Scotland's Future and Scotland's Health

SCOTLAND'S FUTURE AND SCOTLAND'S HEALTH

Alex Neil MSP
Cabinet Secretary for Health and Wellbeing

Scotland's Future - Your Guide to an Independent Scotland sets out the case for independence and outlines the journey following a vote for independence on September 18th 2014.

This extract underlines our commitment to the NHS as a publicly-owned and operated service, free at the point of need. The NHS has touched every life in Scotland, it is a precious institution, right at the heart of our society.

In the community, in hospitals and in clinics the staff of the NHS are working to heal the sick and keep Scotland well. They are the beating heart of that precious institution that is so dear to the people of Scotland.

There is a stark contrast between Scottish Government's approach to the NHS, as a publicly owned and operated service, and that of the UK Government whose privatisation agenda in England is growing ever more pronounced and damaging.

Devolution has shown that where Scotland has the power to do so we've taken better decisions for the people of Scotland. For example, that's why in Scotland prescriptions are free, but prescription charges remain in England under the UK Government.

While devolution has allowed us to protect Scotland's health services from the destructive policies of Westminster, as long as Scotland's finances are tied to those Westminster decisions then every cut made to services through privatisation in England has a direct impact on the budget available to the Scottish Government.

The only way we can continue to protect Scotland's NHS in the future is to put Scotland's resources in Scotland's hands, and only independence will deliver that.

With independence we can protect Scotland's NHS, to keep serving the needs of patients in Scotland for generations to come.

Scotland's Future - Your Guide to an Independent Scotland is available to view online at www.scotreferendum.com

Scotland's Future - Your Guide to an Independent Scotland

CHAPTER 4: Health, Wellbeing and Social Protection

Health, social care and the NHS (pages 170-176)

Why we need a new approach

The provision of health and social care services is one of the major responsibilities of the Scottish Parliament and Government. Since 1999, successive Scottish governments have made steady improvements to Scotland's health and the quality of healthcare, while protecting the NHS as a free, truly public service, consistent with the values of the NHS and the priorities of people in Scotland.

Responsibility for the health service in Scotland has allowed us to show what can be achieved with the full powers of independence. Scotland has taken a very different approach to health and social care from that taken by Westminster governments over the years. We have maintained a commitment to the NHS as a public service and, in delivering free personal care, we have demonstrated that Scotland can provide support for older people in a way that looks after them, maintains their dignity, and respects the contribution they have made to society.

Without devolution, NHS Scotland - like its counterpart in England - would have been repeatedly re-organised by the Westminster Government of the day, regardless of the needs of the health service in Scotland. It would now be exposed to private competition and an unfair system of social care. We would be experiencing today the consequences of Westminster decisions on our health service in the same way as we are seeing the impact of Westminster's welfare choices on our most vulnerable fellow citizens.

Under devolution, NHS Scotland has been reshaped and modernised - but to reflect our requirements and the opportunities for a health service in a country the size of Scotland. Currently this Government and our partners in health boards and local authorities are taking radical steps to join up health and social care, ensuring that organisational barriers do not prevent people receiving the care they need in the setting they prefer, for example, at home.

With independence we can address directly inequalities in Scotland, which are the root cause of many of the country's remaining health issues. If in government after the 2016 election, we will adopt a government-wide approach to the health and wellbeing of our nation with confidence that the actions we take, and their success, will be down to our own efforts and our own decisions. The alternative is for Westminster to continue to control the overall level of Scotland's budget, and to make decisions that directly affect poverty and wellbeing through the tax and benefits systems.

In an independent Scotland, we will continue to provide high-quality, world-leading health and social care to the Scottish people in a way that reflects the founding principles of the NHS and our social care services. Independence will not affect the day-to-day management of the NHS in Scotland or how people access NHS services. However, it has the potential to transform the environment within which our NHS operates. Similarly, it will not mean ending current cross-border arrangements with health services in the rest of the UK, which have continued even though the NHS in Scotland already operates independently.

