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Devolution and divergence in UK health policies
Dr Jennifer DixonDirectorNuffield Trust
IPPR2 February 2009
Background
Divergence in policy in NHS has always existed Before 1998 fundamental political unity Now distinctive trajectories
Scotland
High status medical leaders closely connected to policy
Communitarian values Main battles between Labour and SNP
Scotland
Purchaser-provider split abolished Integration of system into 14 geographical health
boards– No ‘payment by results’
– No competition (no plurality of providers)– No ‘practice-based commissioning’
Focus: chronic disease; public health and reducing inequalities; waiting(Kerr 2005)
Free long term personal care Prescription charges reduced (£5 -1/4/08)
Levers: Scotland ‘professionalism’*
5
providerperformance
Central directive
Regulation
MarketLocal accountability
Professionalism
* Scott Greer
Wales
Main battles between labour and Plaid Cymru
Communitarian values
Wales
2003 reorganisation of commissioning into 22 local health boards co-terminous with local authorities
Emphasis on public health and reducing inequalities Purchaser-provider split maintained, but current
Labour-Plaid Cymru coalition (2007) committed abolishing it
Number of Health Boards and Trusts to reduce No PbR, no foundation trusts Prescription charges abolished 1 April 2007
Levers: Wales ‘limits of localism’*
8
providerperformance
Central directive
Regulation
MarketLocal accountability
Professionalism
* Scott Greer
Northern Ireland
Politics: sectarian representation Little interest in health Change slow
Northern Ireland
Purchaser- provider split remained GP fundholding abolished only 2003 2005-6 UK government began to make decisions Since restoration of devolution that halted that
change Now plans to merge all 4 Health Boards into one
and reduce the number of Trusts to five Managers free to make decisions (unless large)
Levers: N. Ireland ‘permissive managerialism’*
11
providerperformance
Central directive
Regulation
MarketLocal accountability
Professionalism
* Scott Greer
England
Politics: (new) Labour 2000-2006 major changes Purchaser-provider split Autonomy for providers, plurality, competition
and choice, PbR PCT and practice-based commissioning Regulation Devolution of power Central directive
Levers: England ’markets into managerialism*
13
providerperformance
Central directive
Regulation
MarketLocal accountability
Professionalism
* Scott Greer
Comparing NHS performance across the UK
Sensitive Data comparisons not straightforward (who
is interested in VFM across the UK?) Old debates about level of funding for need
(Barnet Formula)(Add in Scott’s graphs on funding and
morbidity)
Copyright ©2008 BMJ Publishing Group Ltd.
Greer, S. L BMJ 2008;337:a2616
Fig 1 Identifiable government spending per capita, 2007-8
Copyright ©2008 BMJ Publishing Group Ltd.
Greer, S. L BMJ 2008;337:a2616
Fig 2 Male life expectancy at birth, 2004-61
England 96-7
England02-3
Scotland96-7
Scotland02-3
Wales96-7
Wales02-3
N. Ireland96-7
N. Ireland02-3
Waiting
Inpatient
<6 month 74.9 80.6 na na na 21 20.6 18.4>12 month 2.7 0 na na 9.9 15.9 17.1 22.0Outpatient
<6 month na 100 na na 94.1 67.6 80.7 61.4
% public satisfied
inpatient 51 49 61 58 63 60 67 84outpatient 50 51 64 60 63 55 70 88general practice
77 72 81 73 79 68 83 90