Vive La Difference!

Devolution of power is beginning to alter health systems in the United Kingdom. Are there lessons to be learned from comparing health care systems across our internal borders?

We plan to compare and contrast the structures and approaches taken by the devolved administrations with the English way, and to consider whether there is any discernible difference in the outcome for patients.

Wednesday 19th September 2007 Eric Liddell Centre 15 Morningside Road Edinburgh EH10 4DP

Main speakers:

Scott L. Greer School of Public Health, University of Michigan – is a political scientist, who does research on the consequences for health policy and the welfare state of federalism, decentralization, and European integration. His work focuses especially on the United Kingdom and the development of health policy in England, Northern Ireland, Scotland and Wales. Scott doesn’t do Powerpoint – notes of his contributions are below.

Professor D J Hunter, Professor of Health Policy and Management, University of Durham. David’s interests lie in health care reform and the development of public health policy and he has published widely in these areas. David is Chair of the UK Public Health Association and is an honorary member of the Faculty of Public Health, and a Fellow of the Royal College of Physicians (Edin.) David’s presentation and contributions are below.

Dr Kate O’Donnell General Practice & Primary Care, University of Glasgow is leading a cross-jurisdictional study of primary care in England and Scotland.

Notes of what transpired:

Scott Greer:

There are in the different countries, different policy elites, symbolic publicised policies (Rhodri’s Clear Red Water, Free prescriptions and Free Personal Care) and also gradually emerging incremental differences. The political pressures faced by the Labour Party, which is now the only party operating effectively in the 3 countries with normal politics, come from different directions. In Scotland and Wales the pressure is all from the left, but in England mostly from the right. The policy communities have developed shared understandings, some over long periods.

In Scotland there has been a highly educated professional medical elite for several centuries. The policy community accepts the dominant role of professionals, professional values, and professional ideas, and looks to a system of co-operation and partnership. The SNP government has not challenged that and is not seeking to restructure health services, only to undo decisions on reconfiguration. The purchaser/provider split has been dropped and there is no one calling for it to be reintroduced.

In Wales there is a universal acceptance of the language of communitarianism. Rhodri Morgan makes a point of quoting the Inverse Care Law in full – including the part about market forces. We have had first strategy without tactics – an emphasis on health rather than healthcare in the Welsh Health Plan- and then tactics without strategy – Health Challenge Wales. Now we have a new, tougher health minister.

In England Julian Le Grande’s theories of knights and knaves has been very influential- probably because it captured the way English policymakers think. Much English policy thinking accepts the two categories, and places health service workers in the category of knaves. Professionals are seen as the problem. Advice is only trusted if it comes from special advisers or from McKinsey because they are not seen as vested interests.

In Northern Ireland there is widespread mistrust of the political system, and a culture of permissive managerialism has developed where managers power has become entrenched. It remains to be seen whether this will be challenged under the new political settlement.

David Hunter:

Devolution has not run long enough for some public health effects to be noticeable. An exception seems to be the impact of the ban on smoking in public places which was introduced in Scotland in March 2006, over a year in advance of England. A recent study from researchers at Glasgow University reveal a 17% year-on-year drop in heart attack admissions to nine hospitals.

Differences within a country may be more significant than those between countries. For example, healthy life expectancy in Didcot is 30 years more than in Middlesborough. And within the North East region in England, there is a difference of 10 years between Berwick and Hartlepool.

The major public health issues centre on Tobacco, AlcoholObesity and Mental Health. Scotland has the highest suicide rate among young men, and consumes 40% more anti-depressants than England. But in general there have not been huge differences in the policy responses across the 4 countries. In the provision of healthy school meals, Scotland was ahead of the rest of the UK and didn’t need the services of Jamie Oliver to put the issue on the map. The health tsar (or rather tsarina) appointed in Scotland got on with the job in terms of banning turkey twizzlers and introducing new nutritional standards. In obesity, noone has an edge. Scotland has a more upstream approach than other countries, but this might have happened anyway under the existing devolved – there was no obvious link with political devolution. Indeed, attributing advances or changes to devolution, other than in respect of the smoking ban, is tricky. Some of us were involved in a review of the Scottish Diet Action Plan which was introduced pre-devolution in 1996. We reviewed it over a 10 year period and while there was evidence of modest progress, especially since devolution occurred, much remains to be done and there is little evidence of a more proactive and vigorous approach (see Lang, T, Dowler E and Hunter DJ (2006) Review of the Scottish Diet Action Plan: Progress and Impacts 1996-2005 ).

