly services from private enterprises. So far, the data indicates that there has been no significant shift in the amount of private provision in English health care. In fact, because NHS expenditure continued to increase during the economic crisis, public spending increased from 79.2 per cent to 82.8 per cent of total health spending. Commentators agree that what is more likely to drive up NHS spending on private health care providers is the public system's inability to be sufficiently flexible when confronting contingencies. Where seasonal fluctuations of demand temporarily increase the NHS appears to be unable to respond quickly and efficiently.
Second, ‘privatisation’ could be taken to refer to the fact that NHS Trusts (such as hospitals) may increasingly operate as private enterprises themselves. This development was set in motion under Tony Blair's government when NHS Trusts obtained more autonomy. The coalition government's Health and Social Care Act in 2010 did not substantially change this main direction of travel although there are now some examples of privately run hospitals or urgent care centres. Increasingly, private companies may manage NHS hospitals in future, although these companies will not own them.
The issue of NHS expenditure and privatisation notwithstanding, the main area for policy divergence has actually occurred in the organisation of the NHS. After 1999, Scotland and Wales quickly embarked on two different paths when it came to organising the health service – despite both being run by Labour-led administrations. Scotland abolished the internal market in 2004 yet largely refrained from any major re-organisation of the NHS and focussed instead on improving care outcomes by increasing stability throughout the service. Wales, on the other hand, quickly engaged in a large scale re-organisation of the NHS by, first, abolishing the purchaser-provider split and, second, merging primary care trusts into seven local health boards, aligned with university hospitals.
The Welsh Government also removed a whole range of targets for hospital-based services which freed medical staff from administrative tasks. Yet it also reduced transparency of health care services, which means that patients now have limited ability to judge the performance of their local hospital. Paradoxically, this decreased ability by the public to scrutinise NHS performance strengthened the position of health care professionals vis-à-vis patients and politicians alike. In the long term, this may not bode well for reforms, since implementing organisational change in the face of vested interests requires effective scrutiny of service performance. A recent report by the King's Fund critically noted ‘that there is little data across Wales with which to systematically track progress over time’ (Ham et al, 2013: 69).
The National Health Service
Since 1946, the founding principles of the NHS have remained largely intact. The NHS provides medical services free at the point of use and is financed through direct taxation. Its broad organisational outlines have also remained remarkably stable. As set down by the National Health Service Act (1946), family doctors (primary care) are self-employed and contracted by the Department of Health, whilst secondary care is delivered through hospital trusts that serve populations in large catchment areas. Specialist services, such as mental health, are located mainly in the community.
Despite this relative stability, the NHS did experience some change since its inception. In the 1950s and 1960s, the NHS took up the fight against population epidemics, such as tuberculosis. Large hospitals were built that catered for huge numbers of in-patients. A second wave of significant change occurred during the 1970s and 1980s. In 1974, responsibility for community social care was moved to local authorities whilst, in turn, public health became exclusively a matter for the NHS. During the 1980s, a commissioning structure was introduced into the NHS, creating an internal market with primary care trusts buying services from hospitals or tertiary care providers for the patients they looked after. Ultimately, this led to pilots in GP commissioning, a step that became significant in the NHS reforms in England after 2010.
Despite this seeming divergence in organisation and spending, it is striking that politicians in England, Wales, Scotland and Northern Ireland continue to use similar terminology when painting a picture of an ideal NHS. Phrases such as ‘improved patient outcomes’, ‘patient centred care’, and ‘integrated services’ proliferate. This indicates that, beyond philosophical arguments about the private or public nature of the NHS, the actual driver of NHS policy is a widely shared recognition of the need for individualised and personalised medical services. The main question, however, is how this language of aspiration can become reality. Governments in London, Cardiff, Edinburgh and Belfast certainly differ over how to bring about the necessary changes to achieve these aims. The main battleground centres on the role of the patient in the agenda for change.
Patient choice – driver for progress?
Policy documents in all parts of the NHS still echo aspirations for patient choice but this ambition is certainly most strongly articulated in England. Patient choice was the favoured driver for change under both the Major and Blair governments. Since devolution, Wales and Scotland have moved away from using choice as a mechanism for change in the NHS. In contrast, in England, choice is still a significant policy lever, but there remain questions as to whether patient choice can actually alter well entrenched organisations defined by a highly complex set of professional groups.
Patient choice as a driver for change in medicine relies on the notion that patients can make informed decisions, sometimes even effectively influence decisions by medical staff. Yet, decisions in healthcare matters are necessarily mediated through the expertise and standardised knowledge of healthcare professionals. Putting patients in charge of choosing their service may rest on an overly optimistic view of the capacity of patients to examine and challenge professional expertise, whilst underestimating the inertia or outright resistance of organisations in the face of pressure from individuals. The belief that the individual voice of patients can bring about change in an environment dominated by organised interests guarding a complex set of budgetary and professional relationships may be unrealistic. One casualty of the ‘choice’ strategy of the English approach may also be public health and prevention. Both are traditionally considered ‘Cinderella’ services that are seen as largely insensitive to patient choice.
