Devolution and health: data and democracy. Any differences will be because of tribalism and a smaller mutual

Sott L Greer writing in the BMJ in 2008 (Analysis BMJ2008;337:a2616 Devolution and divergence in UK health policies) explores how political variation in the UK has led to differences between the health systems of its four nations since devolutionDAPC05GCC

Devolution and spending will probably be the two main health legacies of Tony Blair’s Labour government. Spending, because the historically low cost NHS received one of the greatest bursts of funding in history, with long term consequences for workforce, infrastructure, and patients; and devolution, because it created four distinct health systems just as that spending started. The politics and policy debates of the four systems are very different, and their leaders have used autonomy to pursue different values with, increasingly, different success.

Autonomy and diversity

Devolution gave the Northern Ireland Assembly, Scottish Parliament, and National Assembly for Wales great power over health services and public health. Under the 1998 legislation they are highly autonomous and not subject to any law of shared standards or values. They receive block grants that are not related to need but can be spent as they choose. Some regard them as overfunded, especially relative to English regions outside London (fig 1⇓); questions arise as to whether their worse statistics with respect to health and other issues (fig 2⇓) justify their higher rates of funding.

Now in 2014 Scott Greer writes again and says: Devolution and health: data and democracy (BMJ2014;348:g3096) He calls it “about as good a natural policy experiment as you could imagine.” He says that “rather than UK politicians planning to learn from the experiment, the Nuffield Trust and the Health Foundation are amongst the few organisations that have tried to learn from this experiment. Their fourth report on devolution and health is ingenious and thorough, required reading for anyone wanting to understand health policies in the UK.”


There is no mention of the benefits of being in a larger mutual, and the disadvantages of tribalism.  The Professor does say that “there is scarcely an idea that couldn’t benefit from comparative data and learning across borders”. To most of the profession it appears deliberate that Wales cannot compare outcomes and data with England. Only after sufficient years have passed for WHO approved data: perinatal and maternal mortality, will it be evident which regional decisions were best. Even then, those decisions might have been appropriate if made from the point of view of the size of the mutual concerned.

Only now are the important frontier issues becoming noticed (Infertility post code inequality) and it is evident that access to Stroke treatment centres cannot be eqitably speedy to ensure universally good outcomes… I wonder how many PCT and LHB members have actually read and digested the Nuffield document on quality of care? About as many as have read In Place of Fear A Free Health Service 1952 Chapter 5 In Place of Fear. Any differences will be because of tribalism and a smaller mutual…

Update 15th July 2014. The Economist July 12th in “A Costly Solitude” on Scottish Independence: Wales GVA (Gross Value Added, or output per person) which explains why there is more pressure to ration more in Wales..


This entry was posted in A Personal View, Community Health Councils, Patient representatives, Political Representatives and activists, Post Code Lottery, Rationing, Stories in the Media on by .

About Roger Burns - retired GP

I am a retired GP and medical educator. I have supported patient participation throughout my career, and my practice, St Thomas; Surgery, has had a longstanding and active Patient Participation Group (PPG). I support the idea of Community Health Councils, although I feel they should be funded at arms length from government. I have taught GP trainees for 30 years, and been a Programme Director for GP training in Pembrokeshire 20 years. I served on the Pembrokeshire LHG and LHB for a total of 10 years. I completed an MBA in 1996, and I along with most others, never had an exit interview from any job in the NHS! I completed an MBA in 1996, and was a runner up for the Adam Smith prize for economy and efficiency in government in that year. This was owing to a suggestion (St Thomas' Mutual) that practices had incentives for saving by being allowed to buy rationed out services in the following year.

1 thought on “Devolution and health: data and democracy. Any differences will be because of tribalism and a smaller mutual

  1. Pingback: Wales is an unsustainable state: another good reason not to leave the EU. Graphics in support… | NHS reality. An NHS soapbox. Speakers' corner for the NHS.

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