Health and Social Care in the Community 9(5), 266 – 278 266 © 2001 Blackwell Science Ltd Abstract The United Kingdom is ostensibly one country and yet public policy often varies between its constituent territories – England, Scotland, Wales and Northern Ireland. Health policy illustrates the dilemmas inherent in an apparently unitary system that permits scope for territorial variation. Administrative devolution has now been accompanied by political devolution but their interaction has yet to produce policy outcomes. This paper describes recent health policy reform with regard to primary care in terms of the tension inherent in current policy between notions of a ‘one nation NHS’ and the territorial diversity wrought by devolution. The paper provides a framework for understanding the emergent outcomes by exploring various concepts. In particular, the existing character of territorial policy networks, the properties of policies in devolved territories and intergovernmental relations are considered from various disciplines to examine whether greater diversity or uniformity will result from the dual reform process. Whilst this evaluation can, at this stage, only be preliminary, the paper provides a framework to appraise the emerging impact of devolution upon primary care in the UK. Keywords: devolution, primary care, public policy, territorial diversity Blackwell Science, Ltd Primary care in the UK: understanding the dynamics of devolution Mark Exworthy London School of Economics and Political Science, Houghton Street, London, UK Correspondence Dr. Mark Exworthy L.S.E. Health and Social Care London School of Economics and Political Science Houghton Street London WC2A 2AE UK E-mail: M.Exworthy@lse.ac.uk Introduction The UK is often seen as a paradox of four territories within one country. This paradox entails diversity and uniformity in many aspects of public life such as education, law and order, national identity and sport. England, Scotland, Wales and Northern Ireland (NI) collectively form the UK but each has its own configura- tion of institutions and cultural practices which helps define its own (national) pattern of policy diversity and uniformity. The paradox is manifest in many areas of public policy, especially education and law, but also the National Health Service (NHS). The election of a Labour government in May 1997 has thrown into sharper relief the paradox of diversity and uniformity in the UK. This is due to the parallel implementation of devolution and a raft of health reforms. This article explores the interaction between health reform and devolution upon the pattern of policy diversity and uniformity in a key sector within the NHS – primary health-care (hereafter, primary care). As a subset of health policy-making in general, primary care is likely to illustrate well the emergent territorial out- comes of devolution. It is this sector which has received much policy attention over the past decade (Glendinning 1998) and is crucial, since primary care has close opera- tional and strategic links with education, social services and housing sectors. Moreover, primary care illustrates well the wider processes of governance in recent years (Rhodes 1997). The advent of general practitioner fund- holding (Glennerster et al. 1994), the shift in emphasis from secondary care (hospitals) to primary care, the impact of technology upon the location of healthcare provision (Godber et al. 1997) and the preferences of patients (Lupton et al. 1998) are combining to produce a strong impetus which is placing primary care at the centre of health policy. These reforms are shaping and being shaped by the changing balance of the general practice profession vis-à-vis other professions (such as other doctors and nurses) and agencies (such as social services). These trends are apparent in other countries (WHO 1978) but it is likely that the national pattern of and the policy direction adopted by the UK government will mean that policy outcomes are peculiar to the UK.