Devolution in health policy is threatening unity of the NHS

BMJ 2008; 336 doi: (Published 31 January 2008) Cite this as: BMJ 2008;336:241
  1. Adrian O’Dowd
  1. 1London

    Conflict between the four devolved governments in the United Kingdom is increasingly likely and will affect the NHS, according to an influential report.

    The report about devolution by the health policy think tank The Nuffield Trust says that differences in health policy in the UK could become a growing tension that tears at medical training, puts pressure on representative organisations, and leads to educational divergence.

    The report is based on a series of high level seminars held with government officials, profession leaders, advisers, academics, and other health policy makers in the four countries.

    It says, “Having repeatedly reformed its health services since it came to power in 1997, the New Labour government in the UK is looking to values to provide the glue or story-line holding together the various changes, many of them hotly contested by professionals and public alike.”

    The UK could be facing a problem because it has, by international standards, an “astonishingly weak system of intergovernmental coordination and dispute resolution.”

    The report says that there is potential for “Westminster hamfistedness and devolved anger” because of this lack of understanding and fragile associations between the UK’s institutions of intergovernmental relations.

    Scott Greer, editor of the report and honorary senior research fellow at University College London, told the BMJ, “My message to clinicians would probably be brace yourself because what we have here is the government playing with fire.

    “Everyone knows what the NHS is, and it is wildly popular. There is very little public sentiment for divergence.”

    The prime minister, Gordon Brown, is criticised in the report for his approach to creating a NHS constitution.

    “Gordon Brown talks Britain and Britishness in the NHS and then the NHS constitution he mentions is just for England,” Mr Greer told the BMJ.

    “Most health professionals would react badly to the proposal that we should have different standards of quality between Scotland and England, for example.”

    Mr Greer, also assistant professor of health management policy at the University of Michigan, said after the “disaster” with the medical training application service (MTAS) for junior doctors there was a strong chance that Scotland and Wales would walk away and decide their own systems.

    “We have a Department of Health that is asleep at the switch, which gives you all sorts of things, from bizarrely heated high level arguments about minor payment issues to the potential breakdown of a centrally shared medical training system that has existed in the UK for a long time.”

    Mr Greer thinks there will be increasingly hostile comparisons made between the four countries as the different policies and priorities play out, saying, “Friction on the borders is building up.

    “We need to have a debate about common values, and, ideally, we would have a consensual agreed statement between all the governments. It could be quite abstract—for example, all health care has got to be universal, portable, and public—a statement of principles or of shared values.”


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