Wings Over Scotland

As the Scottish people ponder the merits of independence, it can be useful to examine areas in which Holyrood rather than Westminster already controls policy, and one of the most obvious is healthcare. The NHS is in almost all operational senses already independent in Scotland, and operates in a markedly different manner to the way the service is run in England and Wales.

But as we recently revealed, the Scottish NHS remains subject to hidden budget cuts as a result of the Barnett Formula, as well as the headline cuts imposed to Scotland’s block grant under Westminster austerity. The question, then, is whether this devolved form of “independence” is enough to maintain the standards of healthcare Scots have come to expect.

One significant cross-border difference is that primary and secondary care is integrated in Scotland, unlike in England where secondary services are commissioned by NHS primary care trusts. Indeed, NHS trusts don’t exist in Scotland, healthcare being provided through 14 regional health boards that are subdivided into Community Health Partnerships to provide local services more effectively.

One of the main criticisms of the healthcare reforms in England (the ideological objections to privatisation notwithstanding), is that by emphasising and promoting competition between providers, Westminster is derailing medical efforts in England to provide seamless, integrated services for their patients.

The emphasis on the marketisation of health to drive down costs through competition is fundamentally flawed, because in reality people don’t “shop around” before choosing which hospital to go to after a serious accident or health problem – they just want to get to a hospital, ANY hospital, fast. Likewise, people want a GP that’s convenient and easy to get to rather than a “competitor” on the other side of town.

Compounding the logical fallacy of marketisation thinking is the additional fact that those who are more likely to need long-term and difficult care are not likely to be in a position to travel to distant services and more likely to need what is on their doorstep (or for healthcare to come to them). The combination of these factors makes it unlikely that competition will drive down costs in a marketised NHS south of the border.

So what about the Scottish solution? The Scottish Parliament has adopted different strategies to get more out of the health budget for the public. For instance, in any healthcare system, a large proportion of costs are attributable to older patients with complex needs. Such people typically require an overlapping system of services covering primary care, secondary care, community care and social care.

In the English model this may create a great deal of duplication of patient records and information, patients may need to provide the same information multiple times, and medical checks and work may be repeated by each section in the chain. To further compound the waste and inefficiency, such a system means that patients may “fall through the gaps” as one service presumes that another service has undertaken a specific aspect of the patient’s care. In the worst-case scenario, instead of duplication you get a failure to deliver the required services to the patient at all.

The Scottish system attempts to address these points through integration of services, the best-known of which is the provision of free personal care to the elderly as a universal right, eliminating layers of bureaucracy as well as suffering caused by patients being reluctant to seek help for fear of cost or stigma.

Dr Peter Samuel is a lecturer in human resources management at Nottingham University Business School and undertook research into the Scottish NHS partnership agreements, with funding from the Economic and Social Research Council. His conclusions were very interesting, and worth quoting at length:

“In the wake of political devolution, as part of a determined campaign to engage staff in improving services, the NHS in Scotland set about developing partnership agreements at board and national level. This decision was in stark contrast to that of the NHS in England, which chose to augment its reliance on a market-based approach.

It was never the express intention of the study to compare NHS Scotland with NHS England. But it is worth reflecting on assessments south of the border.

In recent weeks alone the NHS in England has faced damaging criticism from the Care Quality Commission, the Health Service Ombudsman and the Patients’ Association, all of which have raised renewed concerns that nurses have become detached from patients or too busy. In addition, the Health Select Committee has branded the overhaul of the English NHS a “disruption and distraction” that is impacting on its capacity to make the savings necessary to safeguard its future.

Meanwhile, the picture that emerges of NHS Scotland is one of an organisation in which everyone benefits from an extraordinary collective agenda. In achieving this, all sides – government, employers and staff representatives – have striven to meet six key challenges: 

1) A shared aim

In one form or another, partnership agreements now cover nearly a third of all British public sector employees – almost 1.5m of them in the NHS. The basis of these arrangements is a shared commitment to high-quality patient care and the service’s founding principles. 

From this positive starting point, the unique circumstances of political devolution fostered a consensus over the future direction of the health service in Scotland. Unlike the market-based reforms pursued elsewhere, this provided a supportive context. 

2) Appropriate partnership structures

NHS Scotland’s partnership structure consists of the Scottish Partnership Forum (SPF), which debates the service’s strategic direction; the Scottish Workforce and Staff Governance Committee (SWAG), which develops workforce policies; and the Scottish Terms and Conditions Committee (STAC), which handles any outstanding negotiations. Smaller secretariats back all three. 

The separation of major issues from comparatively trivial concerns is essential. Big ticket items – health policy, corporate governance and finance issues – are addressed only by the SPF, whereas workforce planning, pay and conditions, health, safety and wellbeing, training and equality and staff surveys are more likely to be discussed by SWAG. 

3) Frequent partnership meetings

Up-front commitment is crucial to successful partnership. The time spent working together when first developing policies and the workforce practices to reinforce them cuts the time subsequently dedicated to negotiation and dealing with problems.  

4) Scope

Meetings of broad scope extend staff-side representatives’ involvement in a range of issues surpassing those usually covered by collective agreements. The absence of repetition also reduces the risk of a debilitating “we’ve heard it all before” mentality. 

5) Voice

Voice in partnership meetings brings together diverse views. Such an approach permits mutual interests to grow around a shared agenda and a joint commitment. 

6) Positive behaviour

Accepted negotiating behaviour is generally unsuited to partnership meetings, as it involves defending positions as opposed to listening constructively to others. All interactions have to be positive if a cooperative partnership climate is to flourish and endure, with an open and trustful approach to joint problem-solving and the proactive inclusion of others in conversations. 

NHS Scotland’s partnership agreements are the longest-established and most extensive of their kind in Britain. As such, they offer valuable evidence of the extent to which innovative industrial relations can contribute towards improving public service delivery. They unequivocally demonstrate that enhanced participation of employees and their representatives does not just constrain management unilateralism; it grants those employees and representatives a crucial say in the decisions that affect their working lives and, in this instance, the quality of healthcare provision across Scotland. 

Furthermore, there is every reason to conclude that the fostering of shared values, robust negotiation and consultation procedures and genuine staff involvement has left NHS Scotland well placed to cope with the realities of the ongoing squeeze on the public purse. On the other hand, the future for industrial relations in public sector organisations that pursue strictly market-based reforms at the expense of pluralist beliefs and values is likely to be at best stormy and at worst ruinous.”

The NHS in Scotland is far from perfect. But Dr Samuel’s analysis highlights the ways in which the principles of social democracy that still underpin much of the Scottish political landscape (although Scottish Labour is now showing signs of abandoning them in order to align with the neoliberal London party) can mould services to benefit the public, rather than the profit-seeking private sector.

These principles are under daily threat of being undermined by ideologically-driven actions south of the border even as the Scottish Government tries to uphold them. Gaining full economic independence from the UK would mean that the funding in place to NHS Scotland would be more stable and based on the needs of Scotland, rather than falling as a Barnett consequence of privatisation south of the border.

The systems and governing bodies of NHS Scotland are already wholly independent, so any move to national independence would have no negative effect in terms of creating or reorganising infrastructure – the only change would be in the security of the service’s budget.

(It would also safeguard the unique labour relations adopted by the Scottish Government, also highlighted by Dr Samuel in his report, in which he noted “The NHS in Scotland has developed the most ambitious labour-management partnership so far attempted in the UK public sector. More than that, it continues to make it work.”)

The NHS in Scotland is already functionally independent, and delivering palpable benefits in the form of services like free personal care and prescriptions. But its future can only be protected if the entire country goes the same way.