Tuesday, 16 September 2014

Haste ye back?

Posted by David J Hunter, Professor of Health Policy and Management, Durham University and Fuse Deputy Director

Many in the North East will be wondering how their region will fare if Scotland decides to go its own way on Thursday.

Some may be heard to say: ‘if you’re going can we come with you’?  Others might sullenly fear the worst, with our region caught between a hungry new nation impatient to prosper and chart a different course on the one hand, and an England which seems captive to the huge suction pump that is London hoovering up all before it and drawing in talent and resources from across the UK – or what was the UK.   

Where might health policy figure in the scheme of things post-referendum?  Will it fare better under independence? Or will things remain much the same or possibly deteriorate?

Financially, the Scottish NHS has always fared better than its English counterpart, enjoying higher per capita funding.  But spending on health services is not the only factor affecting health status.  Despite the extra funding, Scotland’s health remains stubbornly poor and generally inferior with higher mortality – hence the label the ‘sick man of Europe’.

Of course, with less funding for health care it might be worse.  But it’s more complicated than that. 
Perhaps liberated from the shackles and centralising tendencies of the UK (or London to be more precise), Scotland will be able to restore the public realm or invest in ways which will demonstrate that an austerity economic model can be replaced by a social model of development.

We know from Marmot’s work and WHO’s health strategy for Europe, Health 2020, that tackling the social determinants of health demands a whole of government and whole of society approach. 

Being able to achieve such joined up thinking and work across a whole system is much easier (in theory at least) in a small country.  And there are certainly signs that Scotland wants to be innovative and tackle health differently with its recently departed Chief Medical Officer, Harry Burns, extolling the virtues of asset based approaches and talking about wellness rather than ill-health.           

The Scottish government has been something of a cheerleader in public health policy having been quick to follow Ireland’s lead on banning smoking in public places long before England.

More recently, it took the lead in introducing a minimum unit price for alcohol although whether the policy will survive the EU single market rules remains to be seen. But where England dithers, Scotland appears willing to take bold action.

The real issue is whether an independent Scotland can do more to improve health and tackle inequalities than it can under current devolved freedoms and from others to come which are promised following a No vote.  

The answer is complicated.  After all, what does independence actually mean in our global world where paradoxically everything is interdependent at a time when nations and regions seek greater freedoms.  Are these opposing forces reconcilable?   Or will independence prove to be a chimera with Scotland even less able to realise its social justice aspirations?

Those voting with their heads will endeavour to weigh up the pros and cons and bring evidence to bear on their decision-making.

Those ruled by their hearts will not be swayed by an evidence base which is fiercely contested and offers no definitive answers.  They will be tempted to take the risk believing they have nothing to lose with the status quo and retention of a 300 year old Act of Union holding little appeal. 

But will the politics and the policies be so different in the end or just their packaging and presentation?   Can an independent Scottish government shake off the neoliberal embrace to which all governments since, and including, Thatcher have been enthral? 

In a global economy, no country is an island and to keep at bay, never mind hold to account, the rapacious transnational conglomerates, including the big consultancies and ‘advisers’ and lobbyists that are busy hollowing out the public realm in England, demands both vigilance and political courage of a kind that will tax the most socially enlightened politician.  

This is the true nature of the experiment underway in Scotland regardless of whether it achieves formal independence after the referendum or some form of ‘devo max’.

Can Scotland break with the Anglo-Saxon tradition and replace it with an ethos marked by collectivism, reciprocity and a commitment to public services? 

Or will it buckle under the pressures of global capitalism and dance to its tune?                

Yes or No, Scotland promises to be a fascinating laboratory for years to come for health policy-watchers.

1 comment:

  1. Similar questions expressed by Fintan O'Toole (Guardian 12th Sept): The flourishing of democratic sentiment a symptom of a "broader loss of faith" in the ability of the formal systems of governance to to protect against the " unaccountable power" given to , and held by, those conglomerations of economic power that exist outside the formal policy process.