Sorry for the lack of posts this week. I have been asked to help out with a major re-organisation which will probably take up a lot of my time over the next few months. Posting may therefore be a bit light for a while.
As I have said before, just because those at the top of an organisation devolve power, it doesn’t mean that executives in the tier below will devolve power in turn. Devolution might simply empower people to set up their own centralised autocracies at local or business unit level. I have seen this happen in a few organisations.
Likewise, one of the paradoxes of devolution to Scotland and Wales has been the creation of more centralised public services and a reversal of the shift towards localism that has been taking place in England. As Graham Clews reports in the Health Service Journal:
In contrast to the devolved countries, it is greater freedoms for foundation trusts and local commissioners that have shifted power away from the centre in England. And unlike in Scotland, Northern Ireland and Wales, the focus of the English service has changed frequently to concentrate on at first standards, then targets and governance, followed by competition and choice, with the focus now being on the patient experience and quality.
Marking the 60th anniversary of the NHS last year, former NHS Confederation chief executive Gill Morgan suggested the NHS in England is now about contestability driving improvement and greater choice, while Scotland’s system is “collectivist”, with very little competition.
Political devolution has allowed Scotland to go back to a 1980s style NHS, or something similar, in which health boards, similar to the old health authorities, run the service.
Immediately after devolution, the Scottish white paper Designed to Care softened some of the market dynamics in the NHS there, reducing the number of trusts and introducing managed clinical networks.
In 2003, 15 NHS boards were introduced, now reduced to 14. This reorganisation reduced the purchaser-provider split. The NHS Reform Bill 2004 abolished trusts, absorbing them into the health boards.
The lack of a purchaser-provider split, with unified health boards planning, commissioning and providing the range of healthcare in Scotland, is the biggest obvious structural difference between the health services in England and Scotland.
The Welsh assembly has moved in a similar direction:
[L]ast year, Welsh health minister Edwina Hart unveiled bold proposals to wipe out the internal market completely. Instead the NHS in Wales will be run through seven autonomous local health boards. A National Advisory Board, chaired by the health minister, and a performance monitoring delivery board will be created. A “unified public health organisation” will have executive responsibility for public health through the local health boards.
I have to admit that, when internal markets, foundation trusts and purchaser/provider splits were announced, I was somewhat sceptical. I wondered whether the so-called market incentives would be cancelled out by the bureaucracy that inevitably comes with these initiatives.
However, according to the Financial Times, the devolved NHS has improved in England at a much faster rate than its centralised counterparts in Scotland and Wales.
The introduction of targets for NHS waits in England, followed by more choice, competition and greater use of the private sector, has been highly controversial. While the impact of choice and competition in England is not yet clear, “the terror of targets” worked, according to Carol Propper, a professor of health economics at Imperial College London.
After rises in NHS funding, “waits are down in all three countries”, she said. “But they have come down much faster in England.”
The English NHS is hitting a maximum 18-week wait for treatment that Scotland will not achieve until 2011.
The decisions of the administrations in Scotland and Wales to go back to a more centralised NHS gives us a rare opportunity to imagine a ‘what if’ scenario. The answer to the question, ‘what if the NHS reforms under Thatcher and Blair had never happened?’ seems to be that the NHS in England would be less efficient.
So far so good, then, but what happens when the NHS as a whole needs to reduce costs drastically, as it will have to do over the next few years? NHS Chief Executive David Nicholson has written to NHS trusts urging them to cut costs by sharing back office services. But, when I discussed this with some NHS executives last week, they explained that there is very little appetite for this initiative in the increasingly autonomous Foundation Trusts. After all, why would you work so hard to gain autonomy from the NHS just to surrender part of your empire back to it?
Only time will tell but it may prove easier to implement these cost savings in the more centralised health services of Scotland and Wales than in the buccaneering and centrifugal English NHS.