Wings Over Scotland

This last week has seen the publication of a report that saw the NHS in Scotland deliver its “best performance ever”. The NHS Scotland Chief Executive’s Annual Report 2010/11 was full of praise for the organisation and the efforts it has made to improve safety, service and value in times of dwindling budgets.

“Few issues are as important to us as our health and the quality of the health services we receive. When we come into contact with the health service, we want to know that we are receiving the best possible care – care that is compassionate and safe, delivered by the most competent practitioners and planned with us at the very heart of the decisions about our care. We want to have confidence in the quality and effectiveness of any treatment.

“Some of the most significant improvements in quality include the achievement of the shortest ever waiting times for outpatient and inpatient appointments, including progress towards achieving a maximum wait of 18 weeks between referral and treatment, significant reductions in Healthcare Associated Infection to the lowest levels ever recorded and other measurable improvements in safety in hospitals.

There have been impressive increases in the numbers of people accessing smoking cessation and alcohol brief intervention services, increases in the proportion of older people being supported to stay at home through improvements in services for those with long term conditions, and reductions in the need for people to stay overnight in hospital for treatment or procedures.”

The findings were reported in the national news in a generally positive manner, such as this BBC article published on the 24th of November, detailing the efforts of the management and staff in Scotland and the results they’d managed to achieve.

Fast-forward 48 hours, though, and the story began to be altered from the positive findings of the report to something more sinister. It began with the exposé by the BBC titled “Secret Scottish NHS incident reports released”, which made the alarming claim that research suggests about one in ten hospital admissions result in an “adverse event”.  The article was also an advertisement for a BBC Scotland programme by the name of “How Safe Is Your Hospital?”, a program which implied that falsification of records and breaches of standards were rampant, with the clear implication that the NHS was a failing institution.

(A cynic might point out that the programme was made before the positive findings of the report were published, and that without some negative press beforehand the programme would have looked quite odd and contradictory to the official findings of the report, therefore it was in the BBC’s interest to discredit the report to add credence to their own programme’s findings.)

The report wasn’t one the government in Westminster particularly wanted to hear, as it conflicts with the consensus of the three Westminster parties that privatisation of health services is the best way to deliver improvements for the public, and one which won’t deflect them from that ideology. But in Scotland there’s still a chance that the NHS could survive as originally intended. After all, the birth of universal health care in Scotland goes back much further than the creation of the NHS.

The NHS in Scotland was set up in 1948 after World War 2 by the National Health Service (Scotland) Act 1947 – NOT by the National Health Service Act 1946 which set up the English and Welsh NHS and the Northern Irish HSCNI. Most people aren’t aware of this fact, which indicates that from its very first day the Scottish NHS has always been independent from the services in the rest of the UK.

Though the title ‘National Health Service’ implies one UK-wide body, the (England & Wales) NHS and the HSCNI were originally accountable to the Secretary of State for Health, and the separate NHS Scotland to the Secretary of State for Scotland.

(After devolution the Scottish Government and the Welsh and Northern Irish Assemblies took over running their respective services).

“The four systems are entirely independent, and operate under different management, rules, and political authority.”

Scotland, in fact, has a far longer history with national health care than people give it credit for. In 1913, in a time of (relative) national prosperity before the deprivations and suffering of WW1, a state healthcare system was set up in Scotland. Known as the ‘Highlands and Islands Medical Service’ and run directly from Edinburgh, it provided state-funded health care to half of Scotland’s landmass and was based around Scotland’s distinctive medical traditions (centred on medical schools rather than private practices). By the time of WW2 it had a detailed plan for the future of health provision in Scotland, detailed in the Cathcart report of 1936.

The benefits of state-sponsored healthcare were already self-evident to the Scottish people more than 35 years before Nye Bevan made his courageous moves to set up the two NHS institutions. Though treatment was not free at the point of access, fees were set at minimal levels and people could still get treated even if they were unable to pay. The service came into being as a direct result of the publication of the Report of the Highlands and Islands Medical Service Committee in 1912. This report exposed inadequate medical and nursing services across large parts of the crofting counties and recommended a new way of delivering state-funded medical services.

Doctors would be guaranteed a minimum salary and cost of travel would be reimbursed. In return they would be expected to visit all those requesting help, be involved in public health and school work, attend midwifery cases and provide themselves with adequate transport. The service provided state support to hospitals and specialists and allowed the purchase of ambulances. It also achieved an expansion of nursing services with associated nursing accommodation. To achieve this, the founders applied for, and were granted, an annual Treasury grant of £42,000 (A modest £13.7 million in today’s money).

In 1919 administration moved to the Scottish Board of Health, and in due course the service was seen to be having the desired effect of providing adequate medical services to the population and supporting doctors to live and work in the area. Eventually other aspects of the service were developed, including support for specialist surgeons and physicians, a laboratory in Inverness and even the first air-ambulance service to the outer isles in 1936.

Edward Cathcart was Professor of Physiology at Glasgow University and had earlier studied in St Petersburg under the Nobel Prize winner Pavlov (best known for his studies of dogs). In June 1933 Cathcart was chosen to lead a commission set up by Sir Godfrey Collins, Secretary of State for Scotland:

“To review the existing health services of Scotland in the light of modern conditions and knowledge, and to make recommendations on any changes in policy and organisation that may be considered necessary for the promotion of efficiency and economy.”

