Introduction

A volume on health reforms under the Coalition must necessarily expand its focus beyond Westminster to consider the larger UK policy context. Legislation enacted in 1998 established devolved assemblies in Scotland, Wales and Northern Ireland with powers to make law or issue executive orders in certain specified areas, including health services. This meant that an English NHS overseen by the Westminster Parliament now existed alongside separate NHS systems accountable to devolved governments in the other UK countries. While there had long been significant differences in the legislative frameworks shaping health care across the UK, with a distinctive Health and Social Care (HSC) service in Northern Ireland and separate Acts applying to England/Wales and Scotland, devolution accentuated policy divergence to the extent that it is now misleading to write of a unitary British NHS (Greer, 2004a).

The major Coalition health reforms heralded by the Health and Social Care Act 2012 thus applied in the main to England only. However, the acceleration of market reform in England posed urgent questions for the devolved administrations. They needed to formulate appropriate policy responses that either maintained differences or moved closer to the English policies. There were operational issues concerning interaction with the larger English system, such as the cross-border healthcare arrangements between England and Wales and Scotland, and the sharing of English services such as certain National Institute for Health and Clinical Excellence (NICE) products under agreements made by the devolved governments. Divergence intensified political controversy; increasingly the devolved NHS systems found themselves subjected to critical comparisons, with those lining up for or against the English market reforms searching for evidence that would support their arguments.

Clearly the four UK NHS systems are not equal. The English NHS, serving a population of 53.9 million and employing 1.4 million people, dwarfs the NHS systems of the other three countries. In Scotland 140,000 NHS staff serve a population of 5.3 million, while NHS Wales’ 70,000 employees cater for 3.1 million residents, and Health and Social Care Northern Ireland employs 62,000 staff (including social care staff) to care for 1.8 million people. Yet although the English system dominates in terms of scale and supporting infrastructure, the other systems remain important as alternative NHS models that may yet influence future UK-wide health policy.

This chapter describes these divergent approaches, but also sheds light on the nature of coalition policy making.