Kat Smith, Jeff Collin, Mark Hellowell and Rob Ralston (University of Edinburgh)
In the Scottish government White Paper setting out the case for independence, Scotland’s Future, health policy features prominently among examples of the Scottish Parliament’s achievements. Indeed, health policy is framed as helping to demonstrate what Scotland has the potential to achieve given ‘the full powers of independence’. The Scottish Government’s commitment to maintaining the NHS ‘as a public service’ is contrasted favourably against the market-driven reforms recently introduced in England, whilst the introduction of smoke-free public places and more recent commitments to minimum unit pricing for alcohol are presented as landmark public health achievements. Against this backdrop, this policy briefing examines: (i) how health policy has evolved under devolution; and (ii) the arguments for and against the Scottish Nationalist Party (SNP) claims that independence would enable ‘the full range of levers to [be used to] promote good health.’
Health and public policy in the post-devolution era
Many accounts of post-devolution health policy assert that the associated policy differences have been significant, with health policy in England being driven by a belief in the efficiency and quality-enhancing properties of markets, accompanied by an increasing role for the private sector as healthcare providers. In contrast, organisational reforms have been far more limited in Scotland, where policymakers appear to remain committed to a more traditional model of the NHS in which the public sector operates as the preferred provider. A recent survey demonstrating increasing public support for the NHS in Scotland has led to claims that Scotland’s approach demonstrates that organisational policies based on an ethos of cooperation, rather than competition, are not only politically possible but also popular with voters.
Nonetheless, it is important not to overstate the differences between health service provision in England and Scotland. In all four regions of the UK, the NHS remains free at the point of delivery and is financed to a remarkably similar degree, based on the same basic model of tax-funding(1). Whilst much has been made of the different approaches between Scotland and England in terms of the use of private sector provision within the NHS, the predictions of private healthcare providers in terms of investment opportunities remain remarkably consistent across the UK(1). Indeed, the private sector appears to relate potential investment opportunities more to the unequal spread of population wealth and restricted NHS budgets than to divergent policy approaches(1). Hence, it could also be argued that post-devolution approaches to healthcare policy remain remarkably consistent across the UK, which perhaps reflects the broad public support for maintaining a tax-funded health service that is free at the point of delivery.
As well as being the first place in the UK to implement legislation for smoke-free public places, Scotland has taken exploratory steps towards shaping the supply of tobacco and alcohol products. It has done this through the introduction of a register of all retailers selling tobacco products, a public health supplement (or levy) on larger retailers that sell both tobacco and alcohol, and a law to make proxy sales of tobacco products to those under 18 years old illegal. The Scottish government’s endorsement of standardised tobacco product packaging, and its persistent commitment to minimum pricing for alcohol, contrast starkly with the UK government’s equivocations. The ambition to make Scotland “smoke free” by 2034 further reinforces its claims to public health leadership within the UK.
Recent Scottish policy statements indicate that the SNP government is comfortable with its role as a public health steward and that it is placing a renewed emphasis on the social and economic determinants of health. In contrast, whilst the 2010 Public Health White Paper in England acknowledges the role of socio-economic determinants in health, medical and individualised accounts are also clearly present and (with the exception of tobacco), the English government has largely rejected the need for central government action on public health. For example, the White Paper states that, ‘it is simply not possible to promote healthier lifestyles through Whitehall diktat and nannying about the way people should live’ and concludes that (beyond the need to protect the public from health ‘threats’), public health responsibility rests with local agencies, communities and individuals. The contrasting stance of the current English and Scottish governments on public health policy is therefore visibly different within key policy documents and the Scottish Government has already demonstrated (with the ban on smoking in public places) that it is prepared to lead the way on public health legislation in the UK.
