Why Voting No threatens Scotland’s NHS

This weekend, another key battleground in the independence referendum emerged.  As big as, if not bigger than, currency wars.

Findings from a Panelbase poll commissioned by the Yes campaign demonstrates the importance of Scotland’s NHS to voters.  Asked if the privatisation of the NHS South of the border with its consequent impact on funding for Scotland’s NHS made it more or less likely for participants to vote Yes or No, people made their feelings clear.  46% would be very likely or quite likely to vote for independence, 35% very or quite unlikely to.

It resulted in rebuttal from Better Together, with Jackson Carlaw MSP, the Conservatives’ spokesperson on health, claiming that the Scottish Government is spending more on private healthcare too.

It’s complicated, but it is possible to shed a little light on the situation.

First, how does what is going on in England with the NHS impact on Scotland?  It’s all about the money, innit.

The Barnett formula determines what money we receive from Westminster.  Think of it as a big bag of pocket money to spend on devolved issues, including health.  Westminster hands it over and the Scottish Government divvies it up across all spending areas.  If Westminster decides to put more into funding public services, then we get more too.  Except that in recent years, it has been putting less in and we get handed a smaller bag of cash.  If Westminster cuts the budget by £100 million, we get £10 million less.  Indeed, since 2010, Westminster has taken 7.2% out of the Scottish block grant, putting real pressure and strain on our public services.  The Scottish Government gets to decide what to spend the pot on, but not how much to put in it, even if we in Scotland want more to spend on public services.  It can only make the money it receives stretch as far as it can through prudent management but cuts have been inevitable.  Except in health.

Until now, the UK Government has chosen to ringfence health spending and increase it in line with inflation – Scotland’s NHS has benefited from this too.  And from a separate Scottish Government decision not to pass on any of the 7.2% cut in overall grant to health.  It has chosen to keep increasing frontline health spending in real terms, acknowledging the value placed by us all on health and the need to keep tackling the levels of ill health in Scotland.

But thanks to the actions of the Conservative-Liberal Democrat coalition government at Westminster, the budget for health in Scotland is under threat.  Largely, due to the Health and Social Care Act passed in 2012.

This Act opened the door to private companies bidding for health service contracts south of the Border.  It’s a move that the Chairman of the British Medical Association (the doctors’ union effectively) called “market lunacy” which offered “a bumper year for multinationals”.

At the same time, the legislation also removed statutory responsibility for health care from the government, handing it over to local commissioning agents.

Thus, the framework has been established to enable privatisation of the NHS in England.  Private companies can now “bid” for health contracts that would previously have been delivered by the NHS (publicly owned and accountable).  How do you suppose firms go about winning these contracts?  By bidding lower than the local NHS trusts and bodies to deliver the service.  So the funds that Westminster needs to spend to provide such services are reduced and the UK Government can cut its budget on health.  Indeed, it has already stated that it is committed to cutting health spending in England by £1.1 billion a year – enabling private companies to run services will help achieve this.  Last year, 70% of new contracts for core NHS services were awarded to companies like Virgin Health.  Together, so far, the services either won by private health companies or being bid for are worth £1.22 billion, covering services such as GPs, end of life care and cancer care.

And how does this affect Scotland?  It’s the money – again – innit.

If health services are being run by private firms at reduced costs (we won’t even begin to talk about quality – that’s a whole separate issue) then the UK Government spend on health goes down.  And because we only get what Westminster allows to spend based on the Barnett formula, it can – and will – cut the money it gives us in Scotland to spend on health, even though we want to keep our NHS in public hands and make different policy decisions on health.  Because Westminster controls the purse strings, it puts under threat our ability to continue to fund our NHS and provide all the services publicly we want from it.  Cute huh?

It gets worse.

If a private company wins a contract say for cancer care, it not only has to take the staff already employed in this service in the NHS over to its new service but often also gets to run its new service from the previous NHS facility. So equipment, beds, buildings that would be lying empty because the NHS “lost” the contract get handed over to the private company, either at a knock down price or no price at all.  That’s facilities bought and paid for by the taxpayer.  That’s staff qualified and trained in their skills by taxpayers.  That’s all that experience lost, just handed over to private firms. Again, it reduces the cost of health care to the English budget.

