This is the second of three posts which use case studies of cross-cutting and specific policy areas to add more depth to our discussion of Scottish politics and policymaking.
Most aspects of health policy have been devolved since 1999, and many were devolved before 1999, so we can generate a relatively long term picture of policy change/ divergence in three key areas: healthcare, mental health, and public health. We can then revisit the idea of prevention and inequalities raised in the first lecture.
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 boosted the Scottish Office’s policymaking image as ‘professionalised’, or more likely to pursue policies favoured by the medical profession than the UK’s Department of Health. For example, it appeared to be less supportive of reforms based on the ‘marketisation’ of the NHS.
Devolution turbo boosted this sense of Scottish policy difference (see the Greer and Jarman discussion).
For example, 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).
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. However, there are also major similarities in Scottish and UK Government approaches. For example, the UK tops the European league table on comprehensive tobacco control (and England/ Wales beat Scotland to ban smoking in cars with children).
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.
The bigger picture of continuity: a tax funded service
These Scottish-UK 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.
The bigger picture of prevention and health inequality
Although the Scottish Government pursues an agenda on prevention to reduce service demand and health inequalities, many other policies based on the idea of universal provision have the potential to exacerbate inequalities.
For example, a real rise in spending (cash spending adjusted with the GDP deflator) on health policy of 68% from 2000-11 did not have a major effect on health inequalities (Cairney and McGarvey, 2013: 229). Instead, Scottish Governments tended to use the money in areas such as acute care to, for example, maintain high profile waiting list (non-emergency operations) and waiting times (A&E) targets which did not have a health inequalities component (Cairney, 2011: 177-9). It has also phased out several charges, such on prescriptions and eye tests, which increase spending without decreasing inequalities (particularly since the lowest paid already qualified for exemptions for charges).
It has pursued strongly a public health strategy geared, in part, towards reducing health inequalities, but with the same tendency as in the UK for healthcare to come first. This process includes interesting overlaps in aims and outcomes, such as in tobacco control where smoking is addressed strongly partly because it represents the single biggest element of health inequalities, but most initiatives do not necessarily reduce inequalities in smoking.
I discuss these issues in more depth in Scottish Politics and The Scottish Political System Since Devolution. See also this draft chapter on prevention and health policy by the Scottish and UK Governments