Much of the media and political narrative around the Scottish referendum has, perhaps understandably, focused on economic and sovereignty issues, but recently the NHS has become something of a political football with both sides claiming that they are best placed to protect the health service.
So what could a ‘Yes’ vote in the Scottish referendum mean for those of us working in healthcare?
At first glance, you might think that little would change. After all, the Scottish Parliament has had responsibility for NHS Scotland since 1999 and health is a devolved issue – the Scottish NHS is already substantially different from the English version, with no internal market and no commissioner-provider split.
From a patient’s perspective, in an independent Scotland they would still visit their GP in an NHS–badged surgery, be referred to an NHS hospital and receive their care for free (including free prescriptions and eye tests). Indeed, the Scottish Government has already committed that “the process of becoming independent will not change the way you receive your health care”.
Scotland already has its own drug appraisal system via the Scottish Medicines Consortium (SMC), which acts in place of NICE to determine whether the Scottish NHS will adopt new treatments and technologies, so there would be little disruption to the uptake of new medicines.
From a public health perspective, Scotland has often led the UK in adopting large-scale interventions to improve the health of the public, such as the smoking ban. Given Scotland’s persistently higher smoking, alcohol and obesity rates, it is highly likely that an independent Scotland would continue to innovate significantly in public health.
But there are areas where the potential impact of independence is less clear.
For example, what about patients near the border who travel into Scotland or England for treatment or those who require specialist care like complex transplantation that exists only in a handful of UK hospitals? The English Department of Health has made clear that no agreement is in place to guarantee cross-border healthcare for patients in an independent Scotland. In response, the Scottish Government highlights that reciprocal treatment agreements are in place with many European nations and that the EU requires protected access to treatment in such circumstances, albeit via the complex and time consuming S2 European healthcare system.
It’s unclear how Scotland would retain the services of organisations like NHS Blood and Transplant (NHSBT), an England and Wales body that works across the UK by negotiated agreement between the four administrations. They have already outlined that “in the event of independence for Scotland, NHSBT would go on serving the continuing UK. Any role for NHSBT in an independent Scotland would be a matter for the relevant governments to negotiate.”
BMA Scotland has highlighted several important elements of the health system that would be significantly affected by independence, including:
- Regulation of the medical profession – the General Medical Council (GMC) regulates all UK doctors and is accountable to the UK Parliament. BMA Scotland asserts that “an independent Scotland would have to re-establish the regulation of the medical profession in legislation and replicate the core functions of the GMC in Scotland”.
- Pay structures – Scotland has maintained similar job titles and pay structures to the rest of the UK, but this is by choice and could change after a ‘Yes’ vote in the refurendum.
- Medical research – the seven Research Councils cover the entire UK to distribute funding for university research, and Scotland is included in the regulatory and oversight functions of bodies like the Medicines and Healthcare products Regulatory Agency (MHRA). An independent Scotland would need its own regulatory framework and would need to establish new funding avenues. As Scotland attracts more funding than its relative size would predict, there is of course a risk that funding would go down in the event of independence, potentially threatening Scotland’s world class research base.
As ever, the devil’s in the detail. As we wait to see how Thursday’s vote plays out, it’s clear that a ‘Yes’ in the referendum would be swiftly followed by a ‘Now What’?