Devolution and Health

1999 - 2003

Principal Investigator: Dr Scott Greer

About the Project

• What does devolution mean for health politics and policy?
• What does the conduct of health politics and policy tell us about the politics and societies of England, Northern Ireland, Scotland and Wales?

The Devolution and Health Project based at The Constitution Unit, UCL, was a multi-year project designed to answer these questions over the lives of devolution's first parliaments and to seek lessons for English regions and London. The project combined extensive interviews, a survey of health service elites in the three devolved administrations, analyses of government documents and monitoring reports on the individual countries.

Devolution and Health Updates

England and markets It hardly seems like news, but the English NHS continues to introduce market mechanisms under the various titles of choice and diversity, creating what are in theory revolutionary changes and what are in practice still difficult to interpret. If anything the difference these days is style (and style is important)- Alan Milburn, whom the FT in 2001 accused of creating a permanent revolution in the NHS, played up the radicalism of the Labour agenda while Reid often plays it down in public. Nevertheless, the "diversity" agenda, with fast-track surgery centres, PFI, and so forth is continuing, with the private-sector providers being pushed along by the Department and attracting controversy. It has, for example, irritated the BMA consultants and led to a damning BBC report on events in South West Oxfordshire, where the new localism collided with New Labour's affection for private provision, and lost as badly as one might expect. Essentially, the Secretary of State became involved in forcing an uneconomic private provider on a PCT, and prompted resignations and controversy. This story might be spun to the Department's detriment, but it does point to the determination (dogmatism, some might say) of the Labour government in its efforts to introduce private providers, the resistance it is encountering, and the fundamentally political nature of all the costing decisions that underlie public/private decisions. The academic can hardly wonder if any of them have ever read, in addition to many studies of health policy that question the uses of the private sector, the work of transaction cost economics , which points out that the costs of contracting can exceed those of just doing it yourself.

Wales, capital, and capacity Not a few health policy people in Wales are waiting for some kind of a political explosion, given the consistent poor performance in acute services and conflicts in the upper reaches of management, and it has been something of a surprise that neither the Audit Commission report "Transforming Health and Social Care in Wales" nor the "Wanless" Review of Health and Social Care in Wales sparked major changes. What the Wanless review did appear to spark, though, was a major change in capital investment. The NAW has largely upended its capital investment plans (more soon), arguing that investment should go into shoring up services rather than new builds. This is causing some irritation among trusts, which often have substantial sunk costs and arguments for their capital commitments, and could well create political havoc when communities lose upgrades or promised replacements for withdrawn services. More soon on this site.

Good news from Wales: eye care

Wales has been radical in many policy areas, including health services organisation, education, and public health, and the problems in health services should not blind us to the other good things it is doing. One is policy in the Cinderella service of eye care, among the first services to be cut back after the creation of the NHS systems decades ago and still undervalued. The National Assembly took the opportunity to rethink eye care, and now we see at least part of the payoff, as recognised by an award. Radicalism and reorganisation might not have visibly paid off in health services, and arguably have exacerbated the problems in joint working, but they have also paid off in areas such as childrens policy and this.

Welsh mess? Another summary of the bad news in Welsh health services. This is the report of the Audit Commission in Wales Transforming Health and Social Care in Wales, which paints a depressing picture of the services. It argues against a number of common ideas, including that Wales lacks beds, and instead argues that the problem is poor management and failure to coordinate services across organisational boundaries-- for example, that more than a quarter of hospital beds are 'blocked'. Eliminating such bed-blocking was supposed to be a virtue of the close connection between health and social care in 22 LHBs. So far the best idea we have seen for solving the waiting list problem (around 10% of the population of Wales appears to be on some sort of a waiting list) is a form of patient choice that will allow those who have waited more than eighteen months to get treatment elsewhere-- probably England. Given travel costs for the patient and relatives, and the bills from English trusts, this could cost a fortune, and it is probably not much of a solution. It will especially not be much of a solution when the commitment to free prescriptions kicks in and, around the same time, new money from the Treasury dries up

Whether this new report will be the catalyst for change is unclear. The Wanless-advised report looked like a potential catalyst, and wasn't. If a change comes, there will be a real risk that a new policymaker will throw the baby out with the bath water- i.e. give up on the wider determinants of health in a rush to solve health services problems.

