The challenge when examining the potential impact of Scottish independence on health and social care is disentangling the policies of the Scottish National Party (SNP) from the likely effects of an independent nation. There are clear, established ideological differences between those of the SNP and those of both Labour and the Conservatives. The question is, how much of these ideological differences represent those of the individual parties and those of the beliefs of the people they represent?
As it stands just now, Scotland takes a more egalitarian approach to healthcare – the belief being that if you are unfortunate enough to suffer a health condition then you should not be ‘penalised’ for it. It is this general principal that has led to the divergence in healthcare policies – prescription charges, NHS staff pay and conditions, number of hospital beds, GP to patient ratios, etc.
Since devolution, we have had greater focus on the end-service user (i.e. the patient). Service-level funding has increased. This has led to more GPs, nurses, hospital doctors, and hospital beds per capita than the rest of the UK. This is having a tangible effect on the frontline. Scotland is outperforming England in A&E waits, overall waiting lists, and, in one of my most important measures of performance, time-to-treatment for cancer patients.
It is also having a tangible effect on the patient’s pocket. While there are no official figures on out-of-pocket expenses in Scotland, it is substantially lower than in the rest of the UK. Those in Scotland do not pay for prescriptions, NHS eye tests, dental assessments, or personal (social) care, though they pay more tax. In England most patients must incur a cost for each of these “NHS” services.
Effect of devolved health in the NHS: is it enough?
But these improvements are mainly based on the policies of the SNP. Of course, one can argue that such policies could not be implemented without the partial independence achieved through devolution, and, therefore, that this direction of healthcare is the direction an independent Scotland would likely take. I think that is a reasonable argument. During the last 30 years of devolution, Scotland has never voted for a political party that has tried to diminish the public ownership of healthcare. It seems highly unlikely that if Scotland achieved independence, it would then elect a more conservative government to power, at least in the short to medium term.
So, in this regard one would assume that Scottish independence would at the very least continue this trend toward strengthening the public healthcare system. It’s an important point. The values of the Scottish people toward healthcare are likely to be further amplified with Scottish Independence.
Isn’t health a devolved issue anyway? Sort of
It is true that Scotland is free to allocate whatever it likes out of the allowance given to it by the UK government, and it is free to implement most of its own health policies. However, the only route for Scotland to allocate more of its allowance to healthcare than the UK government is allocating to healthcare in England, is to either increase taxation or to take money away from other public services. It can neither borrow nor create its own money to invest in healthcare.
This was the case with the dramatic shift away from the UK policy of means testing the cost of personal, social care (such as help with washing, dressing, meals, etc.). The UK government policy, both Labour and Conservative, is that people should pay for their own social care if they have a net worth of over about £23,000. In Scotland, all personal care is free at the point of need. The principal being, that our elderly have paid more than enough in taxation already. While many consider this to be an essential policy difference and good for Scottish families, the reallocation of more funds to this social care meant that there was less money to invest in the NHS.
Covid should teach us the importance of self-determination in healthcare
Covid is an apt example of the limitations of devolution on healthcare. During Covid, the UK Government passed an emergency law that allowed the government to ‘create’ money to fund the Covid response – The Coronavirus Act 2020. Due to the lack of autonomy, the Scottish Government didn’t have the power to create money for the Covid response itself, it was also dependent on the UK Government’s decisions about how much funding should be invested in the Covid response. Additionally, issues like furlough were entirely determined by Westminster.
Considerably more far-reaching than the financial limitations of devolution on the Covid response, were the limitations caused by the lack of legal power the Scottish Government has to implement broad public health measures in response to an epidemic. The Scottish Government had no legal right (still has no legal right) to implement any broad, population-level infection control measures. It was, like all four UK nations, entirely dependent on the UK Government (i.e. Boris Johnson) to make decisions about what controls to put in place.
Infamously, the prevailing ideology in the UK Government at the time was that it would be better to let the infection spread and that the elderly were expendable. Scotland had no right to oppose such a decision.
It was not until the Coronavirus Act 2020 was passed in the UK’s House of Commons on 23 March that Scotland was given the powers (temporary and specific to Covid) to implement its own national interventions to control the spread of Covid. Nicola Sturgeon, the First Minister of Scotland at the time, implemented national restrictions on the same day – 23 March 2020. Sadly, these powers came too late and the window to significantly reduce the spread of the infection until vaccines were produced was missed. The health, personal, and economic impact of this delay was substantive and continues to be felt.
