National Assembly for Wales Research paper The organisation of the NHS in the UK: comparing structures in the four countries May 2015 Research Service The National Assembly for Wales is the democratically elected body that represents the interests of Wales and its people, makes laws for Wales and holds the Welsh Government to account. The Research Service provides expert and impartial research and information to support Assembly Members and committees in fulfilling the scrutiny, legislative and representative functions of the National Assembly for Wales. Research Service briefings are compiled for the benefit of Assembly Members and their support staff. Authors are available to discuss the contents of these papers with Members and their staff but cannot advise members of the general public. We welcome comments on our briefings; please post or email to the addresses below. An electronic version of this paper can be found on the National Assembly website at: www.assemblywales.org/research Further hard copies of this paper can be obtained from: Research Service National Assembly for Wales Cardiff Bay CF99 1NA Email: [email protected] Twitter: @SeneddResearch Blog: assemblyinbrief.wordpress.com © National Assembly for Wales Commission Copyright 2014 The text of this document may be reproduced free of charge in any format or medium providing that it is reproduced accurately and not used in a misleading or derogatory context. The material must be acknowledged as copyright of the National Assembly for Wales Commission and the title of the document specified. Enquiry no: 15/1002 Paper number: 15/020 National Assembly for Wales Research paper The organisation of the NHS in the UK: comparing structures in the four countries May 2015 Dr Shane Doheny This paper compares the organisation of health care systems in the United Kingdom. The paper outlines the main differences in the health care systems, paying particular attention to the organisational arrangements that operate across the UK and within each of the four countries.. Research Service Contents Contents 1. Introduction ..................................................................................................................................... 1 2. Designing health care systems ............................................................................................ 2 England ....................................................................................................... 2 Northern Ireland .......................................................................................... 3 Scotland ...................................................................................................... 3 Wales ........................................................................................................... 4 3. Deciding on the shape of the NHS ...................................................................................... 5 Allocating funding to the NHS ...................................................................... 6 4. The Health Service across the UK ....................................................................................... 8 A UK NHS ..................................................................................................... 8 NHS England .............................................................................................. 10 HSC Northern Ireland ................................................................................. 12 NHS Scotland ............................................................................................. 15 NHS Wales ................................................................................................. 18 5. Learning from difference ...................................................................................................... 22 The organisation of the NHS in the UK: comparing structures in the four countries 1. Introduction Rudolf Klein pointed out that "Health care reform has been one of the worldwide epidemics of the 1990s”. Since the 1990’s, health systems in the UK have shown little immunity to reform. Indeed, following devolution, the NHS in each of the four nations has undergone at least one, if not two (in the case of England and Wales), major reforms. 1 2. Designing health care systems The NHS focuses on providing care that is free at the point of delivery. Care is delivered by specialities, using resources that require maintenance, development and management. The system design shapes how specialties connect with each other and patients. At the most basic level, health care systems can either use market type levers - relying on pricing, competition and contracts - or bureaucratic levers - performance management, targets, standards and direct control. In general, health care systems differ to the extent that they use these levers: To the extent that co-operation, integration and team-working are important, then policy makers will press on bureaucratic levers. To the extent that competition, efficiency, and responsiveness to patients are important, policy makers press on market levers. What we have seen in all four countries is a commitment to the values of integration, cooperation and collaboration that bureaucracy promotes. This lever has been of particular importance in Wales, Scotland and Northern Ireland. Only in England has there been an increased use of market levers. This use of levers relates both to the design of the system, and to how the elements interact. In a purely bureaucratic system, power flows down the system and service providers account for their work to intermediaries and ultimately to the government Minister in charge. A market system separates service providers into entities offering services in a market, and competing for customers based on quality and price. So whereas in a bureaucracy, providers are made accountable to the Minister through managers, a market encourages providers to be more accountable to patients. England In 1991, the Conservative administration introduced reforms that separated NHS organisations into purchasers and providers of health care. The New Labour government (1997-2010) refined these market levers when it introduced reforms to provide ‘maximum devolution of power to local doctors and other health professionals’. This was to be achieved by mixing market levers with a renewed focus on quality standards. In 2010 the Conservative/Liberal Democrat Coalition government was again devolving power away from Ministers, drawing on values of fairness and solidarity. Critiquing the 'piecemeal' development of NHS structures, the Coalition sought to ‘establish more autonomous NHS institutions, with greater freedoms, clear duties, and transparency in their responsibilities to patients and their accountabilities’. Power was devolved to place control with professionals and patients. The objective was a system in which ‘organisations enjoy greater freedom and clearer incentives to flourish, but also know the consequences of failing the patients they 2 serve and the taxpayers who fund them’. This was achieved by relinquishing some bureaucratic levers, and enhancing market levers. Northern Ireland Health and Social Care (HSC) in Northern Ireland was reorganised following the Review of Public Administration. The first major change to occur was the merger of 18 HSC Trusts into five geographic HSC Trusts, and a single ambulance service Trust. The administration of HSC has since been reorganised by the Health and Social Care (Reform) Act 2009. The Act created a system that mixes bureaucratic with market levers. According to the explanatory memorandum attached to the Health and Social Care (Reform) Bill, the objective was to put in ‘place structures which are patient-led, patient-centred and responsive to the needs of patients, clients and carers as well as being more effective and efficient (releasing resources for investment in front line health and social care).’ The importance of co-operation is underlined by the Department's ‘duty to promote an integrated system of health and social care designed to secure improvement in the physical and mental health and social well-being of people in Northern Ireland’. A HSC Board is responsible for commissioning services and so market levers are retained. The Board identifies need through five Committees of the Board known as Local Commissioning Groups that assist the Board to purchase care from Trusts on behalf of their resident populations. This system combines a top down bureaucracy associated with targets, integration, co- operation, with market levers associated with purchasers and providers of health care. Scotland The National Health Service Reform (Scotland) Bill was introduced by the Labour- Liberal Democrat Coalition Scottish Executive in 2003. The Bill sought to abolish NHS Trusts further dismantling the internal market in the NHS in Scotland and ‘integrating the management of acute and primary care services into NHS Boards’. This Bill was passed into law in 2004. Market levers were to be removed from the NHS and more bureaucratic levers introduced. The Act increased the powers of the Minister to intervene in failing organisations, introduced a duty of co-operation on Health Boards and allowed for ‘greater involvement of the public in service planning’. In 2014, the Public Bodies (Joint Working) (Scotland) Act was passed into law, further cementing co-operation, collaboration and control as the central pillars of this system. 3 Wales In 2009, a minority Welsh Labour