Scots will decide this September whether or not Scotland should be an independent sovereign state.
“As all key areas of our business are already fully devolved, it’s very much business as usual for us,” noted a spokesperson for Healthcare Improvement Scotland (HIS) in a statement to Eye News. “We remain completely focused on helping to deliver improvements in healthcare ahead of September 2014 and beyond.”
Scotland’s future health
The Scottish government has ruled out what it believes are disruptive and costly structural reforms taking place in NHS England, allowing NHS Scotland to focus on improving safety and quality of care. It says independence will allow Scotland to do more to tackle major causes of ill-health, which disproportionately affect poor communities.
This means that the budget for NHS Scotland will reflect Scottish priorities. By March 2013, 97.5% of patients waited less than the 12-week standard for a first outpatient consultation.
Independence will provide the Scottish government with an opportunity to negotiate its own pricing arrangements directly and in partnership with the pharmaceutical industry to secure the best possible deal. Arrangements for reciprocal specialist treatment for patients will continue and reciprocal arrangements on blood and organ transplantation will not be affected by independence. The Scottish government says it ‘plans’ to continue using the services of the Medicines and Healthcare Products Regulatory Agency (MHRA) in an independent Scotland, unless and until the Scottish Parliament decides to make changes in this area.
“The British Medical Association (BMA) will continue to adopt a neutral position during the debate around the independence referendum and will support balanced debate on the implications for health on the result of a yes or a no vote,” said a spokesperson for BMA Scotland, the trade body representing around 16,000 doctors in Scotland.
In a pre-referendum discussion paper, BMA Scotland identified implications for health professionals arising from the potential status of Scotland as an independent nation:
- An independent Scotland would need to re-establish the regulation of the medical profession in legislation and replicate the core functions of the General Medical Council.
- A ‘Yes’ vote for independence may result in wider divergence from the UK on the Scottish government’s employment and pay conditions for its medical workforce, impacting general practitioners and consultants in the years ahead.
- An independent Scotland would have to determine to what extent public sector pension schemes continued to reflect the current arrangements in other parts of the UK.
- Immigration policy would depend largely on Scotland’s position with regard to EU membership. Doctors and the medical profession will want to know on what basis NHS organisations in Scotland will be able to recruit medical staff from outside Scotland.
According to BMA Scotland, universities and researchers in Scotland must continue to have the opportunities to access and compete for similar or comparable levels of funding from all its existing funding streams in order to maintain and develop its research excellence beyond 2014.
The real threat to research in Scotland’s universities is not independence but continued participation in the union, argues Academics for YES, a group of scholars who say that independence would protect Scotland’s research base and allow it to thrive.
Measured by proportion of GDP spent on R&D, the UK languishes towards the bottom of the G8 league and well below the EU-28 average, according to Campaign for Science and Engineering (CaSE). Scotland makes a good fist of things for its size, securing a high rate of competitive funding from UK research councils and the EU.
The pro-independence group rebuts suggestions that Scotland is ‘too wee’ to compete successfully alone. “Those who disburse research grants are looking for the best people to do the best work and get the best results. Research is an international activity and Scotland excels in it. The international visibility of the Scottish brand would be clearer with independence, develop more opportunities in research and help attract international students.”
Strong support from optometrists for delegated community-based care
In recent years there has been heavy investment in optometry services in the community by the Scottish government, providing substantial amounts for investment in equipment, linking their practices electronically to hospitals, training of optometrists in clinical settings, free optometrist reviews at any age and enhanced remuneration of the general ophthalmic services (GOS) contract. “Still we do not know if this investment is good value for money, whether it will influence hospital activity and whether it will reduce in the mid-term sight loss in the population,” observed a consultant ophthalmologist.
An optometrist in Glasgow explained that devolved healthcare has worked well, with universal eye care available and good use of community-based resources. Uptake amongst Scottish optometrists for government-funded training to secure independent prescribing rights has been very good, with around 20% of Scottish optometrists accredited with prescribing pads. Continuing professional development amongst optometrists will see additional service capacity created within the community, for example in delegated care of discharged glaucoma patients and at-risk patient groups.
