On 16th August, 700 Co. Durham mothers, healthcare workers and trade unionists set off from the banks of the Tyne in a 300 mile walk reprising the 1936 Jarrow protest march at mass unemployment, in order to reach Westminster on 6th September for Prime Minister’s questions. They are doing so to protest and fight against the privatisation and dismantling of the NHS by the coalition government, and to support the continuation of a universal public health service.
So what has this to do with the Scottish independence Referendum? Possibly everything, in the positioning for the last battlefields as we enter the closing weeks of the campaigns. Scotland may, somewhat bizarrely, have the reputation as the sick man of Europe – but it was not always so. Research has previously demonstrated the link between the impact of Margaret Thatcher’s deindustrialisation in the west of Scotland and higher death rates, but Scotland’s Chief Medical Officer for the last 8 years, Sir Harry Burns, went further in December 2012: “In the 1970s and 1980s those jobs disappeared and the men who worked those shipyards were never re-employed. Shipyards, steel works, heavy industry in west central Scotland disappeared and was never replaced the way it was in the north of England … with car factories and so on. A void appeared in men’s lives and the void was filled with drink, drugs and fighting.”
We can measure this relative disparity in terms of Life Expectancy (LE) and Healthy Life Expectancy (HLE), both of which are consistently and significantly worse in Scotland than the rest of the UK (Scottish men and women live 2-2.5 years less than their English counterparts) and indeed than many other EU countries. Although LE has increased across Europe since 1998, the improvement has been significantly less in Scotland (4% for men and 2.5% for women), causing it to drop down the rankings of other European countries. For the most deprived 20% in Scotland, male LE/HLE is 70/50, with female LE/HLE 70.5/52.5.
So it seems that Scotland right now has some greater needs of its health service as part of the ongoing consequences of previous Westminster administrations. Sir Harry Burns warned that health inequalities are the biggest issue facing Scotland, because they “are really a manifestation of social inequality. Social complexity, social disintegration drives things like criminality, it drives things like poor educational attainment, it drives a whole range of things that we would want to see different in Scotland.” Before he left to become Professor of Global Public Health at Strathclyde University earlier this year, Harry noted that a ‘Yes’ vote could see significant health improvements, as health prospects for people improve greatly when they have more control over their lives – but he also warned against the dangers of a ‘No’ vote, with the impact from the ongoing privatisation of the NHS (England) directly pressurising the NHS (Scotland).
So, in what actual ways is the NHS really at risk in Scotland, given that it has always been independent, and is governed by Holyrood? Others have forcefully drawn attention to David Cameron’s use of a personal family tragedy to portray himself as the defender of the NHS – although it did not seem so cynical at the time, in the wake of the 2012 Health and Social Care Act, he seems to have been far from sincere. The passing in Westminster in 2012 of the Health and Social Care Act had two principal effects, the first being (in under 2 pages) the removal of the Secretary of State for Health’s duty to secure and provide health care for all. The other 455 pages prepared the way for healthcare provision to move from a state/publicly-funded, publicly-provided service offering universal access to healthcare on the basis of need and not the ability to pay, to an economic activity, shifting towards US-style profit-prioritised health provision, thus ending the state monopoly by introducing the private market. The private market, of course, means cherry-picking the most lucrative services, with no strategy or planning across the sector for complete coverage, and that some sectors of society will not receive treatment as they will not have medical insurance (eg. the homeless, some of the elderly), and this is why politicians needed to absolve themselves of their duty of care to the population as a whole in those first pages. This process also – perhaps surprisingly – is likely to mean a drop in efficiency through privatisation (administration costing only 6% under the NHS, as opposed to 30-40% in the US). [If you are interested, I would commend you to the video of Professor Allyson Pollock(Professor of Public Health Research and Policy at Queen Mary University of London)’s Tedx talk on privatisation of the NHS – https://www.youtube.com/watch?v=Cz5dl9fhj7o#t=55 ]
The NHS is not about providing care for ‘some’, it is free for all at point of need – that is what underlies the entire principle of it. Sustaining a small part of this idea, nested within a US model of private healthcare (the politicians who introduced it being driven and sponsored by the same companies that thrive in those markets in the US) does not constitute defending the NHS, as we might have understood Cameron’s intention to be. Andy Burnham is an odd voice to be warning of this, as someone who (under the last Labour government) initiated privatization when in post as Health Secretary. Now he criticises – not privatisation itself – but the ‘speed’ of that privatisation. One might cynically suggest that his is less of a Damascine Road conversion, than an opportunity to posture as an opponent in opposition, in the hope of appearing to be a defender (perhaps, again, like Cameron), and win political support for his party going into next year’s general election.
