Evolution after devolution - the future of public healthcare in the UK

Whilst waiting to catch a train from Edinburgh to London, I overheard a pair of commuters talking about George Osborne’s spending review. More specifically they were discussing whether certain cabinet ministers would be jealous of Jeremy Hunt, heading a department that had had its funds ring-fenced. The current discussions regarding expenditure on healthcare are age-old. Less than five years after its formation, the government of the day (it may not surprise some that it was a Conservative one) had identified the NHS as an area where expenditure could be reduced and introduced the prescription charge.[1]

Whilst I’m fairly certain that the commuters were not Scottish, I did think that their discussion was a bit futile if they were. The Scottish rather than the British government decide on how much is spent on Scottish healthcare. However it got me thinking about how people view ‘The NHS’, and how nationalised healthcare has evolved since 65 years ago when it was first created in the UK - because back in the 1950s, it was easy for a piece of policy to effect the entirety of the UK. That is mostly not the case now.

It bothers me when people refer to the NHS as one entity. There were two separate acts to create the NHS in Scotland, England and Wales, and a third act by the Parliament of Northern Ireland to create their own public healthcare system, which has never had the ‘NHS’ label. Since devolution the government in Westminster has control of the NHS in England and very little else within the other nations.

So ‘the NHS’ that people refer to when discussing healthcare in the UK is actually four different entities:

• National Health Service (England)
• NHS Scotland
• NHS Wales
• Health and Social Care in Northern Ireland (HSCNI)

Given that both healthcare professionals and patients can venture between the four systems like a Belgian in the Schengen area, it is understandable why the structural differences may not be well known. I’m sure people will be aware of the headline-making points in delivery i.e. free prescriptions in Scotland, Wales and Northern Ireland and free personal and nursing care for the elderly in Scotland. There have indeed always been differences in the structure of the health services between the nations, but these have grown considerably since Tony Blair became Prime Minister in 1997 due to devolution of power to Scotland, Northern Ireland and Wales.

In 2000 the UK government produced a ten-year plan of reform and performance improvement for the NHS in England.[2] Following its publication Scotland produced the document Rebuilding our NHS (Scottish Executive, 2001) outlining planned structural changes leading to the creation of unified health boards. In Wales, Improving Health for Wales (Welsh Assembly, 2001) led to the creation of what are now Local Health Boards. At the time of devolution The Northern Irish Assembly did not produce an equivalent paper and kept its already differing structure in that the same body provides both health and social care.

The devolved control and organisation of healthcare has meant that local populations have benefited from health policy more tailored to their needs. However the differing policy - particularly now that Labour is no longer dominant party in the governments of the UK - has resulted in differing outcomes for patients. The National Audit Office (NAO) produced a document last year highlighting these.[3]  All very interesting reading, particularly the healthcare budget spend per person – £1,900 in England, £2,072 in Scotland, £2,017 in Wales and £2,106 in Northern Ireland. Even more interesting was England having a quarter less nurses, midwives and healthcare visitors per head than Scotland. This was the first document of its kind and I bet it will not be the last.

So when I look at the future of the ‘NHSes’ I see four planes leaving the same airport heading in different directions. This in itself is not a bad thing. However the mobile phone I own has evolved from its manufacturer paying attention what its competitors are doing, as well as the needs of me as a consumer. The apparent lack of interest in what happens beyond borders is worrying and is a barrier to the evolution of healthcare delivery in the UK. Surely it makes sense for the politicians and healthcare leaders from the nations to pay more attention to what is going on next door? I think I would be asking too much for the heads of the Departments concerning healthcare to meet up once in a while to have a chat about what they are up to.

Personally I don’t think there is any shame in Wales looking at Scotland and thinking – ‘You know that the way they deliver this aspect of healthcare is better than ours. Let's go have a look and see if we can make it work for us.’ Unfortunately, politically this is difficult and herein lies another age-old problem; having governments that have a lifetime of five years responsible for problems that last a genuine lifetime.

References:

1. The Cabinet Papers (1915-1982) – The NHS under the Conservatives. National Archives. http://www.nationalarchives.gov.uk/cabinetpapers/themes/conservative-rul...
2. J Dixon & S Dewar. The NHS plan: As good as it gets—make the most of it. - BMJ. 2000 August 5; 321(7257): 315–316.
3. Healthcare across the UK: A comparison of the NHS in England, Scotland, Wales and Northern Ireland. National Audit Office. 2012 http://www.nao.org.uk/report/healthcare-across-the-uk-a-comparison-of-th...