And when the contracts come up again in three to five years’ time, there will no longer be an NHS England version of that service to put in a bid or to put the service back into public hands. It is a one way journey to breaking up NHS England.

There’s more.  There is nothing to stop any of these private companies recouping the cost of running their services by applying charges.  Indeed, a recent report by the Nuffield Trust stated that 50% of health and care leaders believe that within 10 years, the NHS in England will no longer be free at the point of use.  And there is cherry-picking going on with the easiest health care contracts to deliver the ones the private companies most want.  NHS England is being left to deliver the most complex and expensive services, putting many trusts and hospitals into debt.  Making them all seem like financial basket cases that need to have their financial taps turned off, to prevent them “over spending” and the private sector brought in to “rescue” them.  It is a perfect, dystopian cycle of potential destruction of one of the building blocks of our welfare state.

But it gets worse still.

At the same time as all this is going on, there is an international trade agreement being negotiated between the EU and the US.  This agreement is about free trade and allowing US companies the right to bid for services and trade in key areas in the EU market, of which the UK is part.  The agreement is known as TTIP – Transatlantic Trade and Investment Partnership.  Opt outs and exemptions are allowed; many EU states are choosing to exempt and therefore, protect public services, like health, from big US based multi-nationals.  Guess which member state has not asked to exempt health from TTIP?  Yep, the UK. This means that US healthcare firms could come into the market in England (and indeed, potentially Scotland as we don’t get a say in these negotiations and have no way of exempting NHS Scotland from its application as the UK gets to make the call).

Now, of course, we can continue to protect NHS Scotland from such private companies coming in, if we continue to elect devolved governments that will stand up for Scotland’s interests and for a publicly owned and delivered health service.  But any devolved government’s ability to do so is going to be constrained if the block grant is still being slashed – and there are £5 billion of cuts coming our way in the next two years that we already know of.  Moreover, the pockets of big global private healthcare firms are deep – they wouldn’t be averse to going to court to insist upon TTIP being applied across the whole of the member state which signed up to it.  And who knows if we would be able in the next five to ten years prevent Scotland’s health service being opened up to private companies as it is being in England.  Whether we want this to happen or not.

Yet, the Conservatives claim the private sector is very much playing a role in the NHS in Scotland today.  At the margins.

The amount spent by NHS Scotland on private sector involvement in 2012/13 was £80 million – that’s less than 1% of the total amount spent in Scotland on front line NHS services.  To put it in a slightly different context, that £80 million is much less than the £220 million a year in charges the Scottish Government has to shell out for PFI contracts.  If anyone has allowed the private sector into our NHS in Scotland it’s been Labour – the Scottish Government is locked into these contracts and has no choice about paying out these funds, thanks to Labour bringing private firms into our health service.

The accumulated £400 million spend over six years quoted by the No campaign has been massaged to include the use of locum doctors and agency nurses – temporary staff brought in to cover shortages, holiday periods and the like.  The use of private agency staff in such situations is common and longstanding – if there’s more of this going on than there used to be, then that’s a separate policy and workforce issue.  But the spend on it should not be used to suggest that the SNP Scottish Government has allowed the private sector more say in running health services. It hasn’t, it has done its very best to limit the use of private businesses and only brings them in to carry out specific functions, such as to bring down waiting times on straight forward procedures, and in particular health board areas where such an issue has arisen such as to bring down waiting times on straight forward procedures.

It is vastly different from giving contracts to private businesses to deliver whole services, which is what is going on in England.  None of the private providers in NHS Scotland are contract holders.  In Scotland, we have not opened the door to private companies bidding for health services.  We don’t have a Scottish equivalent of the Health and Social Care Act 2012 – indeed, our most recent health legislation, the Health and Integrated Social Care Act focuses on improving the service people get from public services, trying to join up health and social care provision across the NHS and local government.  The entire focus in Scotland – from the limited input of the private sector in certain fields and geographical areas to the statutory framework around service provision – is to put the patient first.

