Health to get a higher priority in post-devolution Scotland

BMJ 1999; 318 doi: (Published 09 January 1999) Cite this as: BMJ 1999;318:80

Devolution looks set to produce more radical healthcare policies in Scotland, such as “no fault” compensation, but could threaten higher funding. Health minister Sam Galbraith tells Bryan Christie what he hopes the advent of a Scottish Parliament will achieve

It was a simple statement buried in the body of the text of the Scottish white paper on health, Designed to Care, yet it coloured everything around it: “Sometimes changes have been made in Scotland to reflect changes in England rather than in response to specific Scottish needs.” It went on to forecast that the establishment of the Scottish parliament would create a Scottish NHS more finely tuned and more rapidly responsive to Scottish needs.

In those two sentences a new direction was set for the Scottish health service as it unhooks itself from its bigger partner south of the border. Since then, the beginnings of a new identity have been forged in a process which looks certain to accelerate after the parliament opens in July. Scotland's health service is entering a period of substantial opportunity, offset by an element of incalculable risk. Sam Galbraith, the current Scottish health minister, hopes to be at the centre of it.

He is expected to be the parliament's first health minister if Labour becomes the dominant party after the May election. Certainly there can be few people better equipped for such a role. Mr Galbraith has an unrivalled understanding of the health service both as a doctor and a patient. He was the youngest consultant neurosurgeon in Britain when he was appointed at the age of 32in 1977; 13 years later he was to owe his life to the skills of other surgeons when he was given a lung transplant at the Freeman Hospital in Newcastle. He has been a frightened patient and a successful surgeon, and his determination to improve services is driven by both these experiences.

He believes that the previous government was wrong to try to impose a uniform structure on the NHS. Although there should be common provision throughout the United Kingdom, the manner in which that is achieved can differ. This has been recognised since the earliest days of the NHS, which was set up in Scotland with a separate act of parliament and a slightly modified structure from the rest of the United Kingdom. Some doctors hope that radical initiatives will be pursued by the Scottish parliament including such things as the introduction of a system of “no fault” compensation for the victims of medical accidents and the free, or heavily subsidised, provision of fruit and vegetables to people living in disadvantaged areas.

Mr Galbraith hopes to see these sorts of ideas debated by the parliament and believes one of its greatest strengths will be in exposing problems and framing solutions. Scottish health issues were largely ignored under the Westminster system.

During the five year term of the last government, only 90minutes of parliamentary time were given over to Scottish health. In the Edinburgh parliament, it will be one of the major responsibilities. “It will raise the profile of health issues,” said Mr Galbraith.

But the changes which will come about with the creation of a Scottish parliament are not without risk. One of the biggest fears is that it could disturb a UK funding formula which has benefited the Scottish health service. Currently, health spending in Scotland is 23% higher than in England and Wales to reflect the greater burden of ill health in Scotland and the need to deliver services to sparsely populated areas.

Mr Galbraith said that this increased spending is justified and he is confident that it will continue.

However, others are concerned that the day may come when different parties are in power in Edinburgh and Westminster, placing the extra funding at risk. The Westminster government could decide to stop sending extra money over the border when it has no control over how it is being spent.

Another area of concern relates to the control which the Scottish parliament will have over the terms and conditions of employment of NHS staff. In theory, it could set different pay levels for Scottish doctors from those in the rest of the United Kingdom but Mr Galbraith doubted if any substantial change would be made. “This is a national health service and we will want to ensure the continuing flow of services and people.”

Scotland is already making changes in other areas which are leading to clear differences north and south of the border. The National Institute for Clinical Excellence (NICE) and the Commission for Health Improvement (CHI), which are being set up in England, are not being replicated in Scotland. Mr Galbraith said Scotland has led the way with auditing performance, producing guidelines, and publishing information on clinical outcomes.

While promising to be tough on quality through the new Clinical Standards Board, which will come into effect in April, he said there is no intention to introduce “hit squads” in Scotland. “We already know every surgeon's mortality rates in Scotland. We can detect when things are going wrong early on. Because we are smaller it's easier to know what is happening and this allows us to have a more cooperative, partnership model.”

Another major change is that Scotland has completed an intensive review of its acute services which is leading to the development of clinical networks. In these networks doctors work in teams across different hospitals and their work is identified with the service rather than an individual institution.

Mr Galbraith is clear, however, on what needs to be done to deliver quicker, better treatment for patients. He wants the NHS to focus on the output of treatment rather than the system that produces it. “We have been concerned for too long with structure. What we have to do now is concentrate on what it is we are delivering and build a structure around that.”<image;15021>

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Scottish health minister Sam Galbraith hopes devolution will achieve a more focused service for the country

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