Why is all this relevant to the Referendum on Scottish independence? Well, there are three main reasons:
1) Now as shadow health secretary in opposition, Andy Burnham has recently been arguing for a pan-UK combined health policy and approach – presumably also threatening NHS (Scotland)’s independent status since its inception in 1948. So, in such a scenario, what is happening in England would become our own direct health service future. (It is perhaps – as a sidebar here – worth noting that although there is not a united NHS, it is a tribute to the cooperation and reciprocity between the different sections that they work so seamlessly as to make it difficult for us to notice that they are not a single unit. This is also true of NHS Blood and Transplant (NHSBT), which deals with vital organ transplant services – these fully independent units have a number of reciprocal arrangements between the health services, as well as with other countries, which they stated in March 2014 will be unaffected in the event of independence, as these cross-border healthcare arrangements are expected to continue.)
2) Although NHS (Scotland) is a discrete unit, its funding is tied to the funding of NHS (England), such that the continuing outsourcing and privatisation within NHS (England) directly reduces the funding Scotland receives for its NHS. In 2013, contracts to private firms from NHS (England) was in excess of £10 billion. These – effectively – cuts to the public funding of the NHS (England), through the introduction of private ‘strings-attached’ finance have direct financial consequences to the block grant for the Scottish Government through use of the Barnett Formula, which redistributes a portion (around 70%) of taxes from Scotland back to Holyrood as part of the Scottish block grant, a calculation that is based on per head expenditure in England. (Admittedly, the likelihood of the Barnett Formula continuing to survive during the next Westminster parliament is fairly unlikely, and the consequent reductions in finance for Scotland are estimated at somewhere around £4.5-6.5 billion…so there could be even worse news for NHS (Scotland) with the demise of Barnett after a ‘No’ vote anyway.) Even although the money is not ringfenced for health service spending within the block grant, any reduction in the block grant signifies more pressure on the remaining areas to sustain service levels, health included. So there will inevitably be budget problems for Scotland’s NHS while dependency on Barnett funding continues (and these are likely to be cripplingly greater in the likely event of Barnett being dismantled during the next Westminster parliament).
3) The third reason is the Transatlantic Trade and Investment Partnership (TTIP) treaty between the EU and the US, that opens state services to competition from US multinationals. This competition can only occur where privatisation of a given service already exists within a state – which means that for now it can occur south of the border in the health service, but not north of the border. However, there are implications for Scotland if it (through voting ‘No’) declares itself to be a mere territory of the greater UK, as it could be viewed as therefore only a part of a partially privatized whole and thus legitimately open to competition. (Again, if Andy Burnham’s pan-UK health service came to pass, it would be left even more clearly vulnerable to this form of privatizing assault, with no possible defense in declaring itself to be a discrete state unit with an ongoing state monopoly of health provision.)
In contrast, it is planned that the Scottish Constitution will have protection for the NHS enshrined within it. Alex Salmond: “With independence we have the golden opportunity to enshrine Bevan’s founding principles for our National Health Service in the written constitution for Scotland – publicly-owned, clinically-driven, and freely-delivered equally for all – a guarantee that not only will the NHS be kept in public hands, but that the services that are free to access today will be free to access in the future. Constitutional protection for the NHS is our promise to generations yet to come that in the Scotland we seek no one will be denied medical aid because of lack of means. The NHS is the at the heart of our nation, and I want it to be at the heart of our constitution.” Such an idea would not be unique: 9% of the countries in the UN have constitutional protection for free healthcare, 38% guarantee the right to medical care services, and 14% guarantee ‘public health’.
It is for these reasons that there is strong support for a ‘Yes’ vote in NHS (Scotland): as the breast cancer surgeon Dr. Philippa Whitford notes (and Andy Burnham has echoed), the NHS will not exist in England in 5 years time. And, because of the links described above, in the event of a ‘No’ vote, NHS (Scotland) will not last much longer than that.
“In five years England will not have an NHS as you understand it, and if we vote No, in ten years neither will we.” (Dr. Philippa Whitford)