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BMJ. May 1, 1999; 318(7192): 1155–1156.
PMCID: PMC1115566

The NHS after devolution

Will have an even sharper focus on health inequalities
Colin Leys, Visiting professor

Health and personal social services will be the biggest responsibility of the new Scottish Parliament and Welsh Assembly to be elected on 6 May, accounting for over a third of the total spending under their control.1 What are the likely implications for the future of the NHS? How far will devolution affect its core principles of comprehensiveness, universality, and free service at the point of provision? What, especially, is likely to be the impact on the principle of equal care for equal need?

Even in federal systems, where the powers allocated to provincial, state, or regional governments are protected by written constitutions, the central government's superior revenue base usually allows it to secure a large measure of uniformity in return for transfers from the federal budget, as the case of Canada illustrates (p 1201).2 The Canadian constitution makes health a provincial responsibility, but, despite provincial variations in the way health services are delivered, the federal government's substantial share in financing them means that all Canadians get the same free access to family doctors and to a nationally determined range of hospital services, regardless of their province. Where powers are merely devolved, with little or no tax raising authority, as in the new British system, the freedom of regional authorities to deviate from patterns laid down by the central government is narrower still. The scope for significant local variation is really determined by the possibility that local public opinion will be mobilised on some issue that threatens to test the central-local division of powers and fuel sentiment in favour of greater independence, or even total separation. Health policy, touching people's deepest sense of security, clearly has the potential to be such an issue.

The prospects for change arising in this way, however, depend on distinctive national cultures and expectations, as the experience of decentralised health policymaking elsewhere in Europe shows (pp 1204, 1198, 1156).35 Spain, for example, began in 1986 to move from a complex patchwork of national and local healthcare systems towards a more uniform system, characterised by equal access and comprehensiveness and funded and supervised by Madrid—broadly on the NHS model, but with administration devolved to 17 regions. The process has been uneven and is incomplete, with persisting variations in coverage and access. The expectations of United Kingdom voters, after 50 years of effort to achieve national standards of access and equity, are obviously different. It is doubtful how far they are likely to accept a significant re-emergence of local differences arising from devolution, let alone the degree of variation to which Spanish voters have long been accustomed.

Finland and Sweden, on the other hand, combine longstanding traditions of health policy implementation by numerous elected local governments with strong national standard setting and redistributive spending by the central state. With the shift to fiscal conservatism in the 1990s, however, local policymakers, especially in wealthier districts with conservative majorities, have used their devolved powers to introduce or increase user fees and make contracts with for-profit providers, thus reducing equality of access and opening up the system to private interests.

In some respects Scotland and Wales present a directly opposite case. They have sizeable populations (five and three million respectively) and a significant degree of cultural unity and distinctive educational, political, and administrative traditions. In voting for devolution, a majority of their electorates have clearly been reacting against centrally imposed measures to cut back the scope of the public sector, including health services, and to introduce user charges and private provision in both dental and long term care. And they are also faced, in the short run at least, with a central government more likely to reduce the level of redistributive spending to compensate for greater regional needs than to enhance it—the so-called “Barnett squeeze” described by Pollock (p 1195),6 a squeeze that could also impact painfully on Northern Ireland.

What also distinguishes the Scottish and Welsh situations from the extremely decentralised systems of countries such as Finland and Sweden (where local authorities are often too small to support adequate technical resources for health policymaking) is that each nation possesses a critical mass of professional expertise—both clinical and non-clinical—with strong ties into local public life. Under the Thatcher reforms health professionals as well as the local public were increasingly excluded from the policymaking process. Instead a Treasury-NHSE-hospital management nexus drove a process of downsizing acute care, shedding costs (to local authorities and patients), and shifting to private provision, especially in continuing and long term care. If public opinion in Scotland and Wales were to converge with professional opinion and crystallise around a few critical healthcare issues in opposition to these trends, Whitehall and Westminster might well feel obliged to accommodate it to avoid mobilising nationalist sentiment.

What might these issues be? The Scottish National Party, Plaid Cymru, and the Liberal Democrats have variously highlighted the private finance initiative, user charges, the restoration of strategic planning, the abolition of independent trust status for Welsh hospitals, and the introduction of salaried general practitioner services in the south Wales valleys. More immediately, a fight is likely over the Barnett formula (the formula used for allocating central funds to Scotland, Wales, and Northern Ireland), with a much more informed debate about a hitherto arcane administrative process, focusing on the priority that people want to be accorded in health care to disadvantaged areas and social groups.

Such a development would have effects beyond the borders of Scotland and Wales. If the Barnett formula, based solely on population, were to be replaced by one based on needs the debate would inevitably arouse fresh interest in devolution within England, some of whose regions are as acutely deprived as any in the United Kingdom. In addition, whether or not an attempt is made to change the Barnett formula, devolution is also bound to give more prominence to the European dimension in health policy—especially in Scotland, which the Scottish National Party projects as a prospective independent state within the European Union. This will highlight the huge gap between total spending per head on health care in the United Kingdom (parity purchasing power $12977 in 1996) and countries such as France ($1989) and Germany ($2233), with which British people like to compare themselves.

The specific effects of devolution on health policy are clearly impossible to predict. What is certain, however, is that the activities of the new Scottish parliament and the Welsh and (let us hope) Northern Irish assemblies will give rise to a new and overdue focus on inequalities in health and on the NHS's founding principles.

Notes

Editorial p 1156, Education and debate pp 1195-1205, News p 1166, Personal view p 1221

References

1. HM Treasury. The government’s expenditure plans 1999/2000-2000/02. London: Treasury; 1999.
2. Armstrong P, Amstrong H. Decentralised health care in Canada. BMJ. 1999;318:1201–1204. [PMC free article] [PubMed]
3. Reverte-Cejudo D, Sanchez-Bayle M. Devolving health services to regions in Spain. BMJ. 1999;318:1204–1205. [PMC free article] [PubMed]
4. Koivusalo M. Decentralisation and equity of health care in Finland. BMJ. 1999;318:1198–1200. [PMC free article] [PubMed]
5. Diderichsen F. Devolution in Swedish health care. BMJ. 1999;318:1156–1157. [PMC free article] [PubMed]
6. Pollock A. Devolution and health: challenges for Scotland and Wales. BMJ. 1999;318:1195–1198. [PMC free article] [PubMed]
7. Organisation for Economic Cooperation and Development. OECD in figures. Paris: OECD; 1998.

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