This example underlines the terminal limitations of devolution. Ultimately, Scotland must succumb to the decisions of the UK Government, and ultimately, the UK Prime Minister, whoever that might be. It is this critical limitation on the right to self-determination that suggests that an independent Scotland could have significant ramifications for the health of the Scottish people.
How would independence avoid the shortfall in NHS funding?
Borrowing. Unlike the UK Government, the Scottish Government cannot borrow to invest in public services or infrastructure, even during a time of acute need. Most experts agree that in order to get healthcare back on track in the UK we must front load investment in the NHS. That is, we must substantially increase funding over the next three to five years, followed by only modest increases thereafter. This requires borrowing or some form of quantitative easing. Neither of which Scotland has the power to do. Without the power to borrow (or create money centrally), the level of investment Scotland can make in its healthcare remains at the will of the UK Government.
It seems that the UK Government is more focused on creating an industry out of the UK population’s healthcare needs, already privatising much of the NHS. Meanwhile, the Scottish Government has, to date, doubled down on the central premise of the NHS: a universal, tax-funded, healthcare system that is free at the point of need. The UK Government seems set on investing in opportunities for private companies to take advantage of public health, whereas the Scottish Government is focused on investing in the health of the public. An independent Scotland would only, can only, facilitate such a goal.
Perhaps the discussion would be different if Labour were the Labour who founded the NHS. Perhaps we could hold out hope that a Labour-led UK Government would find its healthcare priorities matching that of the Scottish people a bit more. And while Labour have instigated some policies to suggest this may be the case – improved funding, community focused healthcare and NHS management reform – it continues to prop up private healthcare providers in England, shockingly, with UK taxpayers’ money.
Compounding this is the surge in support for far-right politics in England. It seems that blaming immigrants is more important down south than providing health and social care to the public. As it stands, many opinion polls give Reform and Conservatives almost 50% of the public vote, despite both parties being quite explicit with their disdain for publicly funded healthcare.
With both parties looking to monetise the healthcare needs of the population, together with a self-harming immigration policy, the goals of the Scottish people could not be more different than the goals of these popular political parties. While Scotland looks to a proactive immigration policy – actively recruiting health and social care staff from abroad – together with the massive boost to NHS staff recruitment joining the EU would bring, the UK Government looks set to make the UK even less appealing for these essential foreign skilled workers.
UK politics are not aligned with the views of Scottish people
The more recent rise of the Green Party could change the discussion. The Greens have policies very similar to those of the SNP and will assuredly protect the public ownership of the NHS and almost certainly invest more in it. Nonetheless, the oscillating landscape of UK politics doesn’t seem to represent the consistent view of the Scottish people.
Already, England has privatised much of the NHS. Indeed, my colleagues down south consider that NHS England is too far gone to bring it back under public ownership. Certainly, with the direction of UK politics, such an opinion seems warranted.
Whereas ten years ago the question would simply be, would the NHS be better if Scotland achieved independence, the question is now, will the NHS in Scotland even survive without independence? As I say, were we discussing the difference between Labour (even Blair’s New Labour) and Scottish Independence, the conversation would be different. Independence may still have been better for Scottish healthcare under such circumstances, but the debate would be more open. With the shift in England’s politics and the clear evidence of ongoing priorities to privatise more parts of the NHS, the conversation is now about whether remaining part of the Union is worth sacrificing the NHS, at least as we have come to know it.
Scottish healthcare: better in an independent Scotland or in the Union?
Let me put it another way. Is it possible that if Scotland achieved independence, healthcare in Scotland would substantially improve? Yes. In all likelihood, the Scottish Government would create a package of investment involving borrowing and the creation of new money. It would likely aim to match the healthcare funding average of the EU14 countries. A boost of around 20% per person. Given the goals remain about public healthcare expenditure, such a boost in growth for the NHS would make substantial improvements to healthcare access and delivery.
But what about asking the question the other way round: is it possible to substantially improve healthcare provision in Scotland while remaining part of the Union? I can’t see a path to it. Yes, it is likely that the Scottish government will be able to fend off the cuts to the NHS and the privatisation of much of it through the powers of devolution. But it seems inconceivable that the NHS will substantially improve from what it is just now if Scotland remains tied to the priorities of Westminster.
With limited powers to invest in the NHS and many competing priorities, the Scottish Government (and the people), in the absence of Scottish independence, may have to make do with a decent-but-not-excellent healthcare system.
More on health.