Within the report Cathcart covered the massive improvements in health and life expectancy from existing services, as well as looking at the appalling deprivation that remained in industrialised Scotland. At the time many families were still condemned to huddling together in one and two-roomed tenement slums that had seriously detrimental effects on health and social wellbeing.

Cathcart described a “vicious circle in which poverty begets disease and disease begets poverty” and explained his theory that housing, sanitation and environment were more important to health than standard medical interventions. The answer to health problems was to invest in resources to make good health and well being an everyday occurrence:

“Health education should be placed in the forefront of national health policy. It should aim at producing a people who are balanced physically and mentally who enjoy health and take it largely for granted because, by education and training, their outlook and habits are healthy.”

This provided a broad consensus within Scotland on the route to achieving universal healthcare – a blueprint that was lacking in the rest of the UK – and meant that the idea of a Scottish National Health Service was widely supported, with objectives and systems generally planned out in advance. But it was not within the power of the Scots to create universal health care funded by the state.

WW2, though, saw a change in public attitudes, and in response to the spirit of the time a report was commissioned into the social provisions of the state. On 10 June 1941 Arthur Greenwood, the Labour MP and Minister without Portfolio, announced the creation of an inter-departmental committee which would carry out a survey of Britain’s social insurance and allied services:

“To undertake, with special reference to the inter-relation of the schemes, a survey of the existing national schemes of social insurance and allied services, including workmen’s compensation, and to make recommendations.”

The Report of the ‘Inter-Departmental Committee on Social Insurance and Allied Services’ became known commonly as the ‘Beveridge Report’ and was influential in the founding of the Welfare State. One of the members of the committee was a Miss Muriel Ritson (CBE) of the Department of Health for Scotland. Miss Ritson provided extensive input into the committee and brought with her some unique references, not least that she had previously been an administrator for the Highlands and Islands Medical Service.

Beveridge identified five “Giant Evils” in society – squalor, ignorance, want, idleness and disease – before going on to propose addressing them with widespread reform to the system of social welfare. This was extremely popular with the public and led to the Labour Party adopting the Beveridge proposals as party policy.

After Labour’s victory in the 1945 general election Aneurin Bevan, then Minister of Health, spearheaded the establishment of the National Health Service with the aim of ensuring medical care free at point-of-need to all Britons. The combined policies from the Beveridge report were implemented by Labour and became known as the Welfare State.

The 1947 NHS (Scotland) Act provided a uniform national structure for services which had previously been provided by a combination of the Highlands and Islands Medical Service, local government, charities and private organisations, which in general was only free for emergency use and part-subsidised elsewhere. The new system was funded from central taxation and was universally free at the point of use. Existing medical conditions were tackled and vaccinations carried out as a matter of general public health requirements; prescription charges were a later introduction in 1951, and led to the resignation of Aneurin Bevan from the government.

NHS Scotland still remains an independent body from the other public health systems in the UK, although this is often not realised by the public and patients, especially when “cross-border” or emergency care is involved, due to the high level of co-operation and co-ordination that exists between the two services. But healthcare policy and funding is the responsibility of the Scottish Government’s Health and Wellbeing Directorate, with the current Cabinet Secretary being Alex Neil of the SNP, to whom NHS Scotland is accountable. The system already operates wholly independently from Westminster interference, except for NHS pensions.

So if the Scottish NHS is already independent from Westminster, why does it need independence to save it? Because as we’ve previously noted, the money the Scottish Government gets from Westminster is a direct proportion of the money spent on services in England.

The systematic privatisation of services, cuts to funding and promotion of public payment south of the border is set to have far-reaching effects on the Barnett Formula funding allocated to Scotland, since the Scottish block grant is based on a proportion of the spending by the Westminster government in England. If spending in England goes down, the Scottish block grant does too. Under the coalition’s austerity drive, spending south of the border is being severely curtailed and this is set to continue for at least the next eight years, causing the Scottish block grant to be reduced and threatening the viability of funding the NHS north of the border.

This funding issue was picked up on by the Institute of Healthcare Management (Scotland) in a report called “Getting Into Shape: an IHM Scotland policy analysis”. The report was, according to the IHM,

“written in the context of the real terms cut in funding that the NHS in Scotland is about to experience, following the cuts made to Scottish public spending by the Westminster government.” 

The cuts are the result of the Westminster plan to save £20 billion from the NHS through the use of privatisation, a figure that would see a £2 billion reduction from healthcare consequentials in the Scottish block grant. Given that in Scotland’s latest 2010-2011 GERS accounts health spending was £10.9 billion, that would represent an 18.1% decrease in healthcare funding if Scotland remains part of the UK, making it extremely difficult to maintain flagship policies like free prescriptions.

The tragedy of today’s world is that Beveridge’s five “Giant Evils” remain with us. Their names have been sanitised – we now refer not to “squalor, ignorance, want, idleness and disease” but to inadequate housing, poor education, poverty, joblessness and ill-health – but the issues themselves are the same. Despite the giant strides made in the nation’s wellbeing in the last 60 years, just like Edward Cathcart did in 1936 we still see in too many places a “vicious circle in which poverty begets disease and disease begets poverty”. The job of the NHS is not yet complete.

Westminster cuts threaten the very concept of universal healthcare based on need rather than ability to pay, even in the independent Scottish NHS. There is, somewhat ironically, only one way to protect the funding – and therefore the survival – of what is often presented as one of the crowning achievements of the Union, and that is to bring that Union to an end.