Wales, Scotland and Northern Ireland have consistently avoided putting much emphasis on patient choice as a driver for change. Although there are faint echoes of patient choice in some policy documents in Scotland and Wales, both administrations have preferred implementing change through the partnership agenda, which often amounts to little more than exhorting health care professionals to work together for the patient's benefit. In a sense, both the Welsh and Scottish Government thus favour supply side interventions, rather than change through patient demand.
In addition, the Welsh Government has consistently sought to increase its direct control over the health care system, without increasing its transparency for patients. This direction of travel may speak to the more dirigist sentiments of its Labour politicians who publicly denounce private investment in health care. Some of the policies emanating from Cardiff, however, may conflict with the professed collaborative spirit. Whilst the Welsh Government urges all professionals to work together, it is about to introduce separate bills for health and social care services in the Welsh Assembly. This runs the danger of cementing long-standing organisational silos.
Scotland, on the other hand, has arguably made some progress towards improving patient experience through care integration. The main, problem, however, as noted by the National Audit Office recently, is how to judge the extent of this success. The Scottish NHS appears to suffer from a distinct lack of comparable data (NAO, 2012). The refusal of the Scottish government to meddle with health care provision may have temporarily paid off by creating organisational stability for professionals, but this approach may just have reached the end of the line. Most observers agree that Scotland needs to shift its provision from hospital-based services to community care and prevention. This is an enormous task and although absence of political meddling is widely welcomed by everyone, it is not clear that leaving professions to their own devices will deliver that transformation.
Overall, the health services in England, Scotland, Wales and Northern Ireland are still adhering to the primary principles of the NHS as set out in 1946. Since devolution, however, administrations in Edinburgh, Cardiff and Belfast, have subscribed to differently nuanced political narratives. Whilst England has continued on the path to more patient choice and transparency, the Welsh Government has re-affirmed its rejection of a private or mixed economy in health care. In a speech to the Welsh Labour party conference in 2012, first minister Carwyn Jones proudly declared that Welsh health care is ‘free from privatisation’.
This has left the Welsh Government ultimately culpable for anything happening in the NHS. With such strong vertical control, the Welsh government's ability to share responsibility for failures is also significantly diminished. In essence, the Welsh NHS remains a highly politicised health service, whilst in England a cross-party political consensus has slowly been emerging that seeks to reduce political influence on the NHS. In Scotland, the NHS is part of a discourse about an alternative national narrative that has some socialist overtones, but in practice, the Scottish Government has interfered little and largely stayed clear from micro-managing. In Northern Ireland, the power-sharing consociational constitutional setup of the Northern Ireland Executive forces a political consensus on all matters NHS, which has so far translated into very little change in the NHS.
Advantages of a federalised NHS?
There is one aspect of devolution that has remained surprisingly under-explored across all parts of the NHS. While devolved governments are jealously guarding their newly gained prerogative to decide on all matters NHS, they have often emphasised their autonomy from England at the expense of learning from each other. As the four health services embarked on a path of gradual divergence in organisation, funding and political rationality, politicians often defended differentiation across the NHS as a way to make health care more responsive to local needs. Yet there is some concern amongst observers that devolution and its emphasis on uniqueness may increasingly undermine mutual learning (Bevan et al, 2014).
There is a growing awareness that disparate data capture processes across the four NHS services makes it more difficult to compare performance and outcomes between the four constituent services. This is, perhaps, the most problematic legacy of devolution. In theory, the main advantage of federalised systems is the opportunity to test different solutions for similar problems. At present, the NHS in England, Scotland, Wales and Northern Ireland are justifiably celebrating their autonomy, but a lack of willingness to learn from each other may deprive them of a unique opportunity to develop positive change for the NHS as a whole.
- Bevan G., Karanikolos M., Exley J., Nolte E., Connolly S. & Mays N. (2014) The four health systems of the United Kingdom: how do they compare? In: Source Report, p. 128. Nuffield Trust and The Health Foundation, London.
- Grand J. L. (2003) Motivation, Agency, and Public Policy. Of Knights and Knaves, Pawns and Queens, OUP, Oxford et al..
- Ham C., Heenan D., Longley M. & Steel D. R. (2013) Integrated care in Northern Ireland, Scotland and Wales. Lessons for England. The King's Fund, London.
- National Audit Office. (2012) Healthcare across the UK: A comparison of the NHS in England, Scotland, Wales and Northern Ireland. Stationary Office: London.
Axel Kaehne is currently Chair of GORWEL – The Welsh Foundation for Innovation in Public Affairs, and Senior Research Fellow at Edge Hill University.