The choices open to us

With independence, we can build on the gains of devolution for our health and social care services to enhance the health and wellbeing of people across society.

Since the Scottish Parliament was established in 1999, we have had full operational responsibility for the National Health Service in Scotland, and for health and social care policy. Scotland has chosen a different way forward for our NHS compared to successive Westminster Governments. There is no competition, or internal market, in Scotland. GPs refer patients to a treatment centre within their own health board area, and they will be referred elsewhere if the required service is not provided locally. One of the strengths of the integrated model in Scotland is greater consistency of approach and clear responsibility for NHS Boards to deliver safe, effective and person-centred services, for which they are held to account through annual accountability reviews, held in public.

Successive Scottish governments have ruled out the disruptive and costly structural reforms and upheaval that have taken place in NHS England. Avoiding these multiple and costly reorganisations, and privatisation, has allowed us to focus on improving safety and quality of care.

The Scottish Parliament has used its responsibilities to introduce free personal care and protect the National Health Service. Major achievements of the health and care services in Scotland under devolution, which we can build on with independence, include:

• introduction of the smoking ban in public places
• our world-leading patient safety programme with major reductions in levels of hospital healthcare associated infections (a programme which has been endorsed by Don Berwick, adviser on healthcare issues to Barack Obama)
• significant reductions in premature mortality from cancer, heart disease and stroke
• reduced waiting times and delayed discharge from hospital
• the removal of prescription charges and introduction of free eye tests
• the highest level of dementia diagnosis in the UK
• a focus on the importance of the early years as a foundation for long term health and wellbeing through initiatives such as Family Nurse Partnership and the Early Years Collaborative
• protection of the frontline NHS budget
• a single vision for sustainable quality across health and social care services
• agreement to the integration of adult health and social care services
• unique workforce partnership arrangements

Our priorities for action

This Scottish Government plans to continue with current arrangements for the management of the NHS in Scotland, focussing on sustainable quality and for the integration of adult health and social care services. Services will be accessed in the same way as under the devolution settlement.

Despite efforts to address the challenge of health inequalities in Scotland over recent years, health inequalities persist and demonstrate that the "fundamental causes" of health inequalities - the socio-economic inequalities in society - are the most important.

Recent research shows the strong correlation between poor health and poverty^[211]. It suggests that the reason for Britain's high health inequalities is the failure of successive Westminster governments to choose to reduce inequality.

Independence will also allow us to do more to tackle major causes of ill-health, which disproportionately affect poorer communities. In March 2006, Scotland was the first country in the UK to enact a ban on smoking in public places. This has resulted in a dramatic reduction in smoking related diseases^[212]. We have also led the way in developing ambitious proposals to tackle harmful drinking by legislating for a minimum unit price for alcohol.

We have maintained our commitment to strong action to tackle smoking and alcohol misuse with all the powers available to us. In contrast, the Westminster Government has chosen to put on hold proposals for plain packaging for cigarettes, and abandon plans for minimum pricing for alcohol.

With independence, we will have greater scope and clearer powers to regulate alcohol and tobacco, including through taxation - reducing the opportunities for legal challenge which have held up several of our initiatives to date.

We are already taking a distinctive approach to food standards^[213]. Independence will allow this to be linked to tax policy and advertising regulation - allowing a coherent and concerted approach to issues of obesity and poor diet, which disproportionately affect poorer communities.

A major advantage of independence for health and wellbeing in Scotland is therefore to have the ability to use the full range of levers to promote good health. It is matched by the opportunity to grow Scotland's economy for the benefit of all and address inequalities in Scottish society that have not been, and will not be, addressed under Westminster.

After independence, Scotland will maintain a very strong relationship with the other countries of the UK. Scotland will continue to work with other parts of the UK to provide services where this provides access to the highest quality of care and delivers the best outcomes. There are already effective cross-border working arrangements in place, which will provide a strong foundation for continued co-operation, just as there is with Ireland. Partnership arrangements are also in place with a number of European countries, including, for example, Sweden.