April 1 April 1st, as ever, is the big date for reorganisations. This year it was Scotland's trusts (gone) and quality organisations in England (and Wales). CHI and a number of other organisations became CHAI, the Commission for Healthcare Audit and Inspection. There had been some confusion over the last year about how to pronounce the different names (with some pronouncing CHI in Greek as ki, in order to differentiate it from CHAI) and some worry about the words "audit" and "inspection" in the new CHAI, which summoned images of Ofsted). It was not, therefore, much of a surprise that the new organisation will actually work under the name of the Healthcare Commission. It will be led by Ian Kennedy of Bristol inquiry fame. Wales is setting up its own healthcare quality organisation Healthcare Inspectorate Wales and it remains to be seen how this still somewhat undefined organisation will interact with the others (not just the Healthcare Commission, but also organisations at work in Wales such as the National Patient Safety Agency and the Audit Commission in Wales).

Capacity: a note Most observers assumed all along that policymaking capacity constraints in the devolved health systems would matter. It turns out that they do, above all as their effects cumulate over time.

There are two ways we see capacity constraints at work. One is simply the breadth of the agenda. UK ministers (responsible for the English NHS) might be focused on their agenda of choice, diversity, payment by results, and so forth, but down in the Department of Health and in the various executive agencies there are teams at work on all sorts thinking about issues that fall off the political agenda. Scotland, to a lesser extent, draws on its tightly knit and medically dominated policy community to formulate policy-- but still can miss issues. Northern Ireland and Wales rarely have the extra capacity to look ahead or formulate many policies on issues that are out of the limelight. The result is that there is, simply, more English policy activity.

The other way capacity matters is in the ability to implement-- which is where Wales got into trouble. Problems in Wales have partly come about because central services have been unable to stop some bad ideas in the reorganisation and related issues, and then because their ability to manage large-scale organisational change is not enough for the scale of the transformations the NAW envisaged. This is, so far, a Welsh problem since England and Scotland both have greater capacity (Scotland among its medical leaders as well as civil service and management) and Northern Ireland, while probably lacking capacity, also lacks policy to stretch its capacity.

We do not see capacity constraints in the ability of the different health systems to mark out their own directions. Policymaking capacity does not seem to have much of an impact on the main agenda items-- which is why we have four interesting experiments in health policy taking place. Where it matters is in implementation and in the breadth of the overall agenda.

Closing small hospitals: a four-country comparison

This entry is inspired by the increasing profile of small hospitals-- or, better, their closures or service reconfigurations-- in Scottish politics. There are many interesting things going on in Scotland, but it looks like the hot political issue is increasingly likely to be small hospitals (not just rural ones either; the financial problems in the West are not so much in remote lochs as in the towns around Glasgow). But the issue of small hospitals affects everybody, so here is what's being done about it.

The problem is that small acute hospitals and their individual services are increasingly difficult to sustain in the quality and design paradigms we use today. The first reason they are not thought sustainable is their lower quality. The consensus is that the more operations of a given kind that are performed at a given facility, the better the quality and the lower the error rate. The logic is impeccable; one wants an experienced specialist staff. The evidence is not quite as compelling, but strong enough. That means medical reformers dislike small facilities. It also means that Royal Colleges, the bastions of medical reformers, can use their ability to control training slots to effectively shut hospitals down (all hospitals depend on young doctors, so if the young doctors are withdrawn, the hospital will perish). Sometimes increasing the size of the facility might be an option, but not all health organisations can replace one retiring surgeon with three new ones or guarantee the patient flow to keep them busy. The second big problem is that this quality move comes just as the EU Working Time Directive and larger shifts in how professionals wish to use their time create a staffing crunch. If professionals mainly wish to work normal hours, and their workweek is capped by the EU, then hours per staff member plummet and small hospitals find it hard to get cover while large ones look at what they see as their small neighbours' poor use of scarce staff. And the third issue forcing these decisions is the wave of new money into health spending, much of which is going on new buildings. Putting up new buildings forces planners to think about services.