However, as with healthcare policy, it is important not to overstate the level of policy divergence between England and Scotland when it comes to public health(1). This is partly because, as became evident with legislation banning smoking in indoor public places, there appears to be a high degree of policy transfer across the UK. There are also key public health issues for which evidence of any divergence remains limited. For example, when it comes to health inequalities, while policy statements in Scotland more clearly reflect evidence stressing the importance of people’s living, financial and working environments than England’s 2010 White Paper, there is far less evidence of practical policy divergence on the ground.
Similarly, despite multiple expressions of policy concern regarding the potential population impacts of obesity, both regions have largely resisted an interventionist approach to food marketing and diet, relying instead on partnership approaches and voluntary measures (despite uncertainties that food retailers and marketers will comply). While Scottish policy statements have not sought to marginalise the scope for possible state intervention with regards to diet to the same extent as in England, the Scottish Government has, thus far, failed to extend industry commitments beyond existing agreements. Hence, despite an apparent political interest in adopting a more interventionist approach, evidenced by proposals to introduce targets for the reduction of fats and sugars, such measures are noticeably absent in current policy responses. In this respect, the English Public Health Responsibility Deal (PHRD) is likely to have constrained policy innovation on both sides of the border, with companies appearing reticent to extend reformulation targets beyond those to which they have committed themselves to in the PHRD (e.g. salt reduction). This suggests that, when it comes to public health, policy divergence to date has been more identifiable across distinct public health concerns than between England and Scotland.
The potential for future health policy divergence
Key figures involved in the ‘yes’ campaign have recently been arguing that a ‘no’ vote in the referendum represents a fundamental threat to the NHS in Scotland, contending that remaining in the UK will lead to England’s market-orientated reforms being implemented in Scotland. Yet, empirically, England has moved more closely towards marketization since devolution in 1999, while Scotland has moved back to a more traditional, hierarchical regional planning model. Given the current debate is about increasing Scotland’s policy independence, it seems unclear why we would expect future trajectories to be any different. Indeed, such cross-border ‘influence’ from England to Scotland only seems likely within the devolved settlement if public spending on healthcare were to be reduced as a consequence of changes in England (e.g. if private financing was introduced for services that were previously publicly financed). This could then have an impact on the Barnett formula and so further restrict public sector healthcare spending in Scotland. There are currently no indications that this is likely to happen, at least not this side of the UK 2015 general election.
Looking to the future, the key challenge facing the NHS in Scotland, as in England, is funding. Whatever the constitutional settlement, this is going to be very difficult. Under devolution, there is very limited capacity to redirect more of the budget allocated to Scotland to healthcare because health spending has been relatively protected (as in England) and, in consequence, other budgets (e.g. justice and culture) have suffered in a way that many have argued is unsustainable. Scottish independence would certainly allow the Scottish government to consider new funding options but, given most independent analyses suggest that Scotland would not be substantially better off as a result of independence, if Scotland is to continue remain true to NHS principles, the only option is likely to be additional taxation or new forms of taxation. This would be difficult to achieve politically and economically for a newly independent government and there’s certainly nothing in the independence White Paper to suggest that higher taxation is seen as desirable or that a new (possibly hypothecated, NHS-specific) tax is being considered.
Whilst a continuation of current arrangements may limit Scotland’s options when it comes to healthcare funding, it should be noted that: (1) Scotland already has 3% tax varying powers, which so far remain unused; and (2) that it has already been granted further powers over taxation, which are due to come into effect in 2016. Hence, even if Scotland’s population votes against independence, growing fiscal freedoms for the devolved administration mean there may be opportunities for more meaningful divergence in healthcare policy than has been possible hitherto. However, whatever the constitutional settlement, the only option for substantially increasing the funding available for the NHS, raising taxes, is likely to be politically unpalatable and there is certainly nothing in the independence White Paper to indicate that the SNP is seriously exploring such a move.
In Scotland, poor performances in international comparisons of average life expectancy and measures of health inequalities have undoubtedly highlighted population health as a policy problem so the pressure to improve public health is likely to remain, regardless of the outcome of the referendum. Whether one or the other outcome is likely to be better for public health is open to debate.