In any event, public health related to multiple levels of government, from global to local. The European Union was becoming an increasingly important player and driver in respect of health policy since issues to do with smoking, diet, mental health etc transcended national boundaries. In respect of food policy, for example, and tackling obesity, individual small nations like Scotland had difficulty in taking on the global food industry.

There were a number of policy cleavages or tensions in respect of health policy which were evident, and being played out, in each of the 4 countries making up the UK. Most notable were the alternative approaches of individualism versus social determinants in respect of the development of public health policy. A recent focus on individual lifestyles had marginalised or overshadowed a concern with the more upstream structural determinants of health. But the new health secretary in England, Alan Johnson, has signalled a possible shift in policy when he suggested that people may be less anxious about the ‘nanny state’ than the ‘neglectful state’. In every country, despite the rhetoric which was possibly most evident in Scotland and Wales, there remained a fixation on health care to the exclusion of public health. There was in every country more rhetoric about public health than performance, more symbolism than substance, and less divergence in reality than politicians asserted. Some of the substantive differences, such as the Standard Operating Procedures in Scotland, were established before political devolution under the prevailing devolved administrative arrangements evident in Scotland, Wales and Northern Ireland. There were also signs of the smaller countries tracking policy developments in England as their capacity for innovation, and creating new policy ideas was limited. For instance, the rich array of think tanks and policy analysts was concentrated in England. Inevitably, therefore, a tendency to ape and mimic what was being generated by these resources was evident. On the other hand, because of the scale factor, the organisation of government in the devolved countries could take on a new shape. There were interesting developments to report in Scotland following the May election with the implementation of the Scottish Executive’s Taking Stock report which gave priority to tackling cross-cutting issues such as health inequalities and health improvement. It was too soon to comment on the likely success or impact of these developments but they demonstrated that smaller countries with flatter structures and possibly less complicated and fewer departmental silos could organise their affairs in ways that might tackle complex policy challenges more effectively. Time will tell. The Jury is out. Finally, instead of looking to other parts of the UK for inspiration, it is conceivable that the devolved countries will look to other small countries, like the Baltic States or to Scandinavian countries like Finland. In the case of Finland, a special relationship already exists with Scotland.

Kate O’Donnell

There is a problem in paying for cross border research. The English Department of Health is making it clear that it only wants to pay for English research, but the SDO is still interested in cross border work. Such work will be increasingly important as post-devolution changes take place.

In developing its health policy, Scotland has faced the twin challenges of both urban deprivation and rurality. This poses challenges for it. However, as a country with a relatively small population (equivalent to some of the SHAs in England), it has the benefit of policy makers and professionals knowing each well.

Scotland and England face similar issues: aging populations; increase in long-term conditions; rising demand for care from patients; recruitment and retention of staff; changing skill mix. In addition, both countries have had to implement the UK-wide GMS contract for general practitioners. Patients are now registered with practices, not patients, GPs have opted out of out-of-hours services, and some of the care delivered is now incentivised under the Quality and Outcomes Framework (QOF). While there is evidence of Scotland achieving higher points under the QOF, this is a statistical difference and it is still unclear what the impact is for patient care. Monitoring may also be more stringent in England than in Scotland, who have adopted a more collaborative approach to QOF verification.

Services in England had become more innovative and experimental, especially in out of hours care, where there is evidence of a grater involvement of private companies and of new skill mix configurations than in Scotland.