On the other hand, people like their local hospitals. So the UK-- and world-- is full of conflicts between managers who have medical reformers at their backs, technocratic arguments, and often inspiring plans, and local communities that quite rightly see a terrible blow to their pride, economies, and often health care. In the UK it tends to be crystallised by consultation exercises that reveal opposition to the reconfiguration plans but do not change them. Then comes the campaign, and that can turn into a small campaign for the heads of the local elected representatives.

What are the policies to deal with this? England pioneered getting into trouble with hospital closures, with the famous Kidderminster election of Dr Richard Taylor, who won (along with some local government candidates)on a platform of saving local health services. This led to the Department of Health issuing the paper Keeping The NHS Local , with prose that would make the untutored wonder what prompted them to issue it. It is an intelligent effort to square the circle by trying to redesign services in order to enable lots of services to be provided locally. Its problem is that it still has no answers to the chief sources of pressure: staffing problems and the consensus of quality improvers, backed up by Royal Colleges, that bigger is better, and it even lacks the sort of logic of using clinical networks. So reconfigurations will continue, as will the political trouble, and while there are incredible amounts of top-down, bottom up, and every other kind of pressure for service redesign, it has very little beyond the structure of PCTs that should produce attention to local services. Payment by results, the tariff being introduced for procedures, is supposed to push trusts to reconfigure capacity in light of their income from commissioners, and this invisible hand will push "uneconomic" services over the edge.

Scotland has more problems with sparse populations than England, and vastly more sensitivity to issues of sparseness for reasons not unconnected to the role of the Highlands and Islands in the whole of Scottish politics and national identity. It also has powerful medical reformers and, in the West, many small hospitals whose service configurations have, over the last three years, led to the loss of much if not most of the NHS top management in the area (and one unfortunate Labour MSP, whose constituency lost a hospital and gained a high-security psychiatric unit). The solution to this, as to most other issues in Scottish health services, is to be Managed Clinical Networks, which are not just resource allocation mechanisms but also should coordinate the use of resources (they originate in, and get much of their legitimacy, from this role). So the policy reduces the number of freestanding full-service acute centres, but tries to keep provision running, and organises quite a lot of health policy around it. It is typically Scottish: a compromise between the power of local community interests since devolution and the power of medical reformers within the health system.

Northern Ireland's most exciting health debates have been about hospital reconfigurations; in its short devolved career the big polemics have been about the allocation of maternity services in Belfast and the location of a new hospital in Tyrone/Fermanagh. Northern Ireland's local communities defend themselves well against service rationalisers, so it has historically been Royal Colleges that effectively shut down facilities-- it is politically too difficult to take decisions until that guillotine is activated. This almost happened with the hospital in the south-west. The official line is that direct rule ministers are tiptoeing around, disturbing nothing because any minute the devolved government might come back home and turn on the lights (no comment on the realism of this view). But the southwest hospitals were, if not facing the guillotine, at least on the tumbrils, so the direct rule minister went ahead and made the decision. Devolved or not, wait for any further such decisions in Northern Ireland to be made only when doom approaches.

Wales has also been dodging the issue, since its slim capacity has been busy reorganising. It also has a dense enough population in the Valleys to keep that group of hospitals justifiable; the price, if there is one, is paid in poorer quality and maybe efficiency. Devolved government in Wales, without medical reformers to push responses before the Royal Colleges and EU intervene, has not shown any great capacity to raise the issue. Further, the design of health services makes response less likely. If England has harmed its chances of being able to respond in a way that preserves local services by creating a mimic market (Rudolf Klein's phrase), Wales has done so by creating a system with a lot of potential local power in the LHBs, tightly tied to local governments that *never* have an interest in losing services. We don't know how long Wales can ignore the issue, since some moves might even exacerbate it (if anybody out there can explain the investment decisions in Welsh rural hospitals, please let me know-- I can understand the community pride, development, and so forth, but aren't we worried about a new build hospital in Porthmadog?). This reluctance to the deal with the problem is rather sad, since in Powys, where there is no hospital, Wales has a very interesting model worth study and some imitation.

