Scottish Independence: What are the implications for health policy?

[This now appears in Total Politics http://www.totalpolitics.com/opinion/427827/scotland-special-nhs-new-healthy-scotland.thtml]

Most health and public health policy has been devolved since 1999, so maybe the potential for major policy change is not as great as in novel policy fields. Instead, we might see the acceleration of differences in key areas.

The first is healthcare. The NHS has always been a little bit different in Scotland, which enjoyed administrative devolution – through the Scottish Office (a UK Government Department) – before 1999 and maintained its own links with professional groups. Scotland has traditionally trained a disproportionate number of UK doctors and maintained an unusually high presence of Royal Colleges. This greater medical presence in Edinburgh (and Glasgow) boosted the Scottish Office’s policymaking image as ‘professionalised’, or more likely to pursue policies favoured by the medical profession than the Department of Health. For example, it appeared to be less supportive of reforms based on the ‘marketisation’ of the NHS. Devolution turbo boosted this position. While the UK Labour Government furthered the ‘internal market’ established by its Conservative predecessors, the Labour-led Scottish Government seemed to dismantle it (for example, there are no Foundation hospitals). It also bought (and effectively renationalised) a private hospital, which had a symbolic importance way above its practical effect. Since 2007, the SNP-led Scottish Government – often supported publicly by UK-wide groups such as the British Medical Association (and nursing and allied health professions) – has gone big on this difference between Scottish and UK Government policies, criticising the marketization of the NHS in England and expressing, at every opportunity, the desire to maintain the sort of NHS portrayed by Danny Boyle at the Olympics opening ceremony. This broad approach is generally supported, at least implicitly, by the important political parties in Scotland (the SNP is competing with a centre-left Labour Party and the Conservatives are less important). It is also supported by a medical profession and a public that, in practice, tends to be more committed to the NHS (in other words, opinion polls may not always show a stark difference in attitudes, but there is not the same fear in Scotland, as in the South-East of England, that doctors and patients might defect to the private sector if the NHS is not up to scratch). So, we might expect independence to maintain or accelerate these differences.

The second is public health. Scotland won the race to ban smoking in public places and is currently trying to introduce a minimum unit price for alcohol. It has also placed particular emphasis on the wider determinants of health and made the right noises about the balance between public health and acute care. Independence is less likely to have a major difference on tobacco control because the UK already tops the European league table on that score. However, it would help its alcohol control agenda, since key measures (raising the price of alcohol through taxation pricing and further limiting the advertising and promotion of alcohol) would be under greater Scottish Government control.

The third is mental health. To some extent, early Scottish Governments developed an international reputation for innovation in some areas relating to wellbeing. It also reformed mental health and capacity legislation in a relatively quick and smooth way – at least compared to the UK Labour Government, which had a major stand-off with virtually all mental health advocacy groups on psychiatric-based reforms. Part of the difference relates to the size of Scotland and its government’s responsibilities which can produce a distinctive policy style; it often has the ability to coordinate cross-cutting policy, in consultation with stakeholders, in a more personal way. However, this is a field in which there tend to be often-similar policies beyond the Sun-style headlines. Further, independence won’t give the Scottish Government many relevant powers that it doesn’t already enjoy.

These differences should be seen in the context of a shared history and some major similarities. Both NHS systems are primarily tax-funded and free at the point of use, with the exception of some charges in England (which should not be exaggerated – for example, 89% of prescriptions in England are tax-funded). Both governments have sought to assure the public in similar ways by, for example, maintaining high profile targets on waiting times. Both systems face similar organisational pressures, such as the balance between a public demand for local hospitals and medical demand for centralised services. Both governments face similar demographic changes which put pressure on services. Both have similarly healthy (or unhealthy) populations.

Much depends on the bigger picture, including the economic context, government funding and the new attitudes and relationships which develop when a government is responsible for the political system as a whole. As in many areas, health policy in Scotland seems relatively consensual, but new forms of government – and a much harsher economic reality – may open up new forms of conflict and cooperation.