Devolution and the NHS | Institute for Government (2023)

Explainer

In the UK, the NHSis the umbrella term for the four health systems of England, Scotland, Wales and Northern Ireland.

Kelly Shuttleworth Elspeth Nicholson

Devolution and the NHS | Institute for Government (1)

Why are there four different health services in the UK?

In the UK, the National Health Service (NHS) is the umbrella term for the four health systems of England, Scotland, Wales and Northern Ireland.

Health has been a primarily devolved matter since powers were transferred to the Scottish parliament and Welsh Senedd on 1 July 1999, and to the Northern Ireland assembly on 2 December 1999. Responsibilities of the devolved authorities include organisational control and funding of the NHS systems, family planning, provision of health services and the prevention, treatment and alleviation of disease, illness, injury, disability and mental disorder. Westminster retained responsibility for these in England.

However, the existence of separate health services in each UK nation predates the 1999 devolution reforms. The National Health Service Act, which came into effect in 1948, transferred the hospitals previously run by local authorities to the newly established NHS for England and Wales. This was shortly followed by an act which did the same in Scotland, with very limited institutional differentiation, and then the same for Northern Ireland.

Between 1948 and 1999, the health systems of Scotland and Northern Ireland systems were managed by UK government departments – the Scottish Office and Northern Ireland Office respectively. In Northern Ireland, the NHS was merged with the broader social care system in 1973 and called the Health and Social Care (HSC) system rather than the NHS.

In 1969, legislation was passed that separated the Welsh NHS from the English NHS, and put it under the control of a separate UK government department, the Welsh Office.

How are the health services funded?

In England, general taxation accounts for the majority of NHS funding, with some funds being raised by patient fees, such as (means-tested) charges for prescriptions and some other services. After devolution Scotland, Wales and Northern Ireland all abolished prescription charges, making England the only of the four nations in which patients pay for prescriptions. In 2018/19, £576 million was raised through the prescription charge, which accounts for 0.5% of the NHS England budget.

Devolved administrations receive a block grant of funding from the UK government each year. The amount each receives is calculated using the Barnett formula, which determines the change in year-on-year grant money based on the change in UK government spending – for England – on devolved policy areas. 1 Keep, M ‘The Barnett Formula’, House of Commons Library Briefing, 6 January 2020, retrieved 5 August 2020, https://commonslibrary.parliament.uk/research-briefings/cbp-7386

However, the figure is calculated against all UK government spend, and is not ringfenced to any particular devolved policy area (such as health) so the devolved administrations can choose how to spend it. This means that increases in spending on the NHS in England do not automatically lead to similar increases in health budgets in the other nations.

NHS spending per head of population varies between the four nations: it is highest in Northern Ireland and lowest in England. This reflects the fact that the Barnett funding system provides for higher public spending in general in the three devolved nations.

Nation

£ per head of population in 2018/2019

England2,269
Scotland2,396
Wales2,402
Northern Ireland2,436

England and Northern Ireland both have a ‘purchaser/provider split’ which creates an internal market in the NHS and means that the health service (the purchaser) has to contract with other parts of the NHS or independent sector organisations such as Virgin Care or the British Red Cross (the providers) to supply patients with services.

Scotland and Wales abolished this model in 2004 and 2009 respectively, and so run all their healthcare services directly. 2 Harker, R. ‘NHS Expenditure’ House of Commons Library Briefing, 17 January 2020, retrieved 5 August 2020, https://commonslibrary.parliament.uk/research-briefings/sn00724

What role does local government play in healthcare?

There is a degree of decentralisation of health policy in England, Scotland and Wales, with local authorities and certain regions having power over some aspects of health care.

In England, local government lost its control of hospitals in 1948 but retained responsibility for a range of community and public health services until 1974. The Health and Social Care Act 2012 returned to local authorities the responsibility for commissioning of many of these services, such as those dealing with sexual health and substance misuse. Under the Act, each local authority is required to “take such steps as it considers appropriate for improving the health of the people in its area.”

Certain aspects of health funding and responsibility have also been devolved to the Greater Manchester Combined Authority and to Cornwall, as part of the government’s regional devolution agenda. The 2015 devolution deal between the UK government and Greater Manchester allows for “devolved control” of the region’s £6 billion health and social care budget. In Cornwall, the devolution agreement focused on integrating health and social care in the region.

In Scotland, local authorities have a broad power to promote or improve wellbeing within their areas as well as various powers which intersect with public health concerns, such as promoting active travel like walking and cycling. In both Scotland and Wales, local authorities have duties regarding mental health, but did not have any further specific public health powers prior to the coronavirus crisis.

In Northern Ireland, local authorities have no public health responsibilities, which primarily rest with the Northern Ireland Department of Health and its executive agency, the Public Health Agency.

How are health and social care integrated in each of the four nations?

Better integration of health and social care – where hospital care and care in the community are better co-ordinated – remains a priority across the four nations but administrations have pursued different policy initiatives to meet this common goal.

In England, health care remains the responsibility of national government and social care lies in the hands of local authorities. There have been several initiatives to improve the integration of health and social care in the last ten years. These include the creation of Health and Wellbeing Boards, which came into existence following the Health and Social Care Act 2012, and the foundation of the Better Care Fund, a joint budget across the NHS and local authorities. 3 Parkin, E. ‘Health and Social Care Integration’ 20 December 2019, retrieved 5 August 2020, https://commonslibrary.parliament.uk/research-briefings/cbp-7902 The rebranding in 2018 of the UK Department of Health to the Department of Health and Social Care was also a symbolic move towards better integration.

