CHAPTER 6 A HEALTHIER AND SMARTER SCOTLAND
6.1 Scotland has a long history of distinctive education, children's services and health systems within the United Kingdom. Devolution has shown the potential that greater autonomy gives Scotland to bring improvements to these systems, while preserving their traditional features. Free personal care for the elderly and the ban on smoking in public places have been landmark achievements of the Scottish Parliament. Scotland's health service has maintained its integrated structure while reducing waiting times, and public health legislation has been modernised. In education, the Curriculum for Excellence has modernised the schools system, while legislation has given greater rights to those requiring particular support for learning.
6.2 Independence would allow health and education to build on the achievements of devolution, integrating the support offered with important reserved matters, particularly the benefit and taxation system, and contributing to tackling wider issues of poverty, ill health and economic inactivity in Scottish society.
6.3 From its inception, and in particular since devolution, the NHS in Scotland has been largely independent from the rest of the United Kingdom, and shaped by different patterns of need and geography. Such differences have defined the provision of free health care in Scotland, and the NHS in Scotland today is markedly different from that in England and Wales. Scotland has a long-standing integrated healthcare system. General Practitioners refer patients to a treatment centre within their own Board area or elsewhere if the required service is not provided locally. There is no competition, or internal market, operating across the NHS in Scotland.
6.4 Responsibility for the provision of health care is almost entirely devolved and there have been significant achievements over the last ten years: a reduction in waiting times through more efficient ways of working; better workforce planning; more investment in new diagnostic equipment; the development of the single patient record. Prescription charges are being phased out to ensure that all patients have access to the prescriptions they require. Public health legislation has been modernised through the Public Health etc. (Scotland) Act 2008. Scotland led in the United Kingdom with legislation to ban smoking in public places.
6.5 The NHS in Scotland contributes directly to other policy objectives: growth in the Scottish economy through investment in medical and life sciences technology, and continuous improvement in its healthcare services; developing a highly skilled workforce with increasing productivity levels; and improving the health and wellbeing of the working age population.
6.6 Relatively few areas related to health are reserved. Those which are include: regulation of the main health professions; misuse of drugs; medicines, medical supplies and poisons; embryology, surrogacy and genetics; and abortion. 111
Health recommendations of the Commission on Scottish Devolution
6.7 The Commission made one recommendation directly affecting health matters: that regulation of all health professions should be reserved. The Scotland Act reserves to the United Kingdom regulation of health professions which existed when the Act was passed. Regulation of any new health profession has been devolved. If the regulation of all professions was reserved there would be no guarantee that the differences in Scotland's health structures and systems would be taken into account, as there would be no statutory imperative for the United Kingdom Government to seek agreement to its regulatory regimes.
What further steps
are planned to develop
our Health Service as
a public service in
be proud to work?
(Paisley National Conversation event, 14 September 2009)
6.8 Scotland already has responsibility to provide health care responsive and relevant to the needs of people in Scotland, and free at the point of delivery. However, Scotland does not have responsibility in areas that could be used to help reduce the negative health effects of smoking and alcohol misuse. For example, alcohol misuse is one of the most serious health problems facing Scotland, and it also has significant social and economic consequences. Responsibility for some key mechanisms to address this issue - such as taxation levels on alcohol and the advertising of alcohol - remains reserved to the United Kingdom.
6.9 With devolution Scotland has demonstrated its innovative approach to public health and to the delivery of healthcare. Scotland has maintained a high quality service based on a traditional national model, and avoiding market led innovations that have been introduced elsewhere in the NHS. Independence would ensure that Scotland had full responsibility for the entirety of its health system, including the few health policy areas reserved to the United Kingdom, and, wider policy areas which could support health policies in the economic and social fields.
6.10 Under independence, cross-border co-operation in health could be enhanced. In some areas, co-operation has arisen out of necessity, requiring a sharing of scarce resources or consistency of approach to complex issues; in others, it has arisen because of the benefits co-operation has brought for both the people of Scotland, and the rest of the United Kingdom.
6.11 The allocation of organs for donation and transplantation is carried out on a United Kingdom-basis, which ensures the best match between donor and recipient can be achieved. This arrangement could be maintained in an independent Scotland to ensure equal access for every citizen in the United Kingdom who requires a transplant. Likewise, there are United Kingdom-wide arrangements for the commissioning of specialist health services for conditions or treatments that are so rare or specialised that no single United Kingdom country could sustain them alone. Similar agreements exist on a European Union basis. These arrangements are managed on behalf of Scotland by the National Services Division of NHS National Services Scotland, to ensure that the people of Scotland have access to such rare and specialised services when they need them.
