Devolution and divergence in UK health policies

BMJ 2008; 337 doi: (Published 15 December 2008) Cite this as: BMJ 2008;337:a2616
  1. Scott L Greer, assistant professor of health management and policy
  1. 1University of Michigan School of Public Health, Ann Arbor, MI 48109-2029, USA
  1. slgreer{at}
  • Accepted 3 October 2008

Scott Greer explores how political variation in the UK has led to differences between the health systems of its four nations since devolution

Devolution and spending will probably be the two main health legacies of Tony Blair’s Labour government. Spending, because the historically low cost NHS received one of the greatest bursts of funding in history, with long term consequences for workforce, infrastructure, and patients; and devolution, because it created four distinct health systems just as that spending started. The politics and policy debates of the four systems are very different, and their leaders have used autonomy to pursue different values with, increasingly, different success.

Autonomy and diversity

Devolution gave the Northern Ireland Assembly, Scottish Parliament, and National Assembly for Wales great power over health services and public health. Under the 1998 legislation they are highly autonomous and not subject to any law of shared standards or values. They receive block grants that are not related to need but can be spent as they choose. Some regard them as overfunded, especially relative to English regions outside London (fig 1); questions arise as to whether their worse statistics with respect to health and other issues (fig 2) justify their higher rates of funding.

Fig 1 Identifiable government spending per capita, 2007-81

Fig 2 Male life expectancy at birth, 2004-61

The UK political system allows and encourages policy divergence, without much attention to its sustainability or consequences for standards, labour markets, or equity.2 Divergence has always existed; all four parts of the UK have distinctive histories and influences, but before 1998 they had fundamental political unity. Since then, the distinctive party politics and debates of each jurisdiction have created diverse policies and trajectories.3

Scotland: professionalism

Scotland’s trajectory since 1997 has been rooted in the country’s particular politics and medical history. It …

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