Today and tomorrow, I will be writing updates on Scotland’s referendum on independence every few hours for Beacon. To clarify, in the title ‘The end of Britain, possibly – LIVE!’, Britain refers to the country also known as the UK, not the islands we’re sitting on just off the north-west coast of Europe…
— Simone (@cee4cat) September 18, 2014
Whatever happens, the sun is going to rise over the islands tomorrow morning. Possibly behind some clouds, but that’s normal.
Below is my piece for Guardian Healthcare Professionals, published on Tuesday, looking at how NHS Scotland may fare under independence.
The future of the Scotland’s NHS has become a major issue in the independence debate, with both sides arguing that only they can save the nation’s health services.
This is despite Scotland already having operational control of its health services, as a result of 1999’s devolution settlement. The Scottish government used this control to reorganise its NHS in 2004, into 14 health boards which provide all healthcare in their areas, removing the split between organisations commissioning and providing services which is used in England.
Scotland has also removed patients’ choice over which provider to use for some procedures, introduced public health measures such as a 50p-a-unit minimum price for alcohol (although this has been delayed by a legal challenge from the Scotch Whisky Association), and replaced private finance initiative funding with a non-profit equivalent.
So it is not surprising that the Scottish government’s white paper for independence, Scotland’s Future, does not include changes to the NHS’s structure. However, the second televised debate between the yes and no campaign leaders heard first minister Alex Salmond saying that English moves towards “privatising and charging” for healthcare could hit services in Scotland. Alistair Darling accused him of scaremongering, saying that the only person who could privatise the Scottish NHS was Alex Salmond. Former prime minister Gordon Brown has said he will re-enter frontline politics to “nail the SNP lie” about NHS privatisation.
Funding of the Scottish NHS
In reality, the arguments of both sides rest mostly on money. “Devolution only protects Scotland from the policy decisions of Westminster, it cannot protect us from their cuts to Scotland’s budget as a consequence of austerity and the erosion of public spending through privatisation and patient charging,” says the Scottish government. “With independence we have the opportunity to protect the gains of devolution and protect public spending on the NHS and other key public services.” It added that every £10 cut from English health spending would reduce Scotland’s by £1 through the Barnett formula used to calculate transfers from Westminster to the Scottish government.
The no campaign has responded that the Scottish government is already underspending on health. “The Institute for Fiscal Studies (IFS) showed this week again that the Scottish National Party (SNP) has withheld from the Scottish NHS rises in spending which even the Conservative party spent on the English National Health Service,” John Reid, the former Westminster health secretary now sitting in the House of Lords, told a Better Together event last Sunday.
The IFS calculates that both the last Labour government and the current coalition one have increased healthcare spending faster than the Scottish government. From 2002-3 to 2009-10, real terms English NHS spending rose by 43% compared with 29% in Scotland. From 2009-10 to 2015-16 Westminster plans to increase English NHS budgets by 4.4% – despite a 13% overall cut in departments which serve England – compared with a 1% fall in Scotland.
Some of this is down to Scotland shifting money into social care; uniquely among the UK’s current nations, it provides free personal and nursing care for those aged 65 and over. But the IFS also claims that Scotland would struggle to support healthcare spending if independent: “Under a wide range of scenarios, a combination of the eventual fall in oil revenues and an ageing population could make for a tougher fiscal outlook for Scotland than the rest of the UK and hence less room for additional spending on things like the NHS.”
Given the expectation that an independent Scotland would take the vast majority of tax revenue from North Sea oil and gas, it might seem that any such revenue will be a bonus. However, it currently receives much of it back under the Barnett formula, allowing the Scottish public sector to spend £1,267 more per person in 2012-13 than the UK average, according to a report by the Insitute of Chartered Accountants of Scotland (Icas). Icas calculated that, based on an independent Scotland receiving the geographic share (the vast majority) of North Sea tax revenues, it would have had a public spending deficit £239 lower than the whole of the UK in 2011-12 – but that this would have reversed to one £470 higher in 2012-13.
Scotland’s higher public spending includes £203 more per person on its NHS than England, according to the Nuffield Trust. In a recent report, the healthcare think-tank said that in 2012-13 Scotland spent £2,115 a year per person on healthcare, compared with £1,912 in England. This is partly justified by poorer health; Scotsmen die on average when 76.6 years old, 2.3 years younger than the UK average; the figure for Glaswegian men is the lowest of any UK council area at 72.6 years. The expense of serving people in Scotland’s lightly-populated areas is also a factor. But the extra money also provides Scots with free prescriptions, in common with Wales and Northern Ireland.
The Scottish government argues that wider changes would make a difference. In Scotland’s Future, it said: “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.” Benefits are not currently devolved, and would be reformed: “Independence will also allow us to design a fairer welfare system.” Control of welfare policies may also happen in the event of a no vote given recent pledges by the unionist parties, although details are not yet clear.
Changes to policy, research and pay
Sir Harry Burns, Scotland’s former chief medical officer, has also suggested that independence itself could mean Scots feeling more in control of their lives, which “would be very positive for their health”.
Those campaigning for Scotland to stay in the UK have raised particular concerns over medical research. The British Medical Association’s Scottish branch (which is formally neutral, but published a list of questions over independence) has pointed out that Scottish institutions currently receive nearly 15% of UK research council funding, compared with Scotland’s 8.4% of the UK population. The Scottish government responds that “we will seek to agree maintenance of a common research area with the UK with shared research councils”.
Scotland has already taken a different view on NHS pay from the rest of the UK. Unlike England, it implemented UK-wide recommendations by pay review bodies, which it says means that Agenda for Change staff are £200 to £700 better off, with consultants £750 to £1,000 richer. However, it has frozen distinction awards for such consultants since 2010-11, a move criticised by the BMA. However, this is already a devolved matter.
Andy McKeon, a senior policy fellow at the Nuffield Trust, says Scotland’s NHS has followed England’s in successfully cutting waiting times through strong enforcement of targets. The two nations did so in different ways: England increased capacity for conditions with long waiting lists through independent sector treatment centres, while Scotland bought a private hospital in Glasgow and turned it into the Golden Jubilee National Hospital, run by NHS National Waiting Times Centre Board to cut waits for selected procedures.
McKeon adds that under devolution, Scotland’s NHS has had other successes, in improving quality and in successfully introducing electronic health records, although England is starting to catch up on the latter. “They have an advantage over England in having a smaller nation, where you can get all the key people together act with cohesion,” he says. But again, this will continue to apply regardless of the referendum’s outcome.
The main changes to the Scottish NHS as a result of Thursday’s vote look set to be financial ones, and at least one group of health workers in Scotland appears to base its views on this. A survey published in August by the British Medical Journal of 311 doctors working in Scotland found that 60% planned to vote against independence compared with 33% in favour, and the biggest concern of those against was that Scotland’s overall economy would suffer under independence, hitting the tax revenues used to fund its NHS.
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