Services provided for patients outwith Scotland include highly specialised care for people with rare diseases or conditions, and certain types of transplantation. The rare cases of transplants being conducted outwith Scotland are for lung, small bowel and paediatric transplants. Because there is a relatively small number of these procedures, contracting these services from clinical specialists offers the best health outcomes for Scotland's patients. These arrangements will continue exactly as they are at present after independence.

On independence, Scotland will continue the current arrangements for organ donation across the UK, maintaining one donor register and sharing donated organs. This will ensure that all organs are placed with the best matched patient. The Irish Health Service Executive also co-operates on organ transplantation with NHS Blood and Transplant (NHSBT), who co-ordinate transplant services across the UK. This reflects international best practice in transplantation where groups of countries work together, for example Eurotransplant in mainland Europe (Austria, Belgium, Croatia, Germany, Luxembourg, Netherlands and Slovenia), and Scandiatransplant in the Scandinavian countries (Denmark, Finland, Iceland, Norway and Sweden).

Arrangements for reviewing NHS pay are already devolved but NHS Scotland currently operates within UK structures and modifies UK agreements to reflect Scottish circumstances where necessary. With independence, we will review the machinery for pay determination in partnership, including the potential for improvement across the wider Scottish public sector. The Scottish Government has developed a Scottish GP contract in partnership with the BMA, and with independence we will continue to work with them, and all relevant partners, to ensure that GP contracts are developed to meet the needs and circumstances of the people of Scotland. Similarly, for hospital based doctors and dentists, the Scottish Government will work with all relevant partners in Scotland, and seek to co-operate with Westminster where appropriate, to negotiate pay, terms and conditions.

Scotland is already responsible for the regulation of some health professions - those who came to be regulated after the establishment of the Scottish Parliament. After independence, we will become responsible for all regulation. We will seek to co-operate with Westminster, and the devolved administrations, to ensure that health professional regulation is maintained in the best interests of patient safety and the consistent treatment of healthcare professionals. We will also maintain the existing professional healthcare regulatory bodies, which are funded by fees from registrants, and will continue to operate in Scotland after independence.

Scotland's Future - Your Guide to an Independent Scotland

PART 5: Questions and Answers, Health, Wellbeing and Social Protection

Health and Social Care (pages 437 - 442)

196. What will happen to the NHS in an independent Scotland?
The NHS is already the responsibility of the Scottish Parliament. The process of becoming independent will not change the way you receive your health care. You'll still be able to visit your GP and local hospital as now.

NHS Scotland already operates independently in Scotland. NHS Scotland has been the responsibility of the Scottish Parliament since devolution in 1999.

The Scottish Government's vision for the NHS in Scotland is to maintain our publicly owned, publicly funded health service providing care free at the point of delivery.

197. Will the NHS be safe from privatisation?
Yes. Scotland has taken a very different approach from that in England. The Scottish Government has categorically ruled out the disruptive and costly structural reforms happening in NHS England. Avoiding the privatisation of services seen south of the border has allowed us to focus on improving safety and quality of care.

198. Will an independent Scotland maintain the current number of doctors and nurses in the NHS?
In Scotland's NHS, staffing decisions are made by Health Boards in line with their own local needs and circumstances. This will continue to be the case on independence. Under the current Scottish Government, NHS staffing has increased by 5 per cent overall and by 1.5 per cent in the last year. There are now over 1,000 extra qualified nurses and midwives and over 1,500 more doctors working in our health service.

199. What will be the impact of constitutional reform on funding for medical research in Scotland?
Medical research is a Scottish strength.

Scottish researchers win a disproportionate share of the Medical Research Council (MRC) and National Institute of Health Research (NIHR) funds for which researchers based in Scotland can apply. For example, in 2011/12, with a population share of 8.4 per cent, researchers in Scotland won 9.8 per cent of the total funds awarded by the MRC and won 14.6 per cent of the total funds awarded through the NIHR funding streams open to them.

