by James Mittra (Innogen Research Fellow, University of Edinburgh)
The recently published Scottish White Paper on independence includes a relatively small section on health, social care and the NHS (pages 170-176), as part of a larger chapter on Health, Wellbeing and Social Protection (chapter 4). Like the rest of the document, the narrative is very positive in explaining the many benefits that have come with devolution, such as allowing Scotland to respond to its own national needs, which are different from the rest of the UK. The unique challenges that continue to face Scotland are also outlined and full independence is presented as creating new opportunities to respond to these more effectively. As many commentators have pointed out, however, the document is weighty in terms of the sheer volume of pages, but rather light on detail. This is perhaps unsurprising when considering the range of issues that are implicated in the independence debate.
On the topic of health, which is where my research interest lies and is the central topic of an ESRC Future of the UK and Scotland project I run, the focus of the document is very much on reassuring the public that access to NHS services will not be negatively affected by a Yes vote. As health is already fully devolved, the argument is that most aspects of healthcare delivery will pretty much stay the same. The advantages that devolved healthcare has brought about are clearly set out in the document and do represent real success. For example, Scotland has been able to avoid much of the organisational restructuring of the NHS that has taken place in England, and real progress has been made in linking the health boards and joining up health and social care.
So while day-to-day management of the NHS and access to services will likely remain unchanged, the Scottish government claims that Independence could facilitate a transformation in the environment within which the NHS operates, so that health inequalities (which are significant and growing problems) can be tackled more effectively. One positive benefit outlined, amongst many others, is that Scotland would be able to negotiate directly with the pharmaceutical industry on the price of drugs, rather than doing this through UK bodies. These are all laudable goals, and the positive initiatives that have been implemented under devolution suggest that there could be further benefits from Independence.
However, the document says very little in terms of clinical research, which is currently only partially devolved. This is interesting, because clinical research is a key strength in Scotland and there are clear links and contingencies between the research and the health system. Scotland has been pioneering in terms of clinical research, and has built up significant assets and capabilities, particularly in the life sciences. Scotland has traditionally had a very strong commitment to ‘translational medicine’, which is an attempt to capitalise on basic research and ensure it is translated into viable clinical therapies to benefit patients. This has been reflected in a number of initiatives and commitments to infrastructure development since devolution. The question we are asking is how, and to what extent, independence would impact on the clinical research system and the institutional ecology that has been built up.
There are clear opportunities for building this research capacity under independence, and perhaps adopting new specialised strategies that meet specific health needs within Scotland, but this is not mentioned in the White Paper. There are also a lot of uncertainties about the clinical research system in terms of how it would be funded and governed. The White Paper states that under independence Scotland would seek to continue contributing to and drawing from UK research council funding within a single research area, although there is no guarantee yet that this would be supported by the rest of the UK. Again, there is no real detail on what the options might be (only that Scotland would pay into the system based on population size). Furthermore, charities, such as the Wellcome Trust, have expressed concern about contributing to research in an independent Scotland, so one cannot assume things will continue as they are currently. On regulation and governance, the White Paper states that Scotland would continue to contribute to regulatory bodies, such as the MHRA, for approval of drugs and not set up its own regulatory bodies, but again this is something that would have to be agreed and negotiated. It cannot simply be taken for granted.
Overall, the White Paper clearly sets out what the current Government thinks are the key benefits for Scotland of a yes vote, but on the important issue of clinical research and healthcare there are a number of outstanding questions that need to be answered before an informed decision can be made. In particular, the funding arrangements need to be firmly established, scenarios for a range of different contingencies outlined, and a clear strategy for developing research under Independence elaborated. A key question for the debate is whether independence would lower Scottish health and clinical research capacity and/or necessitate a significant change in current strategy and institutional relationships. There are likely to be many new opportunities with independence, but there are also multiple challenges and barriers that cannot be ignored and need to be addressed in the lead up to the referendum vote.