An independent Scotland?

IN November of 2013 the Scottish Government published its 670-page white paper setting out the case for an independent Scotland and kicking off what promises to be a bruising campaign in the run-up to the referendum in September of this year.

Summons asked the opposing camps in the debate to offer views on the implications of Scottish independence for health and social care. We posed three basic questions. Why would the health service be better (or not) under independence? Why should doctors and dentists vote for or against independence? What about cross-border working and professional regulation in an independent Scotland? Here are the replies.

"YES" By Dr Ian McKee on behalf of the Yes campaign

WHEN forecasting how the health service will develop in an independent Scotland there is an important caveat. The vote in September’s referendum will determine solely whether Scotland becomes an independent country – how the country develops thereafter will depend on the political nature of the government which will be elected two years later.

However, there are some useful clues. Since the responsibility for health was devolved in 1999, significant differences have emerged between the way that the NHS is run on different sides of the border. In England and Wales the patient is seen as a customer and health providers are encouraged to compete with each other for business. Within the last year there has been a huge expansion in the role of the private sector in healthcare and this is likely to continue.

In Scotland, on the other hand, patients are regarded more as partners. After all, as taxpayers they do own the service. Instead of competition the emphasis here is much more on collaboration – not only with fellow clinicians but also with the health department. The general view in Scotland seems to be that the time, effort and legal expenses incurred by would-be providers fighting each other would be far better spent directly on patient care. More recently the aim of a service free to all at time of need has been expanded to include free prescriptions. Unless the first government of an independent Scotland is unexpectedly right wing it seems reasonable to argue that these trends will continue.

The No campaign might argue that as this has all happened under devolution, there is no need for independence to develop further a health service sensitive to the particular needs of Scotland. This stance ignores two important points. The first is that the level of allocation of funds to Scotland under the Barnett Formula is under sustained attack from Westminster. It is a fair assumption that nothing has been done until now to alter this allocation because of the coming referendum. If there isn’t a Yes vote this reason will disappear and Scotland will face a large net reduction in income in coming years.

The second is that the Barnett Formula, or its successor, distributes funding according to public expenditure. As England massively increases funding for health and education from private sources, including patient charges and university tuition fees, the amount of public expenditure correspondingly decreases and with it Scotland’s share. Whether we like it or not we will be faced with the choice of having either a grossly under-funded health service or one in which rationing, patient charges and private healthcare rapidly come to the fore unless we take our future in our own hands and vote Yes next September.

In an independent Scotland doctors and dentists will be part of a health service in which professionals are expected to work together rather than against each other in competing provider units. This is far more rewarding and involves much less bureaucracy. Under European freedom of movement legislation doctors are free to cross borders and practise elsewhere so it would be foolish of any Scottish government to create working conditions which encouraged large scale medical emigration to England or elsewhere. There will always be scope for private practice for those who wish it but the driver must not be a failing public service. Both the GP and consultant contracts need to be altered to allow for the rural nature of much of Scotland and the health inequalities in our main cities. One size certainly does not fit all.

Institutions such as the Scottish Medicines Consortium and NICE already work amicably together and there is no reason why this level of co-operation should not continue and develop between these and other regulatory and professional bodies after independence. Of course it is just possible that a central regulatory body might promulgate a policy that is not suited to the needs of Scotland and in this case an independent Scottish Government is an additional safeguard.

• Dr Ian McKee is a former Member of the Scottish Parliament for the Lothians region. He was a partner in an Edinburgh medical practice and served in the RAF as a medical officer

"NO" By Dr Susan Bowie on behalf of Better Together

It is now under 9 months until we will make the biggest political decision of our lives: whether to remain a part of the UK or whether to go it alone. The question isn’t whether Scotland could be an independent country; it is a question about what is best for us, our colleagues, friends, our families and mostly our patients, the poor and the vulnerable.

In Scotland today we have the best of both worlds – a successful Scottish Parliament with full powers over our schools and our own NHS. We also have the strength and security that comes with being a part of something bigger.

As a doctor, I am really proud to be both part of and a product of the NHS. I was born only because of it, trained by it, worked for it for 35 years and have been saved by it. I take great exception to anyone or anything that might jeopardise it.

Although the NHS is a uniquely British institution, treasured by people across our islands, right from the start the NHS in Scotland has tailored its care to local needs. The year 2012 marked the centenary of the publication of the Report of the Highlands and Islands Medical Service Committee or the Dewar Report. The report presented a vivid description of the social landscape of the time and highlighted the desperate state of medical provision to the rural population in the Highlands and Islands. The report recommended setting up a new, centrally planned provision of care that within 20 years transformed medical services to the area and this acted as a working blueprint for the NHS in Scotland.

Indeed, the fact that Scotland has been able to make some radically different choices from England regarding healthcare has shown the great strength of diversity within the Union and devolution process. But being a part of a Union means we also have access to world class centres of excellence across the UK should we need them. When a patient from Aberdeen travels to the world-leading Freeman Hospital in Newcastle they receive the same quality care that they would if from Aberystwyth. In training we also have the best of all worlds – the flexibility to train anywhere from inner city London to rural Stornoway. What would happen to this mobility and flexibility in a separate Scotland?

What would independence mean for doctors in training? How would leaving the UK affect our relationship with the BMA, the GMC and our defence unions? At this stage with 9 months to go, does anyone really know?

Our NHS currently doesn’t recognise borders but separation could put that at risk. We would be replacing a straightforward, internal relationship with an international, cross-border one. Being part of a larger UK allows us to pool and share our resources for the benefit of all.

Pensions too are an example of where being part of the UK benefits us all. Right now, across the UK, we pay into the state pension and we all benefit on retirement. Given Scotland’s population is ageing faster than the rest of the UK, it makes much more sense to spread the costs associated with caring for an increasing elderly population across 60 million people rather than 5 million.

One of my biggest worries and that of colleagues I’ve spoken to is what will happen to our NHS pensions under independence. Having done all those years on-call I was pretty secure in the knowledge of a very decent NHS pension (even with the proposed changes). However, no one at this late stage can make any promises about what will happen to my pension in a separate Scotland – what I will be paid or even in what currency.

To vote for independence with all the uncertainty that brings would be a leap in the dark. Even after reading the Nationalist White Paper, I find there are just too many unanswered questions regarding health and social care. Today Scotland has the best of both worlds. Why put that at risk?

• Susan Bowie is a GP in Shetland with 35 years’ experience working in the NHS