On the one hand, it could be argued that the opportunities for making public health advances are likely to be greater under independence. Although survey data suggests differences in public opinion regarding interventionist policies are only marginally more favourable in Scotland, there are significant political differences. Whilst the Conservative-led coalition in England is ideologically committed to achieving less state intervention, both Labour and SNP post-devolution policies suggest that Scottish policymakers are more comfortable than their English counterparts with pursuing state level interventions for public health(1).
If the SNP were to maintain power in an independent Scotland, the political investment in demonstrating strong public health leadership may provide a particularly favourable political climate for developing innovative approaches to public health. This reflects a context in which health professions and advocacy groups currently appear to have a stronger influence in Edinburgh than in Westminster, due to Scotland’s smaller policy communities and more accessible policymaking system. The exposure of policymakers to policiesproposed by health researchers and advocates may therefore have been greater than in Westminster. In contrast, exposure to opposing business interests may have been lower, given the small number of think tanks, consultancy groups, and commercial headquarters in Scotland. If this were to continue under independence, it could bode well for public health. More speculatively, the political momentum behind innovation in public health could be partially self-fulfilling, offering a small new state a rare opportunity for demonstrating global leadership.
Yet there are also reasons to be wary about claims that an independent Scotland would necessarily offer increased opportunities for public health innovation and improvement. Currently, health is one of the most high profile policy areas controlled by the Scottish government, promoting its relative position on the policy agenda. If Scotland were independent, the government’s expanded remit would cover fiscal policy, foreign affairs, and defence, potentially reducing the focus on public health. Moreover, the accessible and consensual Scottish policymaking system that seems to have favoured public health to date could work against it if commercial interests increase their investment in political activities north of the border. Such changes could, for example, empower attempts by the whisky industry to hold alcohol policies hostage to national interests in expanding whisky exports(2).
The independence White Paper itself cannot clearly guide an appraisal of such prospects. It suggests that the ‘greater scope and clearer powers’ afforded by independence would lead to further strengthening of alcohol and tobacco regulation and that powers over taxation and advertising regulation would facilitate ‘a coherent and concerted approach to issues of obesity and poor diet.’ Yet, the simultaneous commitment to undercut the UK government on corporation tax highlights the strategic priority of creating a business friendly Scotland. In this context, maintaining political will to prioritise the interests of public health over those of the food and drinks industry may prove difficult.
Infatuation with policy innovation can lead to an exaggeration of the real dividends of devolution for the health of people in Scotland(3), and the scope for any government to tackle the social determinants of health or make long-term commitments to NHS funding without control over economic policy, trade, or international relations is clearly restricted. Yet, devolution does seem to have provided health policy with an important window of opportunity. It should not be assumed that this window will remain open for long, or that it would necessarily open more widely in an independent Scotland.
(1) Smith, K.E. & Hellowell, M. (2012) Beyond Rhetorical Difference: A cohesive account of post-devolution developments in UK health policy. Social Policy & Administration, 46(2): 178-198.
(2) Holden, C. and Hawkins, B. (2013) ‘Whisky gloss’: The alcohol industry, devolution and policy communities in Scotland. Public Policy and Administration, 28(3): 253-273.
(3) Smith, K.E. and Collin, J. (2013) Scotland and the public health politics of independence [Editorial] BMJ 347:f7595 doi: 10.1136/bmj.f7595.
Kat Smith is Reader in Social Policy in the School of Social and Political Sciences at the University of Edinburgh. She is the author of Beyond Evidence Based Policy in Public Health: The Interplay of Ideas (Palgrave 2013). Jeff Collin is Professor of Global Health Policy in the School of Social and Political Sciences at the University of Edinburgh where his current research focuses on globalisation and tobacco control. Mark Hellowell is lecturer in global health policy in the School of Social and Political Sciences at the University of Edinburgh where he researches on the public/private interface in health care and health systems. Rob Ralston is a PhD student in Social Policy in the School of Social and Political Sciences at the University of Edinburgh.