Pressure for local control of Scotland's health dates back to the Poor Law (Amendment) Act of 1845 and the Public Health (Scotland) Bill 1848. Even then, opinion in Scotland prevented the over-centralisation of health care administration in London and the Royal College of Physicians of Edinburgh could say that "although we have a high respect for individual members of the General Board of Health in London, yet the confident expression of opinion which these gentlemen have made on several important questions, have by no means tended to increase our expectations of the efficacy of measure applicable to Scotland for restraining diffusion of epidemics."
This demand for local administration led to an arrangement that was to persist for many years in Scotland, namely that a number of independent boards were set up in Edinburgh to deal with Scottish affairs and which operated without much direct political intervention (e.g. the Local Government Board and the Highlands and Islands Medical Scheme Board). In 1920 all the boards connected with health matters were amalgamated as the Scottish Board of Health and, for the first time, a Secretary of State was now in charge of a devolved administrative organisation. In 1939, the process was taken one step further by the formation of a unified Scottish administration in St Andrews House and responsibility for a wide range of Scottish functions given to the Secretary of State, who could and did show some independence. The second world war meant a return to centralised direction of affairs from London, and this loss of Scottish autonomy, commented on at the time, was continued in post-war times. The close identity of NHS legislation North and South of the border in 1948 disappointed even the Scottish branch of the British Medical Association. Since then, Scottish policy documents and proposals have shown remarkable similarity to their London equivalents.
But, underneath, distinctive Scottish attitudes can be detected. Even in doctors' politics, different attitudes appear from time to time. Earlier in the century, the Scots doctors voted for the government's National Health Insurance in 1911, unlike the English practitioners: the same pattern was repeated in 1948, when the Scottish profession voted strongly for the NHS, and again in the debate in 1983 prior to the new arrangements for private practice by hospital doctors.
The present devolution proposals, when seen in the historical context, are thus part of a long slow transfer of power to Scotland.
Scottish health and health care have some remarkable and durable differences as compared with England. In spite of a social policy designed to redistribute resources within the UK according to need, the differences in health statistics remain obstinately at the 1948 levels. Not only that, but Scotland has some of the greatest problems in health care in the industrialised world - notably in lung cancer and dental decays, and one of the highest rates of death from vascular disease in the world. Alcoholism and smoking are major problems in Scotland and have proved to be less affected by anti-smoking policy than in England.
The Scotland Bill will set up a directly elected parliament in Edinburgh and the "cabinet equivalent will contain a Secretary for Health, possibly with responsibility for personal social services. The Secretary will have a budget negotiated from the annual block grant given by Westminster to the Scottish Parliament. The Scotland Act might also permit the salaries and conditions of service of health service employees to be determined within Scotland in the unlikely event that this can be agreed by both sides. Some of the acts and statutes pertaining to medicine may not be devolved - notably the Medical Act, the acts relating to drugs, and environmental legislation. A feature of the Scottish Parliament will be the strong all party political committee which will oversee the work of the Minister.
Doctors for Devolution believe that many of the changes produced by the Parliament will cause considerable alteration to the attitudes and administration of the Health Service in Scotland. We judge that, on balance, these will be beneficial and are as follows:
Since all decisions will be taken in Scotland, the smaller health service will be more personal and decisions will be made more quickly. The Committee structure of the Parliament should lead to more open government and hence greater public accountability.
We do not put forward any particular policies for the Scottish Health Service and, indeed, the various members of Doctors for Devolution would have different views on contentious matters. We argue, however, that devolution would produce an increased awareness of the very considerable problems of ill-health in Scotland that will result in a more vigorous effort by government and the community to combat them.
In setting out these policy matters, the devolved service will utilise the many skills and talents in Scotland which have not had a previous outlet, something which cannot fail to stimulate a new sense of involvement and responsibility in those involved. It should be noted at this point that a restoration to Edinburgh of a legislative Parliament will have a stimulating effect on the life of the city.
Devolution to Scotland will produce, for the first time, alternative ways of running health care within the UK. The choice within the UK could be of benefit to all its parts. As has been pointed out above, the present devolution proposals are only another step in the process of the decentralisation of power, and it is highly likely that, should devolution to Scotland be a success, then the regions of England will soon press for their own devolved or federal systems. The experiments made in Scotland may therefore be of great interest to the entire UK.
Specific policies are the province of political parties and, at this stage, we look instead for any significant traits in Scottish society which would be able to emerge in health policy after devolution. The main assumption we can detect is that, in Scotland, we still have a lively belief in society, rather that the elevation of individualism which was the feature of the 1980s. This means that we see public institutions and public health as important, and a return of the Medical Officers of Health to the city, whose remarkable achievements in the past for the common good were notable in Scotland, might re-emerge to meet the present challenges of rising ill-health and the burden borne by the poorer sections of our society, as well as address specific new problems, such as drug abuse. Another attitude is that Scottish collectivism makes us cool towards any two-tier system in health care.
Though the financial constraints in Scotland and the UK will be likely to continue, it should be recalled that Scotland's periods of distinction in medical services, teaching and research were at periods of relative poverty and national cohesion. Lastly, Scottish society has held research and education in such esteem that it would be naturally strengthened along with returning support for the universities, neglected during recent times. Scottish natural collectivism still exists, and will be re-established under devolution.
In the 1970s, the Scotland Bill met with opposition from the Scottish Branch of the BMA, and from the Royal College of Physicians (Edinburgh). Other bodies declined to comment. Though the BMA were careful to confine their criticisms to the proposals for health, and cautiously said that they saw no advantage in devolution, their comments reveal opposition to the proposals. These criticisms can be dealt with in detail.
It has been suggested that the devolution proposals will produce another layer of administrative bureaucracy in Scotland. This is not so, as the administrative devolution of health already exists (and has been considered valuable), and hence major new expenditure will not be required. It has also been suggested that the committee system of the Scottish Parliament is an extra level of government. This is a misunderstanding, since the committee system is designed as a series of checks and balances on the power and activities of the Secretary of Health, rather than as an administrative tier.
It has been argued that the small Scottish service will be inward-looking, and that it would cut off the members of the professions from those in England and Wales. We would point out that the already devolved Colleges of Physicians and Surgeons in Scotland have not shown any narrow parochialism, nor have cut off the profession from England. Indeed, the Scottish colleges have been outward-looking and international, perhaps even more so than the London colleges, and have strengthened Scotland's professional life and its links with England and the rest of the world. In addition, the devolved Chief Scientist Organisation in Scotland has shown similar strength and is also highly regarded inside and outwith Scotland.
Our main concern is that, under the block grant system (which might contain no clear allocation to the Scottish health service), health care in Scotland would not continue to have its present favourable financial treatment (10% more per capita than in England and Wales). It would be wrong to assume that the Scottish Parliament would look with disfavour on continuing the present health care expenditure. We point out that the Parliament will be very much conscious of being responsible for one of the worst areas of ill-health in Europe. However, reassurance on finances might be desirable.
Doctors for Devolution contend that the devolution of health care to the Scottish Parliament is desirable, workable and would be beneficial.
Devolution would not be an instant cure-all for the ills of the NHS, but it would go far towards using local talents and skills to deal with Scottish problems - which are not always the same as those of the UK - and are not always amenable to UK solutions.
In short, Scotland's instinctive health problems would be met by a profession with a tradition and international reputation for health care and research. The closer relationships and shorter lines of communications between government, profession and patients would inevitably produce a more flexible system to the benefit of all.
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