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Does NHS Scotland need independence?

Posted on November 03, 2012 by

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.

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31 to “Does NHS Scotland need independence?”

  1. Juteman

    As you mentioned, it is all about ideologies, and the NHS is only one of the battlegrounds.
    Do we want money/market based policies, or people based policies. Make no mistake, this is a major part of what folk will be voting for in 2014. That needs to be made clear to the undecideds as the date nears.

  2. Marcia

    This article was touched on the inaugural meeting of  Yes Dundee. The former SNP MP for Dundee East, Gordon Wilson said that Scots should be very afraid if there is a NO vote as the budget for the Scottish Heath Service will face swinging cuts from the scrapping of the Barnett formula as Westminster will determine what can be spent on health not the Parliament in Edinburgh.

    Juteman as you missed last night’s meeting here is a very brief summary. The meeting organised by Yes Scotland had as I counted just short of 80 people there. Most of the crowd I had not seen before as this being a non-SNP organised event. A few Labour for Independence voters in the crowd, some SNP and many of no party. Blair Jenkins did a presentation on how he saw the campaign develop laced with hints on declarations of support coming our way from a variety of sources over the next two years. Then followed a question and answer session which brought up a lot of issues and topics. One questioner asked about getting Labour voters and members involved as many privately support Independence but fear a backlash. Alan Grogan happened to be in the audience and he was invited to the microphone to give his opinions.  The meeting was really held to get a local group up and running and this looks a positive move. The SNP have been running their own campaign in the city for a while now and it will be a case for this now be brought under the Yes Campaign umbrella.  

  3. Juteman

    Thanks Marcia. I intend to get involved, even if only letterboxing.

  4. mogabee

    Jackie Ballie has often claimed that the NHS in Scotland is dire, with various warnings of doom and gloom. But looking south the picture is of a rapidly crumbling system, letting down the very people who are in need.

       Of course we can complain and it is right to keep standards high, but I cannot believe that the wider public knows how bad it could get without this government protecting and shielding us.

    Juteman you are right that this is an important issue , needs wider access. I have heard some of my own family bemoaning the Independence debate as “not likely to happen…” I’ll not rest my case easily!!!

  5. douglas clark

    Rev Stu,
    Thanks for that article. Independence is as much about defending what we have at the moment as about change for the better. I am a huge fan of the NHS in Scotland  as it stands right now. To that extent, I am a conservative. I do not want to see it change for the worse, if anything I want to see it change for the better. My use of the words ‘worse’and ‘better’ should be seen as worse being equivalent to allowing the private sector any access at all, and better as removing this arguement from any disagreement whatsoever. Scots, Jackie Baillie apart, appear to understand that.
    We are in for a rough time over the next couple of years. Cuts in almost every Westminster budget, including the NHS, will impact quite severely on us. It is important that this SNP administration does two things:
    minimise the damage
    point out who is causing it.
    If they can do that, and it is harder than I have made it appear, then 2014 is a given.

  6. dadsarmy

    Good article sneekyboy. Yes, it’s blatantly obvious that in the event of a NO vote, the Barnett formula will be reduced to try to force Scotland to privatise our NHS as well. In fact I daresay a bit of creative accounting will be used to show that savings have been made to the English NHS budget, which won’t take into account the real cost of the real market-driven parts of it.

    It would be worth the YES campaign doing a projection of the parts of the block grant relating to our NHS, starting perhaps from 2010 or even earlier, updated through the next 2 years with real figures as they are known, and projecting up to say 2020 using the UK Government’s OWN PROJECTED FIGURES of savings they expect. We all know those savings won’t occur, the English NHS will in reality cost a lot more for less benefit, but the SG is fully entitled to use Westminster’s projected figures. Such a model, or graphs / bar-charts can then be assessed by independent sources, such as I hope will emerge over the next 2 years.

    Similar financial models can then be created for all our other currently devolved block grant funded institutions. My feeling is that the projected figures will be truly frightening, and prove the status quo is no such thing, but will be a downwards spiral.

