On 15 April, in our first webinar for the Campaign for Social Science’s Devolution Hub, we invited four experts to offer insights, based on their research in the social sciences, about health policy across the four UK nations. Specifically, they were asked to consider the question of “What can the four UK nations learn from each other on health policy?”
The panel was chaired by our President, Will Hutton FAcSS, with presentations by Professor Ellen Stewart FAcSS, Professor Ann Marie Gray FAcSS, Professor Kath Checkland, and Dr Lorelei Jones. The four speakers offered distinctive but interconnected perspectives on how the four UK nations have approached health policy, exploring the different institutional arrangements, political cultures and reform trajectories which have shaped the performance and direction of the UK’s different health services.
Ellen, as Professor of Public Policy & Health at the University of Glasgow, began by giving a perspective from Scotland, noting that much of the commentary in the run-up to next month’s Holyrood elections has been about the health service’s performance in Scotland, particularly focussing on post-COVID recovery. She argued that the tendency around health policy in Scotland has been towards stability, but with two significant exceptions – the dismantling of the internal market under Scottish Labour (1999-2004) and then integration of health and social care under the SNP since 2011. Seen through an academic lens, these two acts can be portrayed as Scottish Labour focussing on professionalism and partnerships, and the SNP on (returning to) a centralising ‘command and control’ model of health policy. Ellen also observed that in recent years, the SNP’s approach to health governance has tended towards adding organisational layers of planning within NHS structures rather than structural reform – which perhaps explains why reducing or reforming health boards is a key dividing line between the party manifestos. Ellen concluded by arguing that the lack of policy substance in health debates post-devolution has been a long-running problem, and that where there has been analysis it has tended to be on inputs and outputs – what can be easily measured – rather than the processes behind them which could drive genuine healthcare improvements.
Ann Marie, who is Professor of Social Policy at Ulster University and one of Northern Ireland’s leading experts on public services, began by reminding the audience of Northern Ireland’s unique structures. Since 1973, Northern Ireland has had a united system of health and social care (so HSC, rather than NHS), and this is overseen politically by Stormont’s mandatory coalition which has made health and care services less obviously ‘value-driven’ than other parts of the UK. In reality though, Ann Marie reflected that this integrated system has still resulted in very little focus on social care, and little real progress on reforming Northern Ireland’s acute care system. Northern Ireland has experienced a high degree of centralisation, with limited opportunities for local political input or public engagement. This has contributed to difficulties in implementing reform, as well as a disconnect between strategic ambitions and practical delivery. Since 2000, there have been multiple independent reviews of health services, but with little tangible change arising from them. This is set against the worst waiting lists out of any UK nation / region, recruitment challenges, and a loss of public trust. More recent policy documents from the NI Executive have focussed on local-based planning and neighbourhood models, potentially as one way to circumvent the political impasse on NI-wide health reform. We can expect to hear more about this from the parties ahead of next May’s elections to Stormont, with an emphasis on more localised changes with a “test and learn” approach before reforms which prove effective are rolled out more widely. But Ann Marie noted that this comes against the backdrop of a huge lack of public engagement regarding the challenges affecting health policy which has been a barrier to reform in NI.
Next up, Kath offered her insights not just as Professor of Health Policy & Primary Care at the University of Manchester, but also as a qualified GP. She began by talking about England’s ‘hyperactive’ approach to health policy over the last 20+ years, framed by two fundamental areas of difference from the other UK nations. The first was the outsourcing of executive control to NHS England (now being reversed by the current Labour administration), which shifted accountability away from Ministers and blurred the lines of policy responsibility for a key public service. This raises an interesting question about what is the appropriate level of politicisation of the NHS – with an interesting parallel to Northern Ireland, whereby England chose to depoliticise and then repoliticise health, whilst NI has had to adopt a ‘dogma-lite’ approach to health policy as a result of the Executive’s mandatory coalition. The second fundamental policy difference between England and the other UK nations which Kath set out was the persistence of the purchaser-provider split as a policy feature. Despite being briefly abolished during the first New Labour term, it soon returned under the guise of ‘patient choice’, and was then turbocharged in 2012 with the application of European competition laws to the NHS. Even when ‘competition’ within the NHS has been out of favour politically, contracts have remained the underlying mechanism for service organisation and delivery. This has many benefits and drawbacks, but one key advantage has been that they have made it easier to measure productivity within the NHS in England than is the case in Scotland or Wales.
Finally, we heard a Welsh perspective from Lorelei, who is Senior Lecturer in Healthcare Organisation and Governance at Bangor University. She emphasised that there is a greater focus within Wales’ political culture on collaboration, and this has extended towards prevention and wellbeing (the latter best exemplified through the Future Generations Act, arguably Wales’ most well-known post-devolution policy). Nevertheless, for all the warm words, major challenges remain within Welsh health systems, especially in secondary care performance and emergency department pressures. These issues, Lorelei argued, are symptomatic of broader system-wide constraints, including capacity limitations and difficulties in coordinating care across sectors. Lorelei praised the development of new, community-based models of care, particularly for older populations. These have included efforts in North Wales to design more holistic, person-centred approaches that integrate health and social care while improving workforce conditions. Such initiatives, she suggested, exemplify the kind of innovation needed to address future demographic and service pressures.
Across four wide-ranging presentation, there were some interesting points of agreement and commonality. First, it was noted that despite over 25 years of devolution of health, there is relatively little difference in terms of health service performance across the four nations – especially given we are still in a post-COVID period where no health service could be expected to be performing at its optimum level. England has had the most turbulent period of change of the four nations, exacerbated by more changes of political direction in that time than the others. But political consensus can be a double-edged sword, as can ‘depoliticisation’ of health if it makes it harder to push through necessary changes. Meanwhile, different political cultures in each of the four nations can be seen in their respective approaches to health policy (notably on different approaches towards an internal market within health services) – but no-one has found a ‘silver bullet’ to a flawless system. Finally, greater integration between health and social care in Scotland and especially Northern Ireland offer valuable opportunities for learning – but even in those nations, stopping social care from being the ‘poor relation’ remains a key challenge.
The full webinar is available to watch below.