In order to chart the likely impact of a public spending squeeze in the rest of the United Kingdom, it is necessary to bear in mind some regional variations. Fiscal policy is set from Westminster, meaning that the tighter funding environment will have an impact on all of the countries within the UK, but Scotland, Wales and Northern Ireland have taken different paths from England in setting health policy that will affect their room for manoeuvre in a financial crisis. In contrast to England, with its internal health market and significant role for the private sector, the devolved Scottish and Welsh governments have eliminated the purchaser/provider split and maintained more centralised control of health policy. Both countries have also largely rejected the introduction of market forces into their healthcare systems. In Northern Ireland, although the split still exists in effect, there is a single national commissioning body that works with providers in different regions, which has limited competition.
In addition, neither Scotland, Wales nor Northern Ireland has implemented policies such as patient choice, payment by results (in which commissioners purchase care from providers according to a fixed-price tariff) and patient-reported outcome measures (PROMs), which gives them more freedom to respond to price pressures in a funding squeeze, according to Jon Sussex, deputy director of the Office of Health Economics, a think-tank. This freedom effectively makes the Scottish, Welsh and Northern Irish healthcare systems less transparent, which could give them more flexibility to adjust to a harsher funding climate while at the same time forestalling the public and political pressure to which English health reform efforts are more sensitive, Mr Sussex adds. Scotland has a number of unique advantages, including a more general health budget than that of its neighbours (giving it an additional cushion when times get hard) and the ability to increase income tax within Scotland to meet rising demands (although this right has not yet been exercised). Mr Sussex nevertheless points out that England retains at least one advantage over the other three: after nearly a decade of investment in capacity, England has the nation’s lowest waiting times for treatment.