If Scotland votes No on 18 September, our health service, NHS Scotland is at risk from the actions of the UK Government.  First, by bringing in the private sector to run whole swathes of NHS England at lower cost than in the public sector, it can cut the overall budget for health.  That will have a knock-on effect to our block grant, making it difficult for Scotland to maintain spending levels on health – the sort of spend we all want to see on health as a priority issue will be under threat.  Second, by refusing to exempt health provision in the UK from the TTIP, US private healthcare firms – and there are lots of them and they are huge – NHS Scotland could find itself subject to tendering for key front line services, with many of them being taken over by big business.  No matter who we vote for in Scotland, no matter how much we want to keep our health service in public hands.

That’s the threat voting No poses to our health service – and indeed, our nation’s health.

Which is why if you want to save the NHS, you need to vote Yes.


Thanks to Jeane Freeman and Philippa Whitford, of Women for Independence, for providing much of the content of this post. 




Could the SNP be losing its charm?

You might find it hard to believe, but this here burd has been hovering over devolution since its inception/reconvening in 1999.  I really have seen them all come and go, heard it all before, and am often amazed at having any smidgeon of idealism left.  I do – I have plenty, probably more than it deserves frankly.  One day, I’m sure, I’ll be stuffed and mounted in a suitably obscure nook and cranny in Holyrood.  This burd woz here.

The earliest days of the Scottish Parliament were like an adult version of How do they do that.  Suddenly a sharp and invasive light was being shone on the workings of government and politicians were lining civil servants up to explain themselves and their arcane workings.  Learning to be accountable – or at least to give sufficient semblance of it so that the parties and their sniffer dogs would go away – was something they learned fast.  They had to.

There were a number of stushies and scandals in the early days.  The biggest was something or other to do with exams and the SQA.  I’d go and google it if I could be bovvered but it is a sign of how things were in those frantic early times that the headlines were dominated for weeks by an issue that caused the nascent Labour-Liberal Democrat administration no end of pain but which now, few can remember the detail of.  Whatever, accountability for errors was demanded and truly received.  Various mandarins’ heads appeared on plates, the quango was reformed and we all moved on.

It’s hard to believe – it’s the kind of tale that historians will recount incredulously, I feel – that we lost a First Minister due to nothing very much at all.  Henry McLeish fell on his sword not because  of double accounting of office sub-lets, rents and parliamentary allowances, but because he could not explain himself on the telly.  I can recall his appearance on BBC Question Time with every toe-curling utterance;  by the time Dimbleby had finished with him, I was literally in the foetal position.  But to have an FM resign over this?  Yep, welcome to the bright, new shiny dawn of Scottish politics where we expect whiter than white and the ability to string a sentence together.

Then we lost a Conservative leader over claiming the odd taxi erroneously for parliamentary responsibilities when he had in fact been on party business.  That little episode was accompanied by the frantic rustling of expense claims all over the old PHQ (it’s now the Missoni Hotel) as staffers and MSPs combed through years’ worth of theirs.  There was also an awful lot of emptying of piggy banks as rogue taxi journeys were suddenly repaid.

When McLetchie finally did the decent thing and took the fall so no-one else had to – good job really or we might not have had an MSP left – the collective sigh of relief was tangible.  No one, least of all McLetchie who seems like a pretty honourable and straight up and down man to me, had ever claimed a taxi journey not quite for purely parliamentary business deliberately;  but that wasn’t the point.  Blood was scented, the political hack-pack got its dander up, and a resignation became inevitable.  In Scotland, like the best, wee country in the world we had become, we like our scandals wee as well.

Over the years, everyone settled down into a rhythm and it all became rather anodyne.   And something key changed the political dynamic, in that the SNP decided to focus on the pursuit of power instead of settling for harrying in opposition.  The rest, as they say, is history.

Once in power, the SNP, having largely forged its political craft in opposition, knew exactly the kind of pitfalls and traps it had to avoid.  Its ability to manage the agenda was made easier thanks largely to the redoubtable and remarkable talents of Kevin Pringle, for whom sleep and holidays are anathema.  Labour, meanwhile, has struggled to work out which way up one opens the box marked opposition and changes in the ranks of political journalists and the loss of specialist correspondents, as well as introspective concern for their own industry’s fortunes, seemed to sap the media’s energy for political dust-ups.

All these – and many more – factors have conspired to provide the SNP with a charmed life.