  7. dadsarmy

    What will be needed is a truly easy side-by-side, well formatted and easy to see and understand, short comparison of now, what it will “probably” be with NO, and what it will “probably” be with YES. Probably just short comparisons, but with references to the detailed workings so the enthusiast can check out the workings, rather than just accept the conclusions.

  8. muttley79

    Good article Scott.  We have not really discussed the consequences of a No vote (well the politicians have not yet).  With the Tories seemingly happy to plough on with austerity it is an important message to get through to the electorate.

    O/t, was just having a look at WoS twitter page and I see that Jim Murphy is up to his old smearing tactics again.  Will the media ever pull him up on this as he always seems to be involved in this?

  9. scottish_skier

    Is this Scottish Labour backing trident?

    Would certainly tie in with the rightwards shift to adopting Ed’s one nation Tory neo-liberal agenda. 

  10. Arbroath 1320

    What’s that large swell of bubbling I see in the distance?
    Oh, nothing to worry about it’s just the good ship S.L.P. sinking below the waves.

  11. douglas clark

    Oops Scott!
    Wrong attribution up above. My apologies.

  12. Silverytay

    The Scottish Health Service is one of the areas where the yes campaign should be hammering home to the electorate what a no vote means .
    The majority of people at some point in their lives will take ill and all we have to do is show people what is happening to the n.h.s in England with privatisation and that only with Independence can we protect the Scottish Health Service .
    A no vote does not mean that everything will continue as before .
    A no vote will give westminster the green light to start dismantling everything that the Scottish electorate hold dear .

  13. muttley79


    Surely there has got to be a sizeable number of both Scottish Labour Party members and elected representatives who are privately angry at the continued march to the right?  I mean first we had the rejection of universalism by Lamont, and now the apparent support for nuclear weapons.  Is Lamont doing it because the SNP holds the opposite position or is it because she is being told what to do by Miliband? 

  14. douglas clark

    I completely agree with what you have to say. It is not, from the point of view of a Scottish voter, that a no vote protects what you have now. It is not. It is a vote for surrendering what you have now. I hope that this isn’t seen as too negative a message.

  15. douglas clark

    @ muttley 79,
    Good questions. I don’t think Labour stand against anything that their focus groups tell them there is a problem with. Unforunately these focus groups have an intrinsic bias, due to population share.  I, for one, find it increasingly difficult to wedge a cigarette paper between the policies of the  Labour Party and the Conservatives.
    One nation – check
    Privatisation – check
    Nuclear Weapons – check
    Bank Bail Out – check.
    There are probably many others.

  16. Morag

    I saw a programme on Channel 4 the other night, about stuff happening in England somewhere where the GP practice has been taken over by Richard Branson.  It was an absolute nightmare.  I mean, truly terrifying.

    I had no idea that sort of thing was happening in England.  I think of our lovely GP practice here where I can get help whenever I need it and the doctors seem to go out of their way to be kind and helpful.  And I don’t want to lose that.

    And yet the Unionists have the gall to list the NHS as one of the things that’s “British” that should unite us, as if they’re threatening we won’t have it if we vote for independence.  I fear that we’ll lose it if we don’t. 

  17. Silverytay

    Douglas Clark       I dont think that the message is too negative .
    What we have to get over to the Scottish electorate is that a no vote will force Scotland down a right wing path that is against Scotland,s values of social justice .
    A no vote will give westminster the authority to strip Scotland bare for even having the effrontery to dream of Independence .
    I know that Scottish-Skier and Weegie Warbler think that we will get another couple of bites at the cherry but I think that all 3 unionist parties at westminster will rush through some form of legislation making it illegal for Scotland to hold a referendum on Independence again . 

  18. Adrian B

    Q. Does NHS Scotland need Independence?

    A. It cannot survive without Independence. 

    All opposition parties in Scotland do not propose keeping things as they are and pretty soon they will start complaining that there is some holes in the Scottish NHS. They will not offer other spending options to plug the gaps.

    The Scottish Government will protect it as much as possible within the serious constraints that a reduced budget will allow  – expect the SNP to be blamed for not having an unlimited budget.  

