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Last Updated: Wednesday, 2 January 2008, 00:01 GMT
The carve-up of the NHS
By Nick Triggle
Health reporter, BBC News

NHS hospital sign
The NHS was founded in 1948

The health service was created in 1948 to provide universal care across the UK.

But as the NHS approaches its 60th anniversary, it is becoming increasingly clear the four devolved administrations have begun to pursue their own agendas.

Is there still such a thing as the "national" health service?


The approach to the NHS can be summed up in one phrase - the market.

Ever since the NHS Plan was published in 2000, ministers have set out to introduce more competition into the health service.

The structure of the system is designed around the buyers - more than 150 primary care trusts which hold the purse strings for three-quarters of the NHS budget - and the sellers - hospitals, mental health trusts, GPs and, increasingly, the private sector.

Indeed, the use of the private sector has become the battleground between the government and much of the medical profession.

England is unique in the way it has pursued its NHS reforms though market incentives
James Gubb, of Civitas

Thousands of NHS operations - mainly minor surgery such as hips and cataracts - are done each year in private clinics called independent sector treatment centres (ISTCs).

And patients can now shop around and choose from hospitals and clinics across England for non-emergency treatment.

The changes have led to large falls in waiting times with the government aiming to have all patients seen within 18 weeks by the end of the year.

When Labour came to power, it was not uncommon to wait two years.

James Gubb, director of Civitas' health unit, said: "England is unique in the way it has pursued its NHS reforms though market incentives.

"It has created a much more efficient system and helped to push through falls in waiting lists."

However, the reforms have not been without controversy and recently there have been signs that the new Brown government is cooling on the concept.

Ministers have announced there is to be no third-wave of ISTCs, while several in the pipeline and already up-and-running have been pulled.


Scotland has completely shunned market-based reforms. Instead, ministers have put their faith in professionals.

There are 15 health boards which both buy and provide the services - unlike the split in England.

The model, fully established since 2003 when individual trusts were abolished, has led to a reduction in managers.

Instead, the allocation of resources and delivery of services is overseen by clinical networks of specialist doctors who pool resources in set areas, such as cancer, and then decide how to deploy them.

Again, the system has proved successful at reducing waiting lists - statistics last year showed the six-month target had been hit and the service was on track to meet its own 18-week goal.

Scotland has been pretty successful without resorting to the target culture which is much maligned in England
Professor Chris Ham, former government adviser

But the lack of a target-based approach and avoidance of the private sector - there are no ISTCs - has led to favourable comparisons to England.

Professor Chris Ham, a former government adviser and Birmingham University heath expert, said: "Scotland has been pretty successful without resorting to the target culture which is much maligned in England."

Nicola Sturgeon, the health secretary in Scotland, added: "We believe it is sensible to deliver healthcare on the basis of collaboration and cooperation, rather than division and competition."

"We are not against using the independent sector capacity at the margins and appreciate that there are occasions when this is necessary.

"But our approach for the future will be to build NHS capacity."

Scotland has also been held up as a pioneer over its decision to give free personal care to the elderly.

Elsewhere in the UK, if an individual has assets of more than 20,500 they have to pay for basic help such as cleaning, washing and dressing.

And Scotland has also announced it is to follow Wales' lead by introducing free prescriptions by 2011.

Such moves have piled pressure on English health secretaries, with current incumbent Alan Johnson defending the means-tested approach south of the border in a heated exchange with MPs recently.

He said: "I think there are better things you can do with your money."


Wales, compared to the other UK countries, has paid much more attention to public health.

As soon as the Welsh Assembly was set up it began planning for the creation of the National Public Health Service for Wales.

The service acts as an advisory body for the 22 local health boards that oversee the health service. They work closely with the 22 local authorities that mirror their boundaries.

It means Wales has adopted a much more integrated and forward-thinking approach to addressing public health, including school nutrition and child obesity programmes long before they became popular elsewhere.

Wales has been much more proactive on public health
Dr Mike Dixon, of the NHS Alliance

Dr Michael Dixon, chairman of the NHS Alliance, which represents health professionals working in the community, said: "The make up of their health boards tend to be more cosmopolitan in involving local government and the voluntary sector.

"This in turn has meant Wales has been much more proactive on public health."

But this push has had a consequence. Professor Ham said: "They have concentrated so much on preventing ill-health that they have been slow to address problems with the actual system."

This has meant that the Welsh Assembly Government has struggled to make progress over waiting lists.

Indeed, during the election campaign earlier this year, opposition parties picked up on the fact that there were 60,000 more patients on the waiting lists than compared to eight years ago.

The assembly government has started trying to address the situation with targets. The most recent of these is an eight-month goal for hospital treatment, but this is compared to the 18-week target hospitals in England are currently working towards.

Unsurprisingly, Welsh politicians prefer not to dwell on these figures.

Instead, First Minister Rhodri Morgan crowed in January that Wales had managed to make the English jealous by introducing free prescriptions.


Northern Ireland in many respects has seen less activity over health than the other countries, mainly because of its yo-yoing between self-government and Westminster-rule.

This has led to what a University College London report called a "permissive managerialism" whereby health chiefs have left front-line workers to pursue their own direction.

It means there is a quite a bit of variety from region to region.

There is a close working relationship between health and social care - one which the other countries could learn from
Gill Morgan, of the NHS Confederation

The system is now broken down into five health trusts - previously it was 18.

But what really marks Northern Ireland out is that each trust also has responsibility for social care. Elsewhere in the UK, this falls to local authorities.

The set-up means there is much more integration between the two.

For example, the frequent disputes seen in England between trusts and councils over who has responsibility for home care services are unheard of across the Irish Sea.

And in some areas, in particular Belfast, it has led to the creation of what England likes to call polyclinics.

These are multi-agency centres, housing GPs, alongside social workers and hospital care.

Gill Morgan, chief executive of the NHS Confederation, which represents health mangers, says: "There is a close working relationship between health and social care - one which the other countries could learn from.

"There are joint appointments in key positions and the co-location of services. It makes for a good working relationship."

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