There are clear benefits, for the whole medical research community in these islands, from Scotland remaining within a research funding system with the rest of the UK. An independent Scotland, contributing directly to the overall research council budget, will be in a strong position to influence research priority setting at a UK level.

Levels of public investment in university research will enable our researchers and universities to remain internationally competitive, with current levels of public investment in university research, through the Scottish Funding Council and Research Councils, at least maintained.

200. How will independence affect the length of NHS waiting lists in Scotland?
As NHS Scotland is already under the control of the Scottish Parliament, its values and priorities will continue on independence. However, with independence, the Scottish budget will no longer be constrained by decisions made at Westminster, and will therefore reflect Scottish priorities.

Our approach to transforming waiting times for patients is an example of how better results are achieved for the people of Scotland when decisions are made in Scotland. As part of the Patient Rights (Scotland) Act 2011, the Scottish Government introduced the 12 week Treatment Time Guarantee for inpatients and day cases which enshrines in law a patient's right to be treated within 12 weeks. By March 2013, 97.5 per cent of patients waited less than the 12 week standard for a first outpatient consultation. This compares with waits of six months in March 2007.

201. Will an independent Scotland still have free prescriptions?
Yes. The move to independence will not change the benefits we currently enjoy. Decisions on things like free prescriptions will form part of the policies set out by parties in their manifestos for future Scottish parliamentary elections, with the political parties each offering their own approach, just as now. The current Scottish Government's vision for the NHS in Scotland is a publicly funded health service providing care free at the point of delivery for all who need it. This includes free prescriptions.

202. What will happen to free personal care in an independent Scotland?
We have no plans to change the successful policy of Free Personal and Nursing Care in an independent Scotland. This distinctively Scottish approach is an example of how decisions made in Scotland provide better outcomes for the people of Scotland.

203. Will an independent Scotland have to put in place new arrangements for medical training and education?
No. Scotland already has five medical schools, which continue to attract high numbers of undergraduates from across Scotland and England, Wales and Northern Ireland, as well as students from overseas, who want to study medicine.

Medical education operates in a world-wide market, and Scotland continues to enjoy a well-earned reputation for providing trainee doctors with high quality training and development opportunities. Given these strengths, we see co-operation on medical training continuing on the same four-country basis as today.

204. Will medical workforce representatives participate in NHS Scotland pay negotiation processes after independence?
Yes. Responsibility for pay, terms and conditions of service for staff in NHS Scotland is already devolved.

The Scottish Government will ensure that they continue to have independent pay advice when setting pay for NHS Scotland doctors and dentists.

In recent years the Scottish Government has successfully developed a Scottish GP contract with the British Medical Association (BMA), and with independence we will continue to work with them to ensure that GP contracts are developed to meet the needs and circumstances of the people of Scotland.

Similarly, for hospital-based doctors and dentists, the Scottish Government will work with the BMA, and seek to co-operate with the Westminster Government where appropriate, to negotiate pay, terms and conditions.

The funding and terms and conditions for General Dental Services, General Ophthalmic Services and Community Pharmacy are already devolved and fully negotiated in Scotland. These arrangements will also not change.

205. Will Scotland continue to access services from NICE (National Institute for Clinical Excellence)?
In Scotland, NHS Healthcare Improvement Scotland provides a similar function to that provided by NICE in England and Wales. The Scottish Medicines Consortium already delivers the functions of NICE in Scotland in relation to access to new medicines and will continue to do so.

The Scottish Government currently purchases some services from NICE via a Service Level Agreement negotiated and operated by Healthcare Improvement Scotland. This arrangement too could continue in an independent Scotland.

