State of the debate: Would the NHS and the welfare state be ‘safe’ in an independent Scotland?

In this state of the debate blog, Kirstein Rummery discusses the prospects of the NHS and the welfare state in an independent Scotland.

Following recent spats between the SNP and the Coalition over the future of the NHS and the welfare state in Scotland, Labour has further politicised the debate by asking just how safe the NHS and the welfare state is currently in the SNP’s hands.

Health and social care policy is already entirely devolved to Scotland, and the Scottish Parliament already has the option to ring-fence budgets and follow its own path.  And Labour has a point, to a certain extent: Scotland spends around 1% of its NHS budget in the private sector – however this has been a fairly recent development, with the sharpest increase since 2011, as opposed to the English and Welsh NHS budget which spends around 6% of its budget in the private sector - moves which began under Labour.

Moreover, the *type* of spending differs between Scotland and the rest of the UK, with most of the Scottish budget going on outsourcing services in order to cut waiting lists, whereas the English and Welsh budget has been largely spent on public private partnerships which involve capital investment in the infrastructure of the health service. Following the 2012 Health and Social Care Act, private companies can now bid to run a whole range of health services – and will win the bids by proving they can provide a service at a lower cost than the NHS (which, experience from commissioning in the social care sector shows, will be done by putting downward pressure on wages, removing social benefits and protection, outsourcing core services and asking patients to make up the difference in cost from their own pockets).

So although Scotland could ‘hold the line’ against privatisation of the NHS in Scotland, it would have to do so under public spending restraints: it can divide the pot as it sees fit, but it can’t decide the size of the pot. Similarly, whilst Scotland has purported to ‘hold the line’ on the privatisation of social care against the Westminster model, in reality it spends around a third of its budget commissioning provision from non-local authority providers, and aims to increase this. Nevertheless, free personal care in Scotland remains a departure from the Westminster model, and a commitment to the integration of health and social care rather than marketisation of the NHS  points to a more universalist approach to welfare than is the case in England and Wales.

However, all of this inter-political wrangling over policy history, funding and personalities misses the essential point about the welfare state under a possible independent Scotland completely.

At the moment, the NHS and the welfare state is not ‘safe’ in anyone’s hands. All of the founding principles of the NHS held dear by the Scots, and by the British public – being funded through national taxation, being available according to need, not according to the ability to pay, being publically funded and owned (if not run) – are at present only available to citizens on the basis of political whim. Any political party could change the way the health service is funded, governed and run, simply by passing a statute that does so.  Similarly, the principles of fairness, equality and universality  in welfare held dear by Scots (such as free higher education, free personal care, antipathy to ‘unfair’ taxes and benefits changes such as the ‘Poll Tax’ and the ‘Bedroom Tax’) are also entirely at the whim of politicians and Parliament, and could be changed or withdrawn at any time.

Only enshrining principles of social justice, universality and equality in a written constitution would make the NHS and welfare state ‘safe’.

And even then, the Constitution would have to be negotiated in such a way that it learned from countries with these principles in their legal frameworks: ie, involving values of fairness, equality and universality being backed by guaranteed governance and social rights: for example, a commitment to public ownership of assets, and universal access to guaranteed services on the basis of need.

So, in a sense, both sides were right. The No campaign’s point that the focus on the NHS was disingenuous, given the devolved nature of health funding and policy, was fair. However, the Yes campaigns point that only and independent Scotland could guarantee the safety of the NHS is also true, because only an independent Scotland would have the opportunity to enshrine that principle into a written constitution that could not be easily undone by future policy makers.

Scottish voters are being asked to vote on whether Scotland should govern itself under a new constitutional settlement, not on possible future policies that in any case nothing more than paper promises. That settlement *could* protect the NHS and the welfare state, but there are no guarantees of that. The status quo almost certainly won’t, unless the 2015 general elections puts a party into power that is committed to social justice, universality and equality.

And where would we find one of those?

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Kirstein Rummery's picture
University of Stirling
21st August 2014
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