English reactions (Wanless) The Wanless report in England, meanwhile, provided roughly one story/pair of stories per paper and did not carry over into weekend papers. What caught the imagination of most of the reporters was the criticism of target-setting, and, to a lesser extent, the criticism of the evidence base for much public health. A report that was broadly optimistic turned into a critical report in the hands of much of the press, while Clare Short etc. meant editors had no problems with lack of news. And any fire it lit will be somewhere out of the view of the mass public.

Devolved silence (Wanless) When the Wanless report came out I wondered what the reaction in Northern Ireland, Scotland, and Wales would be-- anything from condescension to imitation might have been expected. The answer: none that I can find (send me an email if you have encountered something). The report itself makes arguments that could be profitably debated across the UK, but apparently English public health arguments do not interest the devolved press (and devolved health policy doesn't interest the London press, either). No doubt professionals are reading it, but the silence is a sign of just how far apart these policy processes have grown.

England and Public Health: Wanless Report out: first comments Derek Wanless has released his report _Securing Good Health for the Whole Population_, a report for the Treasury (link in documents section). Note that it is an _English_ report. The impact on devolved politics will be interesting-- will the reaction be polite notice that the English are catching up? will it be a rethink in devolved health policy? or will the press report it as if the only public health policy in the UK is England's? This report follows on from the first Wanless report, which focused on health funding and suggestions for its use. That report found that the NHS is basically properly funded and organised, but that the overall health of the UK and the extent of strain on the health services would in large part be dictated by the degree to which the society took the burden off of the health services by becoming healthier (that report's projections for health needs varied wildly by the degree of societal engagement with the wider public health agenda). So this is the report to the Treasury-- note that it is to the Treasury-- on what government can and should do to promote societal engagement with health. The subtext, as ever, is departmentalism-- this report, regardless of what it says and what the Department of Health press release says, is likely to be taken as another Treasury bid to control yet more of what line departments do. Given that the NHS is not the key actor in reducing ill health (rather, it is the key actor in treating it), the Department of Health's loss might be health's gain if it means the centre starts to use the full range of tools in the hands of Treasury and line departments to promote health. After all, healthy cities or good food are not the problems of the Department of Health so much as of others, and this report might be what they need to start to work together better. More analysis soon to come on this site.

Scottish health services organisation The Health and Community Care committee of the Scottish Parliament issued its Stage One report on the National Health Service Reform (Scotland) bill on 10 February (links in documents section). In UK-wide perspective, the bill and the policies in its White Paper Partnership for Care are most striking for the abolition of trusts (the keywords are "single-system working" and of course "partnership") and the experiments with clinical networks. The committe supports this radical rollback of markets and, in truth, management (section 25). What the committee also drove home, though, was the importance of patients and public involvement. This reflects not just the policy issues discussed in its report but also the ethos of the Parliament-- specifically MSPs' suspicion of the old Scottish Office "reign of technocracy."

Wales Not much to report for early 2004; the biggest story is still the tension between acute services provision and the Assembly's focus on localism and the wider determinants of health. The Wanless-assisted report on services last year crystallised much of the discontent created by the reorganisation but also pointed to the importance of a focus on the wider determinants of health (and Wanless will be reporting on England in a few weeks). It led to debates about the relative merits of a focus on services or wider determinants and was a catalyst for many specific critiques (including quite a few from managers). By now the actual things Wanless said are far in the background, but the debate rumbles on even if policy and the tone of Welsh debates remain firmly focused on localism and wider determinants.

