Feature

Devolution stirs policy evolution

A devolved Wales is developing its own distinctive approach to health, rather than simply accepting Westminster’s policy for running a health service, says Steve Davies

With Michael Howard as their new leader, and a revamped shadow cabinet, it is clear the Tories will fight the next election emphasising ‘choice’ in public services and pledged to extend private healthcare. Public provision will continue as a safety net for those unable to afford to go private.

This presents prime minister Tony Blair with a problem. All his instincts seem to be to take a similar path. But if he does so he risks further alienating his party and supporters, as well as making it difficult to put any clear water between the two main parties on health policy.

Although Westminster politicians appear to be moving closer on aspects of health policy, it is the focus on ‘choice’ that will emphasise the growing differences in approach to health provision among the devolved UK countries.

Blair frequently rails against the one-size-fits-all mentality in public services, but devolution is rapidly making diversity in healthcare provision a reality. And there is every reason to believe that Mr Blair might not like what he sees on the Celtic fringe.

For people in Wales and Scotland significant changes are taking place, as distinct differences emerge between Westminster and the devolved nations. These divergences reflect not only different priorities and policies but also a different political culture. As the impact of this is felt by people in those countries, and observed by those who are not, it may become more of a problem for the Blair government.

The fracturing of a centrally imposed ‘consensus’ is leading not just to questions about policy implementation but also to questions about core policies. For example, everyone is concerned about hospital waiting lists but in the devolved administrations there is debate not only about the length of lists but also about what sort of health service is desirable, and how it can be achieved using the devolved powers.

Scott Greer of University College London’s constitution unit argues that we are moving towards four different NHS models in the UK:

• Market-led (England)
• New producerism (Scotland)
• New localism (Wales)
• Pre-1997 internal market (Northern Ireland)

The market-led model championed by the Blair government is familiar, with its emphasis on private finance, contracting and the power of managers.

Northern Ireland has been hampered by the suspension of its devolved assembly, but Greer argues that the lack of interest in developing a distinctive health policy shown by the province’s politicians, and the slowness of movement, have resulted in an opportunity to see the Conservatives’ pre-1997 internal market reforms in action.

Scotland has sided with the medics against the managers, says Greer. The Scottish Executive’s white paper, Partnership for Care, sets out plans to abolish trusts and introduce ‘managed clinical networks’. The effect of this will be to relocate decisions over resource allocation from managers and chief executives to clinical professionals.

Greer describes the Welsh developments as ‘new localism’, and with good reason. The NHS in Wales has been reorganised into 16 trusts and 22 local health boards, which share boundaries with the 22 local government unitary authorities, creating a structure unlike anything else in the UK.

The LHBs are expected to work closely with councils on health and social service issues. Together with the retention of community health councils (which have been abolished in England), this forms part of the Welsh Assembly’s declared aim of democratising health provision. According to health minister Jane Hutt, the new arrangements ‘will bring a greater local voice to NHS decision making’.

It is also seen as the structural basis for a different approach, one based on prevention and focusing on primary care and public health – a health policy rather than a policy for running a health service.

In attempting to put clear red water between itself and its parent at Westminster, Welsh Labour has made only limited (and grudging) use of the private finance initiative, has rejected foundation hospitals and has explicitly ruled out the use of private diagnostic and treatment centres.

There have been some PFI projects in the health service in Wales, but very few. In 2001, the then finance minister Edwina Hart said: ‘Insofar as the rest of the UK finances part of its investment in public services through PFI – and therefore from outside the public expenditure block allocated to the Assembly – we must either mirror this form of investment or accept that Wales will have a lower level of investment.’

This was not exactly a ringing endorsement and where traditional procurement is seen as possible, it is embraced. Referring to the planned construction of two community hospitals using wholly public finance, Ms Morgan told the Wales TUC 2002 conference that this was ‘not some opportunistic aberration’.

Also in 2002, following lobbying from trade unions, the Welsh Assembly government extended the definition of the clinical team in NHS Wales PFI schemes to protect support staff who, elsewhere in the UK, would be vulnerable to transfer to the private sector.

In an important speech in December 2002, Welsh first minister Rhodri Morgan said that a key theme of the assembly’s first term was the creation of a new set of citizenship rights: free at the point of use, universal and unconditional.

He emphasised social solidarity and the individual as citizen rather than as consumer, and mocked the idea that a public services user was ‘some sort of serial shopper’.

He added: ‘Approaches that prioritise choice over equality of outcome rest, in the end, upon a market approach to public services, in which individual economic actors pursue their own best interests with little regard for wider considerations.’

Similarly, Mr Morgan objects to foundation hospitals because, as he puts it, ‘the experiment will end not with patients choosing hospitals, but with hospitals choosing patients’. His preferred aim is for hospitals to ‘develop specialisms through collaboration rather than competition between trusts’.

During its first term, the Cardiff administration abolished prescription charges for 16 to 25-year-olds and over-60s and froze them for the rest of the population. It also abolished dental charges for the same age groups and eye-test charges for the over-60s. In its second term, it has pledged that prescription charges will be phased out by 2007, with the first reductions in October 2004.

It has also pledged to introduce free school breakfasts in primary schools (in Community First areas from September 2004 and then in all primary schools in Wales from September 2006). This is seen as an example of the integrated approach to public health policy.

The Welsh Assembly government faces many of the same problems as the Westminster government, particularly regarding waiting lists. Expectations are high and to date results have been limited.

The challenge is enormous, perhaps even more so than in England. After conducting a health review of the NHS for the UK government, Derek Wanless was asked by the assembly government to do a similar job for health and social care in Wales. The report, published in July 2003, recognises that demand in Wales is disproportionately high because of an ageing population and the impact of socio-economic factors on general health (with lower than UK average life expectancy).

But it also points out that ‘Wales does not get as much out of its health spending as it should’. Wanless warns that the current position is unsustainable. His report recommends a series of reforms, an emphasis on prevention rather than cure and calls for individuals to take more responsibility for their own health.

There are critics in Wales – even within the Welsh Labour party. Cardiff MP Jon Owen Jones has attacked the assembly government’s lack of enthusiasm for PFI and warns that rejecting foundation hospitals will mean there is a danger that English foundation hospitals do not have an obligation to treat Welsh patients from over the border. He has also criticised the assembly’s record on reducing waiting lists.

The ultra-loyal MP for Clwyd West, Gareth Thomas, also recently attacked the assembly government, claiming that ‘political correctness’ is preventing PFI being used to improve healthcare. He favours foundation hospitals and claims that the assembly’s failure to extend greater financial freedoms as a reward to the best-performing Welsh NHS trusts is a disincentive for managers and staff to improve their performance.

There are more pressing problems for the NHS in Wales than opportunistic broadsides from parliamentary private secretaries eager to impress Number 10 with on-message declarations of loyalty. Wales has serious public health problems related to poverty, unemployment, alcohol and diet, sedentary lifestyles and smoking.

The health service also works under a number of limitations. As Scott Greer points out, it is not just finance, but includes a relative lack of autonomy and the lack of policy capacity.

However, despite these limitations and the scale of the problems, there are real opportunities to achieve positive results and refocus health policy on primary care and prevention.

While Tony Blair stresses the role of the market, praises the efficiency of the private sector and emphasises consumer choice, the language of Labour politicians in Wales is more likely to refer to citizenship, equality of outcome, universality, collaboration, and public rather than private provision.

The challenge facing Welsh Labour is to develop this non-market approach to health policy reform and to make it work for the benefit of the people of Wales.