How else to explain how the SNP escaped unscathed from having the most MSPs, including high-ranking government ministers, of any of the parties to use (and some might say, misuse) the parliamentary allowance scheme which allowed them to purchase flats in Edinburgh, pay the mortgages at the taxpayers’ expense and then sell them, pocketing the often huge capital gain in the process.  Some deigned to offer to pay the capital gains tax – has anyone bothered to check if they did?  We did nothing wrong was the cry at the time, but it didn’t seem very right either.

Currently, we have a brew of incompetence and intransigence of potentially enormous proportions in the failure of the education system and its serried ranks of vested interests to implement in any meaningful fashion the Curriculum for Excellence.   A few weeks ago, the Education Secretary assured us the final and vital phase relating to a switch in exam qualifications would go ahead.  Then he was forced to throw some money at it to help make this happen and now, he has had to offer schools the opportunity to delay if they need to.  Today, the teachers’ unions are bleating for still more concessions.

This is the major flagship education reform of our time.  It is huge and has been nine years in the making.  Work started on implementation as soon as the SNP came into power, five years ago.  And still we are not ready.   To be fair to Mike Russell, he inherited this mess rather than made it and is doing his best to sort it out.  But failure to get this right threatens the life chances of a generation of Scots – it is that serious.   And yet, no one has suggested that heads need to roll.   He is clearly deploying a policy of appeasement in order to get the job done but surely at some point, there needs to be accountability.  The problem is that having learned how to be accountable, many have spent these middle years of devolution mastering the art of how to bury the evidence and get away with it.

Health might prove a turning point.  This week, we’ve had not one but two stones skimmed across the political pond, and they are creating a bit of a bounce.  In the Health Secretary’s back yard, Labour alleged that old people were being left to shiver without blankets in hospital.  Nonsense cried the Government, but then Labour presented the First Minister with Exhibit A – the pensioners in person – this week in Holyrood.  One example does not a scandal make, but if Labour can find more hospital patients experiencing the same indignities, they might be on to something.

If they want to land a blow on the Health Secretary, they have their work cut out.  What’s the best way to diffuse a potential timebomb?  Announce it yourself.   Hence, Nicola Sturgeon, whose political streetsmarts were always way beyond her relatively tender years, laid bare the false accounting of waiting times going on at NHS Lothian and condemned it utterly.  Labour is now asking for an audit in other health board areas.  Deliberate massaging of key health policy is unforgiveable and if there has been wholesale fraud – in its truest sense – then an awful lot of senior health managers and chairpersons might want to start clearing their desks.

At last, Labour is showing small signs of getting its act together in being able to nose out potential scandals that might stick.  To date, the Scottish Government has shown huge skill at delivering on manifesto headlines, even if the reality behind the scenes is much less clearcut.   It has bossed the news agenda to a remarkable degree (despite what the SNP rank and file might think); its attitude to government enthused many government officers and that helped things along.  This gloss, in particular, is wearing thin and implementation “issues” are starting to appear.  Crucially too, the SNP has also enjoyed a very large dollop of luck.

So far, the wind has been set fair for this Scottish Government;  it will be interesting to see how it copes with a change in direction and these, and other as yet unidentified, squalls on the horizon.

The odd relationship between less and more

Even I have to admit that the burdz mind is a scary place.  There is a constant swirl of questions on policy matters to which I, and no one else, seem to have the answer.

Scottish Labour reckons 13,500 jobs will be lost under this year’s local government settlement.  Is this necessarily by itself, a bad thing?  If the work these people used to do is no longer there, why should they continue to be employed to do nothing?  Of course, the removal of that work is what might well be the bad thing but is that necessarily so?

Take police funding, numbers and crime levels. Generally, police funding has been protected in this round of budgeting, largely due to it being ring-fenced and therefore, allocated separately by the Scottish Government.  Where police forces have identified shortfalls between government grant and their spending need – often, it is claimed, to keep services and police numbers at previous levels – local authorities will top up out of their funding allocations, taking money away from other services in the process.

But why is no one challenging the assumption that the police needs this money more than other areas?  Crime levels are down generally, although there are stubborn and worrying upward trends in violent crime.  Even the fear of crime is decreasing.  The Cabinet Secretary for Justice, Kenny MacAskill, regularly trumpets the Scottish Government’s success in this area.  So why do we continue to need more police, or at least, the same number of police as before?  Or is it – as is asserted – that the high number of police officers has resulted in those crime figures dropping?