“Healthcare is fully devolved in Scotland, with successful differentiation from England, and we stand to gain little or no benefit from independence,” said an Edinburgh optometrist. “There’s also a risk that replication of professional regulatory bodies following independence would be prohibitively costly and lead to higher fees.”
Current concerns among ophthalmologists and optometrists
“The NHS is facing huge pressure (not only to provide eye care) and is not coping well with demand both north and south of the border,” observed a consultant ophthalmologist. “The Scottish government appears to support a more traditional NHS service, which is probably favoured by the general public, while in England the NHS is rapidly evolving with commissioning and welcoming private healthcare provision which may be more controversial and less acceptable.
“From my point of view, I would want to know which system provides best care for patients, provides better value for money, and from an ophthalmologist’s point of view, is there a difference in professional satisfaction? I do not know the answers.”
Another consultant ophthalmologist cited concerns about moving front-line staff to a seven-day working week ‘within existing resources’ to address waiting lists and treatment time guarantees, along with a growing medical recruitment crisis due to unattractive changes to the Scottish consultant contract and fewer private practice opportunities. There are fears too that an independent Scottish government might mean counterproductive health policies.
“How do we attract doctors back to the north with political and economic uncertainty, unappealing job plans, seven-day working weeks, fewer private practice opportunities and a NHS culture of low-grade managers empowered to micromanage consultants?” said the consultant ophthalmologist.
“Ultra-high taxation would undoubtedly provide funding to address many of the social inequality problems that persist in Scotland, but it would penalise highly-paid PAYE professionals and may worsen any recruitment shortfall that already exists,” commented another consultant ophthalmic surgeon.
“Scotland is haemorrhaging doctors to England – 33% of new anaesthetist CCTs went south of the border last year,” commented a consultant in anaesthetics and intensive care. “The UK is losing doctors abroad. Consultant vacancies in parts of Scotland are running at 25%. What are they going to do to enable Scotland to compete in the international job market? How will they make jobs attractive?”
Privatisation and the shape of NHS Scotland
An independent Scotland would help preserve the country’s NHS, avoid disruptive outsourcing and better address the country’s inequalities and healthcare challenges, say campaigners for independence. But it might require higher taxation levels to fund a Nordic-style welfare economy.
“An independent Scotland will help protect the National Health Service from damaging privatisation,” argued Dr Willie Wilson, co-founder of NHS for YES, one of the largest sectoral groups in the referendum campaign.
He highlights the determination of the Scottish government to keep private health provision in Scotland to an absolute minimum (well under 1% of total expenditure) but fears that devolution is not enough to guarantee that NHS Scotland will survive in its present form. Prescription charges keep increasing every year in England and ‘self-funding’ by those who can afford to jump the queue is encouraged.
“The Health and Social Care Act of 2012 has made competition and commercialisation mandatory, a process that involves the NHS at all levels,” said Dr Wilson. “Privatisation in England has not been a success so far, according to its retiring head Sir David Nicholson. Around 70% of recent contracts awarded there have gone to private healthcare companies such as Atos, Capita, G4S, Shire and Virgin. In a few years, NHS will just be a brand name in England and Wales.
“Our NHS takes up 40% of our block grant, so the further huge austerity cuts promised by Chancellor Osborne after 2015 (and supported by London Labour) will mean we’ll be forced to privatise NHS Scotland. Austerity cuts still to come will be greater than those endured so far, which means there will be little further flexibility in the Scottish budget after 2015.
“With Scotland’s university sector placed by some as the best in the world, and our NHS having thrived over the years of control by the Scottish government, we have an enviable position,” added Dr Wilson. “The prospect of enhancing both reputation and performance with independence is very attractive.”
“NHS is fully devolved,” notes the Better Together campaign group in an email response. “That means that all relations to health services are already made in Scotland by people living and working in Scotland. We also benefit from being part of the larger UK with public spending protected by the costs being shared across the broad shoulders of the UK and 63 million rather than just five million in Scotland. As part of the UK we get a higher level of public spending than the UK average and that allows us to tackle specific health issues in Scotland.