BOX 11: FREE PERSONAL CARE112
1. Free Personal and Nursing Care has been one of the most high-profile Scottish policies since devolution. Over 50,000 vulnerable older people in Scotland are currently receiving assistance through the scheme. Around 42,000 people are now receiving personal care services at home at no charge allowing them to remain in their own homes and live independently for longer. 9,600 self-funders in care homes are receiving a weekly payment of £153 towards their personal care and around 6,100 of these self-funders are also receiving £69 per week towards their nursing care costs. The balance has shifted from residential care to supporting people in their own homes for long as possible.
2. The implementation of free personal care illustrated a difficulty of implementing devolved policy which interacts with the reserved benefits system. The United Kingdom Government withdrew Attendance Allowance from those people in care homes receiving free personal care. The Scottish Government had to ensure that these individuals are not disadvantaged financially as a result at a cost of £30 million a year.
BOX 12: SMOKING BAN
1. On 26 March 2006, Scotland became the first part of the United Kingdom to introduce comprehensive legislation to ban smoking in enclosed public places. The legislation has been hailed not only as the most important piece of public health legislation since the introduction of the NHS but as a defining moment in devolution. It is widely acknowledged that the leadership shown by the Scottish Parliament encouraged smoking bans elsewhere in the United Kingdom.
2. The legislation was preceded by an innovative work programme to raise awareness of the health risks of passive smoking, research current smoking policies, gather international evidence about the health and economic impact of smoking bans, and to test public opinion by a major public consultation through a number of routes. This provided a wealth of evidence, including of public support, on which to base the ban.
EDUCATION AND CHILDREN
6.12 Scotland has long had its own education system, with a distinctive curriculum framework, qualifications and examination system, and compulsory periods of education. The quality of Scotland's Universities is recognised internationally (see Box 6). Scotland has its own systems of pre-school education, childcare, children's services, a children's hearings system, social work and youth work. With devolution in 1999, the Scottish Parliament gained legislative responsibility for this education system.
6.13 Successive Scottish Governments have used devolved responsibilities to improve the Scottish education system, including the Curriculum for Excellence, the biggest reform of the Scottish education system for a generation. Legislative action has been taken to strengthen the rights of parents and young people with additional support needs, and planned provisions will update and strengthen the consultation practices and procedures for proposals that affect education services, such as the closure of schools.
6.14 However, the current constitutional settlement places limits on the action that can be taken in Scotland to improve the lives of children and young people. In particular, the benefits and tax credits system is not responsive to Scotland's specific needs and is organised on a United Kingdom-wide basis.
Children recommendations of the Commission on Scottish Devolution
6.15 The Commission made only one recommendation concerning children services: that in dealing with the children of asylum seekers, the relevant United Kingdom authorities must recognise the statutory responsibilities of Scottish authorities for the well-being of children in Scotland.
How are we going to equip our children
to meet the challenges of recession?
Is independence going to bring more
opportunities from them?
(Edinburgh CEMVO National Conversation event, 22 April 2009)
6.16 This recommendation reflects recent practice. Scottish and United Kingdom Governments have regular discussions about statutory duties to promote the well-being of children seeking asylum in Scotland. Since January 2009 all United Kingdom Borders Agency staff and contractors have been operating under a statutory Code of Practice to keep children safe from harm, and will be subject to a new statutory duty from the autumn to safeguard and promote the welfare of children. When children are detained at Dungavel, an agreement exists between the Borders Agency and the local authority to ensure that children are given the help and support they need, though the Scottish Government remains opposed to any such detention of children.
6.17 Independence - or full devolution -would allow children's services to be integrated with support through the tax credit and benefits system. For example, support with the costs of childcare (demand-side funding) is reserved to the United Kingdom Government and is funded through the tax credit system, while childcare provision (support-side spending) is devolved to the Scottish Government. Parents find this split of responsibilities confusing and there is widespread criticism of the way the tax credit system works. If the Scottish Government had responsibility for supply and demand side funding for childcare it could construct progressive support for the costs of childcare, which is simple and accessible for parents.
6.18 The achievements in health and education since devolution demonstrate the potential for Scotland to flourish when it has full responsibility and can develop and implement policies to meet particular Scottish priorities and needs. Independence would allow Scotland to bring a similar approach to all areas of government activity, as well as integrating existing health and education services in wider mechanisms to support and develop the people of Scotland.