Scotland’s Future, the 670-page report published last week by the Scottish Government promoting Scottish independence, includes detailed plans on how the BBC, the Royal Mail and the security services would be divided up if Scotland votes in favour of a split next September.
On the last, Scotland would set up its own security and intelligence agency, spending around £200m a year (compared with the £2bn combined budget for GCHQ, MI5 and MI6). “The rest of the UK will be our closest neighbour and our most important friend and ally,” the report says, then adding: “There is no doubt that intelligence-sharing will be in the best interest of the people of Scotland and the rest of the UK.” As I argued in the Register in September, there is plenty of doubt about that, actually.
Leaving spooks aside, given the size of this report you might expect something of substance on healthcare. But chapter four, ‘Health, Wellbeing and Social Protection’ starts by discussing more welfare spending, with health getting just over six pages near the end. Healthcare was devolved in 1999, and Scotland had a degree of independence from the NHS’s birth in 1948, so it could be argued there’s not so much to do. But that would ignore the fact that, in some areas including life expectancy, parts of Scotland have terrible health.
The report doesn’t argue that everything is perfect, but does assert that Scotland’s health will be improved through other routes than reforming its NHS:
Responsibility for delivering health services to our population is not enough. To tackle these major challenges, we also need responsibility for our society’s wellbeing and welfare. The solution to ill-health is not in the hands of the NHS alone – it depends on breaking the cycle of poverty, educational under-attainment, worklessness, poor mental wellbeing, and, through these, preventable ill-health.
You can make that case. However, England currently has the same benefits as Scotland, so if too low welfare payments were to blame, Manchester and Liverpool would suffer the same level of health problems as Glasgow, and they don’t (although things are hardly great). Meanwhile, education, mental and preventative healthcare are already devolved, so it is hard to blame unhealthy Scots on Westminster. Perhaps that’s why there’s not much on healthcare in this report: past Scottish innovations are mentioned – minimum alcohol prices and plain tobacco packaging – but there is little clue as to the nature of potential new ones. (There’s no shortage of innovation in the Scottish NHS, as this year’s EHI Awards demonstrated, but that’s not reflected here.)
Scotland has, and would continue to have if independent, serious problems with its health and its NHS. It spends significantly more than England, Wales or Northern Ireland on healthcare per person (as detailed at the end of this article – the study was from 2005, but the spending difference remains). It has an odd structure; while you can make a case for its integrated health boards (as you can make a case for England’s commissioner/provider split), it’s hard to understand why these boards vary so greatly in size, including as they do both the largest and the smallest NHS providers in the UK (Greater Glasgow, 1.2m patients, and Orkney, 20,000). As the much more substantial section in Scotland’s Future on public services details, Scotland has merged its police forces into one to share on administration costs. A single health board might be too big, but why does it make sense to run 14 health boards, when four Greater Glasgow-sized ones could cover the country?
Other parts of the report give a clear idea of what an independent Scotland would do, even if the plans often seem implausible (not least in assuming extraordinary generosity from the rest of the UK, the EU, its member nations and a wide range of currently UK-wide organisations). But it implies Scotland’s NHS is basically fine as it is. In reality, it faces some severe problems, and while many are not unique to Scotland, they are often at their most extreme there. On the strength of this report, the Scottish Government appears to have few ideas on how to tackle them.