The four national governments in the United Kingdom need to work far more closely and to coordinate formally over health issues or face growing conflict, a major report says.
Since 1999, devolution has meant ever widening differences in health policy between the four countries, and lack of coordination will damage all four healthcare systems, warns the report by the health policy think tank the Nuffield Trust.
Its report says that extensive overlaps and complexities have arisen since devolution was agreed, leading to “messy intergovernmental relations.” Its findings are drawn from research and extensive interviews carried out over the past seven years.
A basic problem, says the report, is that the current systems for identifying and resolving conflicts are informal and rely on a level of political goodwill that cannot be guaranteed to last.
The Joint Ministerial Committee, which was set up specifically to manage relations between the four countries and to resolve disputes in several sectors, including health, has not achieved its purpose and only met for the first time in six years in June. A meeting specifically on health has not been held since the end of 2001.
The report’s authors, Scott Greer and Alan Trench, identify stresses and strains that are already creating or could create political conflicts and that stem, for example, from financing. Any change in the healthcare budget in England affects the devolved administrations’ resources.
There is also the so called West Lothian question, the term used to describe the political problem that means that Scottish MPs sitting in Westminster can vote on health policy in England but not on health policy in their own constituency north of the border, as this is covered by the Scottish parliament.
Other areas of potential conflict emerge from flows of patients across the borders, which cause a “remarkable” amount of administrative and political tension, says the report.
“They are a simple case of the friction that ensues when two neighbouring governments do not care much about each other and do not pay much attention,” it says.
This is mostly a Welsh and English problem, as around 13 000 patients from Wales are treated in hospitals in England each year and 7000 English patients in Welsh ones.
“Given that there is no structure in place to deal with cross-border administrative issues,” says the report, “conflicts between two NHS organisations on different sides of the border tend to become heated, and escalate to inappropriate levels of both bureaucracy and passion.”
Despite many differences between the four governments, some issues remain UK-wide, such as contracts for doctors and other health service workers; but regulatory organisations are a complicated patchwork, with different sets of responsibilities in different countries.
Different clinical standards are also having an effect, adds the report. NHS Wales does not adopt the national service frameworks that structure medical practice in England, for example. “As a result, doctors educated and trained in Wales will have different understandings of good practice from those of potential employers in England,” it says.
The report’s recommendations include a call for a more systematic coordination between governments, including the full re-establishment of the Joint Ministerial Committee, and preparation of a more comprehensive intergovernmental agreement for the resolution of health policy issues.
Health and Intergovernmental Relations in the Devolved United Kingdom is available at www.nuffieldtrust.org.uk.
Cite this as: BMJ 2008;337:a832