Healthcare Policies Post-Devolution 1 Overview

Following the introduction of devolution in 1999 there was evidence of greater health policy divergence between the four UK countries, although it took some time for these differences to emerge. Two years after the introduction of devolution in 2001, it was reported that the Green and White papers from the different countries detailed ‘challenging agendas which would not be implemented overnight’ (Constitution Unit 2001, p.8), however differences were already emerging in the way health services were being delivered particularly primary care services. At the outset of devolution there was also a commitment from all four countries to deliver policies rooted in ‘investment and reform’ (Woods 2004, p.337) and related to this targets were set for nursing workforce growth in England, Scotland and Wales. The different policy priorities for each of the four countries are outlined in the sections below.

2.3.2 England

The NHS Plan. A plan for investment. A plan for reform (Department of Health 2000a) outlined plans for the NHS in England over the next decade. The key focus of this policy was on ‘modernisation’ of the health service.

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Commitments were made to cut waiting times, reduce health inequalities, address inequities in access to care, improve quality of care and cleanliness of hospitals. These reforms would be delivered through re-design of services, supported by the NHS Modernisation Agency, and an increased focus on performance management. Core national standards and performance targets would be monitored and action taken where healthcare organisations were seen to be failing. The NHS Plan also included proposals for a concordat between the NHS and Private Sector enabling the NHS to make use of extra capacity in this sector to benefit the care and treatment of NHS patients.

Commitments were made to improve pay and working conditions for NHS staff along with increased numbers of staff including targets for 20,000 additional nurses and 1,000 Nurse Consultants. The Modern Matron role, unique to the English healthcare context, was introduced to oversee the quality of care in clinical areas. Opportunities were cited for nurses to take on new roles and increased responsibilities.

The publication of The NHS Improvement Plan Putting People at the Heart of Public Services (Department of Health 2004a) reinforced the principles of reform and improved performance associated with implementing the second phase of the NHS Plan. The focus of this policy was on the next stage of the NHS in England’s journey to: ‘ensure that a drive for responsive, convenient and personalised services takes root across the whole of the NHS and for all patients’ (p.8). It emphasised the need for staff to work flexibly and in new ways to deliver more personalised patient care in a modernised health service.

Subsequently, the NHS Next Stage Review programme of work led by Professor the Lord Darzi, required each of the ten Strategic Health Authorities in England to develop plans to transform services across eight defined care pathways; staying healthy; maternity and newborn; children;

acute care; planned care; mental health; long term conditions and end of life. The principal aim of A High Quality Care for All: NHS Next Stage Review (Department of Health 2008a) was to stimulate locally led changes across these care pathways which were both patient focused and clinician driven. There was a strong emphasis on improving the quality of care, increasing patient choice and creating opportunities for greater personalisation in healthcare.

The key role of nurses in leading and delivering these improvements was highlighted in A High Quality Care for All, whilst the accompanying policy document A High Quality Workforce (Department of Health 2008b) detailed the expectations of clinicians in delivering the aims of the NHS Next Stage Review. This included work to ‘reaffirm the role of the nurse’ and update definitions of current day nursing; develop mechanisms to measure the quality of nursing care; increase investment in preceptorship periods for newly qualified staff; greater flexibility in career paths including strengthening clinical academic careers; new national standards for advanced nursing roles and the proposal to explore options for graduate entry to pre-registration nursing (Department of Health 2008b, p.18).

2.3.3 Scotland

In Scotland Our National Health: A Plan for Action, a Plan for Change (Scottish Executive Health Department 2000) outlined plans to re-build the NHS and identified the national priorities for health. There was a clear focus on the opportunities for health created through devolution. Increased investment would be directed at improving health and creating a health service fit for the 21st century. Proposals included a national health improvement fund, increased hospital redevelopment programmes, new GP practices and community health services. Managed Clinical Networks would be established linking local and regional services, strengthening clinical leadership and improving the quality of care. The key clinical priorities were reaffirmed as being: coronary heart disease, cancer and mental health.

Commitments were made to modernise pay for NHS staff, in line with the other UK health departments and there was increased investment planned to support learning and development. Partnership working with staff was seen as essential as was the need to develop consistent personnel policies for use across the NHS in Scotland.

The Partnership Agreement committed to bring 12,000 nurses and midwives into the NHS by 2007 as part of an initiative to deliver improvements in the NHS in Scotland (Scottish Executive Health Department 2003a).

In 2005, Building a Health Service Fit for the Future commonly known as the ‘Kerr Report’ was published (Scottish Executive Health Department 2005a). The recommendations included the rationalisation of specialist and complex care into fewer centres to reduce clinical risk; the importance of supported self care for long term conditions; maintaining local services particularly to meet the needs of remote and rural areas; harnessing the use of telemedicine and information technology to improve efficiencies and further action to reduce waiting times and health inequalities. It acknowledged that in order to deliver these changes a re-profiling of the existing workforce was required including investment in education and training to develop new ways of working for example the implementation of Hospital at Night teams. There were opportunities for nurses to have a lead role in these new teams.