Public health, prevention and anticipatory care have featured highly in recent Scottish policy documents. Scotland has now re-organised primary care delivery into Community Health Partnerships, bringing together primary care, community care and social care. A major thrust for these organisations is the reduction of inequalities in health, with the first major anticipatory care programme for CHD drawing heavily on the approach developed by Julian Tudor-Hart in Wales. Again, we do not yet know what the impact will be for patients of staff.


(reordered to make it more coherent than it was)

There are a lot of issues relating to scale which make devolution attractive to people like us anxious to influence the process. The smaller and more local administrations are much more approachable in every sense than Westminster, where the scale of the operation makes policy makers very inaccessible. In the devolved countries relations with the professions, with managers and with the voluntary sector are much easier. Accountability is on a more personal level. This may of course not necessarily mean that the services are better – they may be more cosy and complacent. The English seemed to believe that a market based approach would lead to more effective innovation, but it was not clear that the same could not be achieved by planning without the considerable additional costs of marketisation. The English NHS is about ten times bigger than any other unitary health system in the world. The smaller administrations may be better able to tackle cross cutting issues.

Approaches to health inequality did not seem hugely different in the different countries. There were tensions between individual lifestyle approaches and more collective social determinism. In each country there was increased targeting or disease finding and successful attempts to ensure that medication, especially statins, reached more deprived communities. But the more fundamental problems related to income and social inequality which was difficult for small governments – or indeed large governments – to tackle. Some of this related to things which were not devolved, like the benefit system, which delivered large sums of money from tax payers in the South East to each of the devolved economies. The Brown government was still committed to the abolition of child poverty and steps in the direction seemed likely to affect all the countries. There didn’t seem to be marked differences in approach to issues such as breastfeeding (though Scotland had very interesting legislation it wasn’t clear that it had widespread effects), or traffic accidents to children. The Treasury seemed to have accepted arguments about social determinants of health and to be doing good by stealth even though politicians didn’t like to talk about them.

Relations with NHS staff and professions seemed better outside England which was suffering from reorganisation fatigue. There had been a lot of structural tinkering in Scotland but no big disruptions. In England there had been an unhealthy fascination with novelty. Tony Blair was addicted to policy announcements. In each country there were considerable gaps between the rhetoric of policy pronouncements and the reality.

There were differences in public and patient involvement, which had been reorganised more than once in both England and Scotland. Wales had kept and strengthened its Community Health Councils. England had developed the role of local authority scrutiny committees. Scotland had a more centralised system. It was not clear whether any of these approaches had much effect. The Scottish Parliament was now considering direct elections to health boards, and English ministers have raised the possibility of direct elections to PCTs. There was considerable interest in the possibility of regional government in England which had been severely damaged by the failure of the North East referendum. Commissioning in England could fit happily with elected local authorities.

The approaches to decisions about cost effectiveness of new treatments was similar across the countries but sometimes produced conflicting results, for reasons which were not clear and generated confusion among patients.

Approaches to the voluntary sector varied to some extent across the borders, but problems of short term precarious funding did not. In Scotland there was a tendency to apply public sector solutions to public health problems where the voluntary sector might be more effective.

Making the policy making process more participative, as in Scandinavia, and less centralised seemed likely to be more successful and less likely to arouse resentment among the staff. In the end all healthcare systems are run by the professionals. We need a system which encourages responsible autonomy and a culture of professional engagements. Goodhearts Law of targets applies: the Law is that once an indicator becomes a target, it is no longer an indicator

Choice as in the English system would be a genie which would be difficult to put back in its bottle, but choice of hospital for planned surgery was not a choice most people cared about. Choice about how they were treated, especially for chronic conditions, was much more important, more difficult to deliver, and very little influenced by structural reorganisation.

There were some serious difficulties with the English approach to commissioning. Firstly there had been a lot more talk than action. But a system which rewarded hospitals for admitting patients when the intention was to treat more people at home seemed hard to justify. In a more integrated system there was less incentive for game playing and more common ownership of problems