The independence referendum takes place on 18th September 2014. But it is the days that follow which are more important. It is what Scotland does with its existing, or future further devolved, or independent powers which matters most – not simply where the constitutional border is drawn. The argument is not therefore primarily about the constitutional power, but about what we do with them.
The NHS in Scotland is THE case for Devolution – choosing public over private health services, and mitigating against the whims of Westminster ideology. However, it is public health policies and legislation including smoke-free public places and minimum unit pricing which mark the key achievements of the Scottish Parliament and of devolution. Successes which have also become central to the Scottish Government’ s case for independence in their White Paper – Scotland’s Future. Nevertheless, both the preservation of the values and quality of the NHS in Scotland and the pioneering of public health legislation are key achievements of devolution.
Both devolution of more powers or independence could bring further opportunities for progressive public health action. The White Paper states an independent Scotland would “use the full range of levers to promote good health,” but there is little detail on specific policy, nor is the future of public health or health services given much attention. Under current devolution arrangements, health is one of the largest budgets and highest profile policy areas controlled by the Scottish Government. But, the questions need to be asked: if Scotland were to become independent, would the attention given to public health be substantially less when the focus will inevitably be drawn to fiscal, foreign and defence powers, as well as the substantial efforts needed to disentangle the country from the rest of the UK and establish the independent state bureaucracy? And, how radical could public health policy be in terms of taking on big business, for example, the alcohol, tobacco, or food industry on advertising regulation or taxation policies? when at the same time the independence white paper sets out a business friendly low corporation tax priority that undermines the determination that would be needed to take on big business in these areas.
However, it is on health inequalities that the recent Audit Scotland report was damming on health policy. Despite the investment from successive devolved administrations, inequalities in health have just not budged. It is well recognised that health inequalities are the result of the unfair distribution of income and power and to a degree they are also associated with the inverse care law of wider public (as well as health) services – where those who need them the most are least likely to have access to them. So, on this count, it could be that our failure on health inequalities is because we do not yet have enough fiscal or economic levers. However, it could also be that we have not yet fully utilised the powers we currently have at our disposal including our lack of will or action to meaningfully reallocate resources (in our current gift) towards those who need it most. Couple this to the proposed low corporation business friendly taxation system proposed in an independent Scotland and it does not bode well for demonstrating that an egalitarian society will emerge and deliver us justice on health inequalities. First independence then equality? A leap of faith is needed here, because the case is not convincing.
The Scottish Government’s White Paper sets out the health case for independence:
This Scottish Government plans to continue with current arrangements for the management of the NHS in Scotland, focussing on sustainable quality and for the integration of adult health and social care services. Services will be accessed in the same way as under the devolution settlement.
Despite efforts to address the challenge of health inequalities in Scotland over recent years, health inequalities persist and demonstrate that the “fundamental causes” of health inequalities – the socio-economic inequalities in society – are the most important. Recent research shows the strong correlation between poor health and poverty. It suggests that the reason for Britain’s high health inequalities is the failure of successive Westminster governments to choose to reduce inequality.
Independence will also allow us to do more to tackle major causes of ill-health, which disproportionately affect poorer communities. In March 2006, Scotland was the first country in the UK to enact a ban on smoking in public places. This has resulted in a dramatic reduction in smoking related diseases. We have also led the way in developing ambitious proposals to tackle harmful drinking by legislating for a minimum unit price for alcohol.
We have maintained our commitment to strong action to tackle smoking and alcohol misuse with all the powers available to us. In contrast, the Westminster Government has chosen to put on hold proposals for plain packaging for cigarettes, and abandon plans for minimum pricing for alcohol. With independence, we will have greater scope and clearer powers to regulate alcohol and tobacco, including through taxation – reducing the opportunities for legal challenge which have held up several of our initiatives to date.
We are already taking a distinctive approach to food standards. Independence will allow this to be linked to tax policy and advertising regulation – allowing a coherent and concerted approach to issues of obesity and poor diet, which disproportionately affect poorer communities.
A major advantage of independence for health and wellbeing in Scotland is therefore to have the ability to use the full range of levers to promote good health. It is matched by the opportunity to grow Scotland’s economy for the benefit of all and address inequalities in Scottish society that have not been, and will not be, addressed under Westminster.
After independence, Scotland will maintain a very strong relationship with the other countries of the UK. Scotland will continue to work with other parts of the UK to provide services where this provides access to the highest quality of care and delivers the best outcomes. There are already effective cross-border working arrangements in place, which will provide a strong foundation for continued co-operation, just as there is with Ireland. Partnership arrangements are also in place with a number of European countries, including, for example, Sweden.
Services provided for patients outwith Scotland include highly specialised care for people with rare diseases or conditions, and certain types of transplantation. The rare cases of transplants being conducted outwith Scotland are for lung, small bowel and paediatric transplants. Because there is a relatively small number of these procedures, contracting these services from clinical specialists offers the best health outcomes for Scotland’s patients. These arrangements will continue exactly as they are at present after independence.
On independence, Scotland will continue the current arrangements for organ donation across the UK, maintaining one donor register and sharing donated organs. This will ensure that all organs are placed with the best matched patient. The Irish Health Service Executive also co-operates on organ transplantation with NHS Blood and Transplant (NHSBT), who co-ordinate transplant services across the UK. This reflects international best practice in transplantation where groups of countries work together, for example Eurotransplant in mainland Europe (Austria, Belgium, Croatia, Germany, Luxembourg, Netherlands and Slovenia), and Scandiatransplant in the Scandinavian countries (Denmark, Finland, Iceland, Norway and Sweden).
Arrangements for reviewing NHS pay are already devolved but NHS Scotland currently operates within UK structures and modifies UK agreements to reflect Scottish circumstances where necessary. With independence, we will review the machinery for pay determination in partnership, including the potential for improvement across the wider Scottish public sector. The Scottish Government has developed a Scottish GP contract in partnership with the BMA, and with independence we will continue to work with them, and all relevant partners, to ensure that GP contracts are developed to meet the needs and circumstances of the people of Scotland. Similarly, for hospital based doctors and dentists, the Scottish Government will work with all relevant partners in Scotland, and seek to co-operate with Westminster where appropriate, to negotiate pay, terms and conditions.
Scotland is already responsible for the regulation of some health professions – those who came to be regulated after the establishment of the Scottish Parliament. After independence, we will become responsible for all regulation. We will seek to co-operate with Westminster, and the devolved administrations, to ensure that health professional regulation is maintained in the best interests of patient safety and the consistent treatment of healthcare professionals. We will also maintain the existing professional healthcare regulatory bodies, which are funded by fees from registrants, and will continue to operate in Scotland after independence.
With independence, we can build on the gains of devolution for our health and social care services to enhance the health and wellbeing of people across society.
This article first appeared in Healthier Scotland – The Journal Published by Socialist Health Association Scotland March 2014