Delivering for Health (Scottish Executive Health Department 2005b) the Government’s response to Building a Health Service Fit for the Future (Scottish Executive Health Department 2005a) endorsed the report’s recommendations and identified actions aimed at shifting the balance of care from acute hospitals to an increased delivery of health and wellbeing services in the local community. It also included plans to strengthen performance management of key priorities and targets.

Following the change of Government in Scotland in 2007, the strategic vision of the new Scottish National Party was outlined in the Better Health, Better Care: Action Plan (Scottish Government 2007a). There were three main themes in this policy:

 developing a ‘mutual’ NHS

 supporting health improvement and tackling health inequalities, with a particular focus on disadvantaged communities

 better, local access to healthcare including improved patient safety, quality, efficiency and effectiveness.

Central to this policy was the concept of a mutual NHS where the public and staff are partners in the NHS. This included a prominence on the shift in the ownership and responsibility for health to individual citizens. Performance management targets were revised to address health improvement; efficiency and governance; access and treatment. The importance of Managed Clinical Networks was reinforced and plans were included to expand and strengthen these. There was a clear statement in the policy foreword detailing that NHSScotland was distancing itself further from the ‘market orientated models’ (Scottish Government 2007a, p.v), which was Scotland signaling its rejection of the model of healthcare in place in England.

Although the Better Health, Better Care: Action Plan made specific reference to workforce planning, new roles and leadership development, a related document ‘Better Health, Better Care: Planning Tomorrow’s Workforce Today’ (Scottish Government 2007b) was published outlining proposals to deliver further improvements in workforce planning, including developing workforce planning capacity at NHS Board level. There was also a focus on creating new roles based on patient needs and the importance of education and training for both the current and future healthcare workforce.

2.3.4 Wales

In 2001 Improving Health in Wales: a Plan for the NHS and its Partners (National Assembly for Wales 2001a) set the strategic direction for the NHS in Wales over the next decade. The main focus was on improving health and addressing inequalities in health. The vision was for an integrated healthcare system across primary, secondary and tertiary services, with stronger partnership working across organisational boundaries and greater patient involvement. This plan also committed to modernising pay and terms and conditions for staff and a number of initiatives were included to ensure the workforce was prepared for future roles: for example leadership development, partnership working, reviews of job design and increased opportunities for flexible working.

Building upon and updating the work of Improving Health in Wales, in 2005 a further ten year strategy was published Designed for Life – Creating World Class Health and Social Care for Wales in the 21st Century (Welsh Assembly Government 2005a) the focus of this policy was on promoting a national health service for the people of Wales, as opposed to a national illness service. This vision encompassed increased personal responsibility for health and well-being amongst the public. Targets were included for prevention, better access to services and improvements in quality for the following priorities: mental health; chronic disease management; children and young people’s services; older people’s services and cancer services. A range of enablers were identified encompassing performance management; service reconfiguration; professional leadership; clinical networks; research and evaluation; education, training and workforce re-design. A commitment was made for 6,000 additional nurses and the development of a workforce strategy to support the implementation of Designed for Life.

In 2006 Designed to Work (Welsh Assembly Government) was published and this workforce strategy was aimed at supporting the development of new roles and different ways of working. The key principles included more

responsive workforce planning and education commissioning; working in partnership with staff to deliver change and workforce re-design based on patient pathways, across both professional and organisational boundaries. This strategy also included the introduction of two new organisations: the Workforce Development and Contracting Unit and the National Leadership and Innovation Agency for Healthcare.

2.3.5 Northern Ireland

It was reported that after the prolonged period of direct rule from Westminster, the resultant position in Northern Ireland was that health policies were out of date and did not meet the needs of the population, additionally the delivery of structural change was slow (Greer 2001). The political situation in Northern Ireland resulted in a culture of ‘minimal policy activity’ where the main focus was on keeping health and social care services running during the civil war (Greer 2004a, p.159).

Between 1999 and 2002 the policy activity in Northern Ireland was centred on developing primary care services and reviewing acute care provision (Department of Health, Social Services and Public Safety 2000, 2001, 2002a). Following the suspension of the Northern Ireland Assembly in October 2002 and the consequent reversion back to direct rule by Westminster, the policy activity was mainly directed at modernising health and social services in Northern Ireland (Department of Health, Social Services and Public Safety 2004; 2005a).

The sections above provided an outline of the key policy documents in each of the four countries, however there was one particular area of common policy across the four countries worthy of note which was the shift of care from acute hospitals into community settings.

2.3.6 Shift in Care to the Community

Over the period since devolution, a range of health policies have been developed detailing the need to shift care from acute hospital settings to the community or primary care (including Department of Health 2001a, 2006a, 2008a; Scottish Executive Health Department 2003b, 2005a, 2005b, 2006a; National Assembly for Wales 2001a, 2001b; Welsh Assembly Government 2003a, 2005a 2007; Department of Health, Social Services and Public Safety 2001, 2004; 2005a, 2005b). Integral to these policies was a greater emphasis on working in partnership with patients and service users.