“Expert analysis from the Institute for Fiscal Studies (IFS) has shown that a separate Scotland would face spending cuts or tax rises of between £3 billion and £10 billion. Under the most optimistic scenario that would mean public spending cuts of 8% or a 9% increase in the basic rate of income tax. That would put the budget for our NHS at risk.”
Pro-union Westminster warns against split
The UK government’s conclusions of the Scotland analysis programme were presented to parliament by the Chief Secretary to the Treasury in June 2014, supporting arguments that Scotland is better off as part of the UK. The union offers people in Scotland lower taxes and higher public spending than would be possible in an independent Scotland, worth £1400 per person per year in Scotland.
Public spending in Scotland in 2012/13 was more than £10 billion greater than tax revenues raised in Scotland, even including a geographic share of oil revenues. On independence, all public spending would have to be funded from taxation and businesses in Scotland, and / or from higher borrowing. The IFS calculates that public spending per head in Scotland is around £1200 higher than the UK average.
An international border would slow growth with the rest of the UK, make Scotland’s large financial sector more vulnerable to financial shocks, raise borrowing costs and increase energy bills, says the UK government. It is estimated by the UK government that as part of the UK, over the next seven years, Scotland saves at least £750 per household on the costs of EU membership.
In 2016/17, the proposed year of independence, the IFS estimates that the Scottish deficit will be more than 5% of its economy, which is more than twice the deficit expected for the whole of the UK in the same year. Using the latest forecasts from the International Monetary Fund, an independent Scotland would have the second highest deficit of any advanced economy.
Wealth and poverty
Scotland’s state finances would be healthier than the rest of the UK on independence, noted James Knightley, Senior Economist at ING in London.
A spokesperson for the official nationalist campaign ‘Yes Scotland’ wrote in an email response: “We know that Scotland is a wealthy country, we’re the 14th wealthiest, wealthier than the UK, France and Japan. Our public finances are in a strong position because we have generated more tax per head than the rest of the UK for each and every one of the past 33 years. Additionally, over the past five years, Scotland has generated 9.5% of UK taxes, yet only received back 9.3% of total UK spending.
“A ‘Yes’ vote puts Scotland’s future in Scotland’s hands by ensuring that we always get the governments we vote for. With independence, we’ll no longer be subjected to hated policies like the Poll Tax or Bedroom Tax and instead of mitigating the UK government’s austerity agenda, we can create an economic policy that always puts Scotland first.”
The rate of relative poverty in Scotland is climbing, despite its wealth. The median income in Scotland in 2012/13 was £23,000, equivalent to £440 per week. National statistics show that 820,000 individuals (16%) in Scotland were living in relative poverty (<60% of the average household income) in 2012/13, a rise of 110,000 from the year earlier.
Business as usual?
“Scotland is held back by the UK; after independence we’ll see a flourishing of Scottish business as the already strong Scotland brand is improved and used to market our goods and services around the world,” explained a ‘Business for Scotland’ spokesman.
“With a government closer to the people and, by necessity, having to listen to and act on the concerns of Scots and their businesses rather than the square mile of the City of London, we’ll have a business framework that can benefit Scottish businesses, allowing them to survive and then thrive.
“In addition, the current fetish for austerity being displayed by all of the main parties at Westminster is extremely damaging to society and to the economy and exchanging that dismal regime for a government looking to provide social and economic security and growth will benefit Scotland enormously.”
Economic and social policy controlled by Scotland for Scotland is understandably an attractive proposition, and indeed the Scottish government is set to receive more powers under the Scotland Act 2012. It is unclear, however, whether a break-up from the rest of the UK will generate a material benefit for Scotland long term.
TAKE HOME MESSAGE
An independent Scotland would help preserve the country’s national health service, avoid disruptive outsourcing and better address inequalities and healthcare challenges, say pro-independence NHS campaigners.
In the UK Government’s view, the UK is better off with Scotland in it, and Scotland is better off in the UK.
As part of the UK, Scotland receives a higher level of public spending than the UK average and that allows the country to tackle specific health issues in Scotland, argue ‘no’ supporters.
It is unclear whether a break-up from the rest of the UK will generate additional material benefit for Scotland long term.