Northern Ireland Not much policy change and not much sign of it; the consultation period for the Review of Public Administration was extended to 27 February, though.

England and Fruit: A Devolved Debate There is at least one concrete new public health policy in England: a press release from the Department of Health announced on 16 February that England is adopting a free fruit for toddlers initiative (link in documents section). Its policy impact is desirable but limited, but it is an interesting example of how devolution and policy interact. Scotland and Wales both have been debating the issue of poor fruit consumption for some time. While they have particularly serious problems of bad diet, they are not alone (the poor have been known to get rickets in Birmingham, too). What they have, though, is policy communities with stronger representation for public health advocates, and parties to the left of Labour that campaign on public health issues (the Scottish Socialist Party in particular lit onto free fruit in schools as an issue). That means the rising global tide of anti-obesity research and advocacy hit Scotland and Wales first-public health advocates are closer to the centre of policy debates there and the politicians see more to gain from public health policies. The way the English scheme will work is also typical of the way devolved policy divergence works. It will be a means-tested, voucher-based scheme rather than rely on direct distribution of fruit in schools. In other words, what we see here is the differential receptivity of different parts of the UK to a global policy idea. It is also striking that obesity, one of several serious "lifestyle" risk factors that make good candidates for a campaign, is apparently easier to target than smoking.

England: Public Health consultation On 3 February Secretary of State for Health Reid announced, in a speech to NHS Chief Executives, a consultation on public health. This is partly a way to move quickly and avoid public health being another way for the Treasury to extend its reach in social policy when the next Wanless report comes out. We should also pay attention to the reasons Reid gave, though. The structure of his speech does not just reflect the awkward scheduling of using a speech to health services executives to launch a public health strategy. It also reflects the structure of much English government thinking. Namely, having sorted out the biggest problems of delivery and variation, now it is time to move on to causes. That might or might not be an accurate statement about the condition of health services in England, but it does reflect a popular view at the upper reaches of the Department that the emergency surgery is over and the NHS can convalesce or even walk unaided.

Outputs

• Greer, S. L. 2001a. Divergence and Devolution. London: The Nuffield Trust.
• 2001b. The Real Regional Health Agenda: Networks, Soft Money, and the Wider Determinants of Health in the East Midlands. London: The Constitution Unit.
• 2003. Policy Divergence: Will it Change Something in Greenock? In The State of the Nations 2003: The Third Year of Devolution in the United Kingdom, ed. R. Hazell, 195-214. Exeter: Imprint Academic.
• 2003. Health: How Far Can Wales Diverge from England? In Second Term Challenge: Can the Welsh Assembly Government hold its Course? Ed. J. Osmond, 52--64. Cardiff: Institute of Welsh Affairs.
• 2004 Territorial Politics and Health Policy. Manchester: Manchester University Press.
• 2004 Why Do Good Health Politics Make Bad Health Policy? In Future Health Organisations, ed. S. Dawson and C. Sausman. Basingstoke: Palgrave.
• 2004. Four Way Bet: How devolution has led to four different models for the NHS, London: The Constitution Unit.
•  The Fragile Divergence Machine: Citizenship, policy divergence, and intergovernmental relations. In Intergovernmental Relations in the United Kingdom, ed. A. Trench. Manchester: Manchester University Press.
• . Stresses and strains: Governing the regions from Whitehall. In The English Question, ed. R. Hazell. Manchester: Manchester University Press.
• Greer, S. L., and M. Sandford. 2001. Regions and Public Health. London: The Constitution Unit.
• 2004. Ideas Matter The London Health Commission and Policy in London.
• Hazell, R., and P. Jervis. 1998. Devolution and Health. London: The Nuffield Trust.
• Jervis, P., and W. Plowden, eds. 2000. Devolution and Health: First Annual Report of a Project to monitor the impact of devolution on the United Kingdom's Health Services. London: The Constitution Unit.
• 2003. The Impact of Political Devolution on the UK's Health Service. London: The Nuffield Trust