Localization and Partnership in the ‘New National Health Service': England and Scotland Compared
| Author | Brian Hardy,Bob Hudson |
| DOI | http://doi.org/10.1111/1467-9299.00258 |
| Published date | 01 July 2001 |
| Date | 01 July 2001 |
LOCALIZATION AND PARTNERSHIP IN THE
‘NEW NATIONAL HEALTH SERVICE’:
ENGLAND AND SCOTLAND COMPARED
BOB HUDSON AND BRIAN HARDY
This article examines some important and interesting differences in the designs of
the ‘New NHS’ in England and Scotland in respect of two common guiding impera-
tives – localization and partnership. In examining the view of key local stakeholders
faced with introducing the changes, we contrast the generally more flexible and less
prescriptive approach in Scotland. In England there was, initially, a raft of guidance
from the centre: in Scotland, by contrast, there was virtually none. In England the
prime bases for localization will be PCGs and PCTs: in Scotland they will be Local
Health Care Co-operatives (LHCCs). The latter, like the English PCGs, are to be
GP-led; but unlike PCGs, membership is voluntary. Underlying such redesign of
the organizational architecture are some important changes in cultures and modes
of governance. In particular, we note the rhetoric of a shift, at macro-level, from
hierarchies and quasi-markets to networks and the perceived reality of a micro-
level shift from individualism to collegiality amongst GPs.
INTRODUCTION
In a memorandum to his Cabinet colleagues on 5 October 1945, Aneurin
Bevin stated, of the proposed National Health Service (NHS), that ‘We have
got to achieve as nearly as possible a uniform standard of service for all’
(quoted in Pollitt et al. 1999). Such an emphasis implies a centralized and
hierarchical governing arrangement leaving little to the discretion of
localities or individual practitioners. In reality, the British NHS has never
attained this position, with studies showing that local implementation of
national policies has often resulted in significant variations in priorities,
resource levels and service patterns (see, for example, Elcock and Haywood
1980). These variations are even more pronounced when the comparison is
made between England and Scotland, rather than simply within either coun-
try. Petch (1999), for example, highlights a number of important differences,
with Scotland showing a higher rate of long-stay hospital residents, a lower
use of independent providers of nursing home care and social care and a
lower take-up of GP fundholding.
What is distinctive about the approaches of the recent Conservative
government and the current Labour government to NHS governance in
respect of localization and partnership, is that they constitute a recognition
of this de facto decentralization, and seek to institutionalize it into governing
Bob Hudson and Brian Hardy are at the Nuffield Institute for Health, University of Leeds.
Public Administration Vol. 79 No. 2, 2001 (315–335)
Blackwell Publishers Ltd. 2001, 108 Cowley Road, Oxford OX4 1JF, UK and 350 Main Street,
Malden, MA 02148, USA.
316 BOB HUDSON AND BRIAN HARDY
arrangements. In the case of the Conservatives, their 1989 NHS White Paper
(Secretaries of State for Health 1989) stated that ‘as much power and
responsibility as possible will be delegated to the local level’ (p. 4). The
main vehicle for securing this on the provider side was to be local NHS
Trusts with freedoms to take their own decisions without detailed super-
vision from above, while on the purchasing side it was the encouragement
of fundholding status for general practitioners (GPs).
The main thrust of the NHS reforms by the Blair government is to reform
the nature of decentralized purchasing, while leaving the provider side –
for the time being – relatively untouched. Rather than concentrate upon
practice-level purchasing, the focus of the Labour reforms is upon locality-
level activity, and is based upon the belief that the fundholding model is
both inequitable and inefficient (Audit Commission 1996). However, the
exact form which this locality-based model will take varies significantly
between England and Scotland. This article examines these differences and
reports upon some formative research into the emerging position in
England and Scotland – the reforms did not go ‘live’ until April 1999. It has
three main sections. The first examines the main similarities and differences
between the two nations in respect of localization and partnership working;
the second reports on the research findings; and the final section places
both of the earlier sections in a broader theoretical context examining poss-
ible shifts in modes of governance between hierarchies, markets and net-
works.
LOCALIZATION AND PARTNERSHIP IN THE ‘NEW NHS’
Localizing the NHS: England
The 1997 NHS White Paper for England (Secretaries of State for Health
1997) proposed that the chief responsibility for purchasing health care
should move from the existing 100 health authorities and 3600 GP fundhol-
ders, to around 500 Primary Care Groups (PCGs) each covering ‘natural
communities’ of around 100,000 population. The White Paper describes
them as comprising all GPs in an area, together with community nurses,
who will take responsibility for commissioning services for the local com-
munity. They will be accountable to health authorities, but will have free-
dom to make decisions about how they deploy their resources within the
framework of a new Health Improvement Programme (HImP) to be drawn
up by the Health Authority. From April 1999, all general practices – not
just volunteer fundholders – were required to become part of a PCG which
will, at a minimum, manage a cash-limited budget covering the prescribing
expenditure of the practices involved and their cash-limited practice infra-
structure expenses. Over time, all PCGs will be required to develop so that
they are responsible for at least 85 per cent of the total Hospital and Com-
munity Health Services (HCHS) and General Medical Services (GMS)
expenditure for the local population – effectively collective fundholders for
Blackwell Publishers Ltd. 2001
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