The results of English devolution could be profound for the NHS

Last week HSJ received a call from an influential Labour health figure. They were travelling back from Scotland and were clear the Scots had effectively just fired the starting gun on the next round of English health and social care reform.

Why so? The fact more powers for Scotland would spark a demand for change in England was already well recognised.

What is only now becoming clear is how significant it could be in the long run for the health and social care services in particular.

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The scenarios

There are a number of scenarios that could come into play.

First, and most obvious, is the possibility that devolving greater powers to English regions could combine with a desire to give local government greater say over healthcare and specific policies like the better care fund.

It is not difficult, for example, to see how through the use of regional pooled health and social care budgets the North East and South East might end up pursuing very different “health and wellbeing strategies”.

‘It’s worth reflecting on the relative smoothness with which the English, Welsh and Scottish health services were decoupled’

While it may seem unlikely at present that health could be a significant part of devolution south of the border, it is worth reflecting on the relative smoothness with which the English, Welsh and Scottish health services were decoupled.

Areas like the Liverpool-Manchester conurbation or East Anglia have the same advantages in this context of a relatively self-contained healthcare economy.

This scenario might develop quickest under Labour (or a Liberal Democrat-Labour coalition) and it could prove very useful to the policymakers of that government.

Labour’s problems

The most problematic aspect of Labour’s developing healthcare policy is how it achieves the change it deems necessary, while sticking to the “no top-down reorganisations” pledge.

This genuine and welcome commitment to avoid another round of deckchair arranging and to let local services plot their own path produces constant clashes with those requiring a greater degree of certainty about the pace of change and their part in it.

‘Greater regional devolution may give Labour a way to present more radical change’

Sometimes maintaining a structure that is clearly misaligned with overarching policy goals can be just as distracting as embarking on a reorganisation, as constant short term fixes are applied to keep the system ticking over. Witness the slow motion rationalisation of primary care trusts from 300 to 150 to 50 “clusters”.

A clamour for greater English regional devolution may (and admittedly it is a big “may”) give Labour policymakers a way to present more radical and rapid change as something inspired by “bottom-up demand” rather than central diktat.

Idle speculation?

The implications of the Scottish referendum under a Conservative administration are more difficult to determine and will only become clearer with the development of ideas for an “English parliament”. But it is worth considering how radical healthcare reform in England has, on occasion, relied on the votes of those not affected.

Without the support of Scottish MPs for example, the legislation creating foundation trusts would have never cleared the Commons.

This may seem like idle speculation at a time when the NHS faces a number of immediate challenges, but the law of unintended consequences has often affected the NHS.

‘Without the support of Scottish MPs, the law creating foundation trusts would not have cleared the Commons’

Andrew Lansley, for example, will largely be remembered for kicking off a reorganisation that distracted the service from the generation-defining efficiency challenge without any warning to the electorate.

But a quick glance at the Coalition’s “programme for government” shows that was not his original intention.

Primary care trusts were to be preserved and, indeed, “top-down reorganisations” were specifically foresworn. Yet coalition negotiations over an increased role for local authorities in subsequent weeks consigned PCTs (and eventually Mr Lansley) to history.

It is a fool’s errand to state exactly how English devolution might affect the country’s health and social care, but just as foolhardy not to contemplate that the consequences could be profound.