Unlike in England, the principles of health and social care funding and delivery in Scotland and Wales are set at the national level, through legislation, rather than by individual local authorities. In Scotland, in 2016, the Public Bodies (Joint Working) (Scotland) Act brought health and social care under one integrated system. There are now 31 integration authorities across Scotland responsible for £8.5bn of funding for local services. 4 Director General of Health and Social Care ‘Health and Social Care Integration’, retrieved 5 August 2020, www.gov.scot/policies/social-care/health-and-social-care-integration

In Wales, the Social Services and Well-being (Wales) Act 2014 5 Social Services and Well-being (Wales)Act 2014, retrieved 5 August 2020, www.legislation.gov.uk/anaw/2014/4/contents places a legal duty on local authorities to promote the integration of health and social care and the Wellbeing of Future Generations (Wales) Act 2015 promotes the principles of long-term collaboration of public bodies to better plan for the wellbeing of Welsh citizens. To meet the requirements of these acts, the Integrated Care Fund was created as a way to facilitate collaboration across the social services, health, housing, the third and independent sectors. 6 Welsh Government, ‘Integrated Care Fund’, 1 April 2019, retrieved 5 August 2020, https://gov.wales/sites/default/files/publications/2019-02/integrated-care-fund-revenue-capital-and-dementia-guidance-april-2019.pdf

Northern Ireland has had integrated health and social care since 1973.

How have the four health services worked together in response to coronavirus?

There has been a high level of co-ordination between the governments and health authorities across the UK in responding to the coronavirus pandemic.

Co-ordination is facilitated at several levels. First, there are expert scientific advisory groups convened at a UK level which provide advice to the chief medical officers of the four nations, to health authorities in the devolved administrations, and to the devolved governments directly. These include the New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG), an expert committee of the UK Department of Health and Social Care, the Advisory Committee on Dangerous Pathogens, and the Scientific Pandemic Influenza Group on Modelling. There are also frequent meetings of senior clinical groups, with the chief nursing officers and senior clinicians, to share the latest evidence and translate that into guidance.

To expand critical care capacity, temporary hospitals have been set up across the UK. These include seven NHS England Nightingale hospitals, NHS Scotland's Louisa Jordan hospital, NHS Wales's Dragon's Heart hospital, and the Northern Ireland Nightingale hospital. These were set up independently by the health systems in each nation, but were influenced by the original English Nightingale model.

Guidance on the correct use and types of personal protective equipment (PPE) has been agreed jointly between all four UK nations. NHS England has played a key role in co-ordinating procurement for all the health services, but health services in Scotland, Wales and Northern Ireland have also placed separate orders for PPE.

There have been some minor disagreements over allocation of resources, with the head of Scottish Care claiming in mid-April that England had been prioritised by suppliers of PPE to the UK. 7 Peterkin, T, ‘Scottish care workers lose out as UK PPE manufacturers focus on England, leading care industry figure claims’, The Press and Journal, 13 April 2020, retrieved 5 August 2020, www.pressandjournal.co.uk/fp/news/politics/scottish-politics/2143489/scottish-care-workers-lose-out-as-uk-ppe-manufacturers-focus-on-england-leading-… The UK health secretary, Matt Hancock, assured the devolved administrations that this had not been at the request of the UK government. 8 BBC News, ‘Coronavirus: Suppliers 'not asked' to divert PPE to England’, 14 April 2020, retrieved 5 August 2020, www.bbc.co.uk/news/uk-scotland-52279578

What is the strategy for coronavirus testing in each of the four nations?

Testing for coronavirus is carried out both by the separate health systems for each of the UK nations, and by a network of new national Covid-19 testing facilities established by the UK government.

For example, in Scotland there are drive-through testing centres operated by the UK government, though the Scottish government decide the eligibility criteria for their use. There is also a ‘Lighthouse Lab’ in Glasgow, funded by Westminster. As of 5 August, there had been 408,134 Covid-19 test results from Scottish NHS labs and 340,897 from UK government labs in Scotland. 9 Scottish Government, ‘Coronavirus (COVID-19): Daily data for Scotland’ 4 August 2020, retrieved 5 August 2020, www.gov.scot/publications/coronavirus-covid-19-daily-data-for-scotland

There is also a UK-wide programme for home testing for anyone who has symptoms of coronavirus. These tests are processed by NHS England, whichever nation they are taken in.

The UK government’s testing targets, such as the pledge to carry out 100,000 tests per day by the end of April, include the numbers of tests carried out by all these different testing facilities.

There have been some differences in who has been eligible for testing at different stages throughout the outbreak. For example, during April and May the UK government expanded testing for all those with symptoms aged over 65 (down from 70) in England on 28 April. The same access was not available in Wales until 18 May when it was announced that everyone over the age of 5 with symptoms in England, Scotland, Wales and Northern Ireland would be eligibility for a coronavirus test. 10 Department of Health and Social Care, ‘Everyone in the United Kingdom with symptoms now eligible for coronavirus tests’, 18 May 2020, retrieved 5 August 2020, www.gov.uk/government/news/everyone-in-the-united-kingdom-with-symptoms-now-eligible-for-coronavirus-tests

Each administration is also responsible for their own ‘test and trace’ services. Northern Ireland launched its programme on 19 May, England and Scotland on 28 May, and Wales on 1 June.

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