There is an unhelpful trend in policy circles, now that the Scottish Government has committed itself to shifting expenditure away from just in time (or after the fact) intervention to acting early and therefore, preventing problems happening further down the line.  This approach clearly has implications for current services and fiefdoms with services and areas of expenditure at the wrong end of the spectrum at risk.  So everyone is now making a claim for what they do as amounting to preventative spending.  The police is no exception.  Investing in high numbers of police officers is preventative because it is resulting in fewer crimes – see?  Look at the figures, there is the evidence.

But in truth, that is spending at the wrong end of the spectrum.  That is waiting for problems to arise, for the circumstances which allow crime to flourish to continue unchecked and unaddressed, sitting back and watching the children who get themselves into “bother” at an early age graduate as full-blown potential adult criminals.  Surely, if we are serious about preventing things, the money currently spent on expensive police officers should be being spent on much cheaper health visitors, family support workers, nursery and classroom assistants, play workers and therapists who can stop the chain of supply, or at least try to.

Yet, these are the kinds of things being cut from many council and health board budgets.  Sarah Boyack was right to point out that women workers, in particular, are most likely to be worst affected by jobs going.  So here’s another question – why is it that women’s work and jobs are expendable when cuts have to be made, when men’s are not?

More questions, this time on health.  Why are health boards overspending despite having their funding protected?  The increasing cost of drugs is not a good enough answer, frankly.  Aren’t there cheaper ones available?  If not, why not?  And why are we continuing to spend so much on drugs in any event?  Significant progress is being made on tackling some of Scotland’s biggest health ills – cancer, heart disease and stroke.  So why then is having fewer nurses and doctors – as Labour is wont to decry – by itself a bad thing?

Surely, if we are all healthier and our wellbeing is improved, we need fewer health professionals to treat us?  Or is it because we have huge numbers of health professionals that we are all getting better?  But, of course, we are not all getting better.  In many deprived areas, the outcomes in terms of wellbeing and life expectancy are woeful.  Are we diverting resources into these areas – in serious amounts – to try and fix these problems, to address the huge inequalities that exist?  Are better off areas getting significantly less to spend as a result?  Of course not.

Yet, some of those areas with better health outcomes are highly rural.  Providing any level of healthcare costs more because of rurality and the lack of economy of scale in provision.  It is much cheaper to provide key services in high population areas than in low ones, where higher numbers of people can be provided for.  Have we managed to resolve this conundrum yet, beyond the time-honoured swing back and forth between centralisation and specialism, and localities and generalism?

This dichotomy exists all over the public sector.  There are fewer children, so why do we need more teachers, unless it is to invest in smaller class sizes, something most councils paid lip service to in the years of plenty and have now largely given up on, now times are lean.  Is the spend per pupil the same in well-off areas as in poorer ones?  Is universalism the right approach anymore if 20% of children are still being left behind, despite record levels of investment in education over the last thirteen years?

Local authority housing has, for many years, provided one of the best/worst examples of illogicality in expenditure.  Look at most housing revenue accounts over the last ten years and you will find a pattern of falling numbers of houses, reduced or at best, largely static maintenance budgets but increased spending on staffing and especially, management activity.  And rising rents to pay for it all.  The result?  Tenants paying more for less.

Admittedly, this was much more heightened when right to buy was at its peak, but the point is the mindset.  It is prevalent and redolent everywhere in the public sector.  Short term decisions are made, largely to preserve vested and self-interest, when what we need is strategic policy-making at all levels of government which applies resources, methodically and evidentially, to where and how they might be needed most and will have the greatest effect.  We’ve been promised shifts in the planning, design and delivery of services for years, yet now the chips are down, we’re getting the same old, panic driven, slash and burn approach to making cuts.  Yet, by and large, there is still “more” right across the public sector, even when it is required to tackle “less”.  Worst of all, is when there is “more” but “less” to show for it.

I told you my mind was a scary place, but one final question.  Isn’t it scarier still that key influencers and policymakers – politicians especially – aren’t asking questions like these and applying themselves to finding or working out the answers?