206. How will an independent Scotland agree the price of medicines with the pharmaceutical industry?
The UK Department of Health currently agrees the pricing of medicines on a UK-wide basis given that this is currently a reserved area. Negotiations on new pricing arrangements from 1 January 2014 have been agreed between the Department of Health and the Association of British Pharmaceutical Industry (ABPI). The agreement will run for a five year period in line with previous agreements.

Independence will provide the Scottish Government with an opportunity to negotiate its own pricing arrangements directly and in partnership with the pharmaceutical industry with a view to securing the best possible deal for both NHS Scotland and Scottish patients.

207. What will happen to blood donor services in an independent Scotland?
Scotland already has a fully independent blood donor service. NHS Blood and Transplant (NHSBT) has in place a reciprocal agreement with the Scottish National Blood Transfusion Service (SNBTS) and the other UK Blood Services to provide mutual assistance in the event of a blood shortage or unplanned event that affects their ability to supply hospitals. Following independence, this Government proposes to continue this reciprocal arrangement.

208. How will an independent Scotland organise organ donation and transplantation services?
Organ donation and transplant activity across the UK is co-ordinated by NHS Blood and Transplant (NHSBT) which operates in Scotland under a contractual arrangement with the Scottish Government. The Scottish Government contributes to the running costs of NHSBT and the organisation is accountable to Scottish Ministers for the organ donation and transplantation activities it undertakes in Scotland.

Donations and transplantations are organised jointly across the UK as it is in the best interests of patients to ensure that organs have the best match to recipients. We will be able to continue these arrangements following independence, in much the same way that the Health Service Executive of the Republic of Ireland currently works with NHSBT on transplants. This is the same as other parts of Europe where groups of countries work together across borders to achieve the best outcomes for their patients.

209. Will I still be able to get specialist treatment in England?
Yes. The NHS in Scotland already co-operates with England, as well as with other countries for some services, to provide a range of specialised services not routinely available in Scotland. Access to a range of highly specialised services in England is managed and paid for by NHS National Services Scotland. Similarly, services currently offered in Scotland to patients from England will continue in an independent Scotland.

The Westminster and Scottish Governments also have arrangements in place with a number of other nations, including the Republic of Ireland, for reciprocal treatment. It will be in everyone's interest for such arrangements and co-operation to continue in an independent Scotland.

210. Will I be able to get NHS treatment if I am taken ill while in England?
Yes. Following independence, should someone resident in Scotland take ill while in England, Wales or Northern Ireland they will be treated by local health services according to their clinical need, just as they are now.

Equally, visitors to Scotland from elsewhere in the UK will be cared for and treated as they are under current arrangements. EU directives protect access to such treatment.

211. What will the law on abortion be in an independent Scotland?
On the principle of continuation of existing law, current legislation on abortion will continue to apply within an independent Scotland until such times as that legislation is amended or repealed by the Parliament of an independent Scotland. There are no plans to change the current abortion time limit.

Health Industry Regulation (pages 405 - 406)

95. How will an independent Scotland access services from the Medicines and Healthcare products Regulatory Agency?
The Medicines and Healthcare products Regulatory Agency (MHRA) is an Executive Agency established by the Department of Health in England. The MHRA takes forward reserved issues around the licensing, safety and efficacy of medicines and functions on a UK-wide basis. The Scottish Government plans to continue using the services of MHRA in an independent Scotland, unless and until the Scottish Parliament decided to make changes in this area.

96. Will current legislation to regulate doctors, nurses and other health professionals continue to be in force in an independent Scotland?
Laws which are in force in Scotland prior to independence will continue in force after independence until such times as that legislation is amended or repealed by the Parliament of an independent Scotland.

The regulation of all health professionals will become the responsibility of the Scottish Parliament on independence. The Scottish Government will seek to work in cooperation with Westminster, and the devolved administrations, to ensure that health professional regulation is maintained in the best interests of patient safety and the consistent treatment of healthcare professionals.

The Scottish Government will seek to maintain the current professional current healthcare regulatory bodies, which are funded by fees from registrants, which will continue to operate in Scotland after independence.