Is Devolution Good for Health?

Jeremy Felvus observes that devolution has brought significant divergence of policies as the devolved administrations have sought their own distinctive solutions.

Monitoring the different ways in which health policies have affected different parts of the UK is a fascinating exercise, but also a sensitive one. Yesterday I presented a paper at Cardiff University on both the similarities and the differences between performance in specific areas of healthcare in the newly-devolved nations.

At Pfizer we have commissioned research to see if innovation in healthcare improves health outcomes. In particular, we have looked at this issue in Scotland, Wales, Northern Ireland and the UK as a whole. As is often the case with research, the results have prompted further questions, notably, how valuable such a comparative study is, and whether devolution itself is good for health – and, if so, how to avoid postcode lottery on a national scale.

The NHS could never claim to be identical in every corner of the UK, but one of the consequences of devolution is that policy and practice continues to diverge as administration are empowered to seek local solutions to local challenges.

Leaving aside UK-imposed commonalities, such as professional regulation, the NHS of today no longer consistently reflects the NHS founded in 1948. Only the main principle, that the service should be free at the point of delivery, remains as an established constant, and even this consistency is under threat with top-up payments for end-of-life cancer medicines.

Devolution has provided the potential for a natural experiment to provide policy lessons, but this is the first time anyone has tried to carry out a systematic comparison of health policy and practice.

The research had two purposes: to uncover differences in policy that might provide lessons for policy makers, and to promote discussion of the bigger questions, including whether innovation is valued, how resources are invested and, most important of all, which actions actually improve health outcomes.

To do this, the research, carried out by IMS Health Consulting, looked at policy and practice in four areas: cancer treatment, cardiovascular disease, healthcare-associated infections and access and investment.

Its findings have been shared with UK health professionals and there has been a chance to compare and contrast the approaches taken in each of the devolved nations — not always a process that has been comfortable.

If the process of devolution is about maturing, from dependence, through independence and on to inter-dependence, then Wales, for instance, is in the middle stage – doing its own thing, but not necessarily doing the right things. The ‘right things’ will come when policy-makers and practitioners start to recognise the inter-dependent nature of NHS policy and provision.

Performance in Northern Ireland is affected both negatively and positively by its size. The research highlighted the benefits of effective clinical leadership and engaging in working partnerships.

Northern Ireland needed to realise the importance and value of cultivating a knowledge economy. And although Northern Ireland performed very favourably compared to the other devolved nations, particularly in oncology, the examples showed that investment in innovation could improve patient care and outcomes.

In terms of access and investment, Scotland, with its Scottish Medicines Consortium (SMC), thought it had the best system for evaluating new medicines. The SMC makes quick decisions compared to England’s National Institute for Clinical Excellence (NICE) and scans the horizon for developments. This hasn’t necessarily, however, resulted in greater investment in new proven medicines.

Where treatments are not considered cost-effective, they are restricted or denied. The rub comes when SMC and NICE reach different decisions about the same medicine. Even then, there is scope for regional variation within the nations. NICE has one advantage over the SMC, in covering a wider range of technologies, not just medicines.

Given the inter-relation between therapies, some health professionals feel Scotland may have missed a trick when it comes to assessing the cost benefits of other forms of care.

Devolution naturally breeds a desire for locally-accountable bodies and processes, even though this may mean costly duplication. The main points to emerge included the need for better data collection to allow ongoing like-for-like analysis; the necessity for culture change among both clinicians and the public to achieve sustainable improvement; and improved cost analysis of innovations to reflect wider budgetary implications.

Population-based health promotion strategies, while laudable, will take time to reap rewards in terms of health outcomes. Until then, people will still need to be treated, and will rightly expect the best possible preventative care and treatment.

Meeting the costs of innovation will demand improved analysis of the benefits of all treatments and technologies, and a commitment to service change.

Better public understanding of the necessity for that is required, as is strong clinical leadership to make improvement happen.

Equity of access is recognised as a challenge, given the latitude that exists for local decision-making. There were differing views about that, but it was agreed that it is important for the public to be more actively involved in the debate, particularly when there are likely to be increasingly acute financial pressures.

Jeremy Felvus is head of UK government affairs at pharmaceutical firm and presented a paper on these findings at Cardiff University on 1 December 2009. Earier this year the IWA and Academy Health Wales organised a conference on the findings from this research. A paper based on the conference, Challenges facing the Welsh NHS in tackling cancer, heart disease, and healthcare associated infections is available from the IWA at £5.

Also within Uncategorised