1. Devolution and divergence in UK health policies Dr Jennifer Dixon Director Nuffield Trust IPPR 2 February 2009

2. Background Divergence in policy in NHS has always existed Before 1998 fundamental political unity Now distinctive trajectories

3. Scotland High status medical leaders closely connected to policy Communitarian values Main battles between Labour and SNP

4. Scotland Purchaser-provider split abolished Integration of system into 14 geographical health boards – No payment by results – No competition (no plurality of providers) – No practice-based commissioning Focus: chronic disease; public health and reducing inequalities; waiting(Kerr 2005) Free long term personal care Prescription charges reduced (£5 -1/4/08)

5. Levers: Scotland professionalism* 5 provider performance Central directive Regulation MarketLocal accountability Professionalism * Scott Greer

6. Wales Main battles between labour and Plaid Cymru Communitarian values

7. Wales 2003 reorganisation of commissioning into 22 local health boards co-terminous with local authorities Emphasis on public health and reducing inequalities Purchaser-provider split maintained, but current Labour-Plaid Cymru coalition (2007) committed abolishing it Number of Health Boards and Trusts to reduce No PbR, no foundation trusts Prescription charges abolished 1 April 2007

8. Levers: Wales limits of localism* 8 provider performance Central directive Regulation MarketLocal accountability Professionalism * Scott Greer

9. Northern Ireland Politics: sectarian representation Little interest in health Change slow

10. Northern Ireland Purchaser- provider split remained GP fundholding abolished only 2003 2005-6 UK government began to make decisions Since restoration of devolution that halted that change Now plans to merge all 4 Health Boards into one and reduce the number of Trusts to five Managers free to make decisions (unless large)

11. Levers: N. Ireland permissive managerialism* 11 provider performance Central directive Regulation MarketLocal accountability Professionalism * Scott Greer

12. England Politics: (new) Labour 2000-2006 major changes Purchaser-provider split Autonomy for providers, plurality, competition and choice, PbR PCT and practice-based commissioning Regulation Devolution of power Central directive

13. Levers: England markets into managerialism* 13 provider performance Central directive Regulation MarketLocal accountability Professionalism * Scott Greer

14. Comparing NHS performance across the UK Sensitive Data comparisons not straightforward (who is interested in VFM across the UK?) Old debates about level of funding for need (Barnet Formula) (Add in Scotts graphs on funding and morbidity)

15. Copyright ©2008 BMJ Publishing Group Ltd. Greer, S. L BMJ 2008;337:a2616 Fig 1 Identifiable government spending per capita, 2007-8

16. Copyright ©2008 BMJ Publishing Group Ltd. Greer, S. L BMJ 2008;337:a2616 Fig 2 Male life expectancy at birth, 2004-61

17. England 96-7 England 02-3 Scotland 96-7 Scotland 02-3 Wales 96-7 Wales 02-3 N. Ireland 96-7 N. Ireland 02-3 Waiting Inpatient <6 month 74.980.6na 2120.618.4 >12 month 2.70na 9.915.917.122.0 Outpatient <6 month na100na 94.167.680.761.4 % public satisfied inpatient 5149615863606784 outpatient 5051646063557088 general practice 7772817379688390

18. www.nuffieldtrust.org.uk jennifer.dixon@nuffieldtrust.org.uk © Nuffield Trust 2008