  19. DougtheDug

    “…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.”
    Although all the unionists are promising jam tomorrow if Scotland votes no only the Scottish region of the Lib-Dems have come up with an idea of what that jam would look like. It’s worth a read even though it’s not been adopted as policy by the ruling Federal/English bit of the party.
    The red line in that report is that Scotland gets no more public funding or access to money making resources than any other region of the UK. This was the red line in Calman and it will be the red line in anything the Conservatives or the Labour party come up with in their jam tomorrow scenarios.
    Scotland in the union, in jam tomorrow unionist heaven or not, will always be tied to the social policies implemented in England through the block grant or top up block grant proposed for the Scottish Government. A no vote means Scotland will always get what England gets eventually as it will be enforced through the tying of Scotland’s funding to England’s expenditure. That red line is not going to go away.
    That’s something that has to be made plain. It doesn’t matter how clever someone like John Swinney is in cutting up the budget cake eventually everybody’s going to get a smaller and smaller bit if we remain with England and the cake itself gets smaller and smaller. Devolution cannot vault that funding hurdle and that is especially true of our NHS.

  20. muttley79


    I am not sure how Westminster could ban future referendums, would this not be a violation of the right to self-determination?  Would this not be a violation of this right under international law?  Anyway, it is not as if they can ban the SNP, who can then get a future mandate for a referendum from the Scottish electorate.  To be honest, if they even tried this the Scottish people would probably vote for independence in retaliation and out of spite. Westminster is distrusted enough according to opinion polls.  Look what happened to the Tories after 1979. 

  21. Boorach

    It’s not only the Scottish NHS need to worry about as a consequence of a no vote. Academy (privately run by amateurs) schools, police offices in supermarkets, etc, etc. perfidious Albion knows no bounds when it comes to the family baubles he is prepared to pawn in the name of free market capitalisation Caithness God Mammon!

  22. Boorach

    With apologies to Caithness. Should have checked the spell-checker ‘and the God Mammon’!

  23. Boorach

    Not to forget the number of businesses which would like to get their sticky little hands on Scottish Water

  24. Silverytay

    Muttley 79    If we are daft enough to vote no , you don’t honestly expect the unionists to let us carry on as normal .
    The whole history of this  corrupt union is littered with cases of the  establishment breaking international law when it comes to protecting their interests .
    I am sure you have heard of Willie McRae , Dr David Kelly and Hilda Murrell , If the establishment had a hand in their deaths , then they are not going to be too worried about bringing in a law to stop Scotland having a referendum on Independence in the foreseeable future .
    All they have to say is we voted no and there won’t be another vote for 50/100 years , take your pick , by that time they will have bled us dry and we will be no further use to them .

  25. mrbfaethedee

    Scottish Water – ‘what would you do with it?” is the question the needs to be asked of each of the three neolib unionist parties publicly and frequently.

    btw- great article!

  26. Arbroath 1320

    Sorry for being O/T but it would appear that good old Herman van Rompuy can’t keep his nose out of OUR business. Perhaps he should have a wee chat with Viviane Redding one of the European Commission’s Vice Presidents.

  27. Grendel

    I heard a rumour that my local MP Pamela Nash was calling for Scottish troops to be returned to Scotland for 2014 to boost the No vote. Can anyone confirm this/provide links?

  28. Cuphook

    @Arbroath 1320

    That video is from 2011 – though it doesn’t stop the Guardian from describing it as an ‘intervention’ in the current debate.

    And how about this article from the Independent – it’s like stepping into an alternative reality.

  29. Arbroath 1320

    You really have to wonder about the intelligence of these people Cuphook.
    On second thoughts do they actually have any intelligence to start with? 😆
    With all these “interventions” you really have to wonder about the thought processes, they do have these in the BBC and MSM don’t they?
    I can not believe that everyone who works for the BBC and MSM is taken in with all this drivel and misinformation. Surely a point is going to come when even the MORE level headed intelligent individuals are going to call it a day.

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