The settled will of the Scottish people that Scotland should remain part of the UK was expressed in the outcome of the independence referendum on 18 September 2014—at least for the time being. The campaign has left not only the nation divided but also split families and put strains on longstanding friendships. Strong proponents of independence, despite being told initially that this was a once-in-a-lifetime, then once-in-a-generation opportunity, have become even more determined to achieve their goal to end any rule from Westminster.
The campaign was a far from healthy debate at times. One of our local elected representatives stated that people who intended to vote No were second-class citizens, and social media was dominated by the ‘cybernats’ who attacked anyone that expressed support for the UK. In order to avoid the systematic defacing of posters, one local farmer ploughed a giant ‘No’ into a hillside stubble field overlooking our town. In her British Medical Journal column, Margaret McCartney felt almost obliged to apologise for voting No.1 When a former UK treasurer of the Royal College of General Practitioners (RCGP) highlighted in a newsletter the potential problems of a ‘Yes’ vote for the College, the RCGP had to quickly issue a clarification that this was a personal view.
Health featured prominently in the campaign. The Nationalists maintained that only independence would save the Scottish NHS from English-style privatisation. They have yet to explain the reasons why, since they are responsible for all decisions about the NHS in Scotland and health spending depends on political decisions, not the constitution. Very few independent commentators believed that gross domestic product would go up in an independent Scotland, so potentially there would have been less money to spend on health. Research published by the Institute of Fiscal Studies showed that between 2009 and 2016, spending on the NHS in England will have risen by 4% in real terms but fallen by 1% in Scotland.2 The Scottish National Party has placed less priority on funding the NHS in Scotland than Westminster governments have for England. What the Yes campaign did very successfully was to convince Scottish voters that in England, privatisation meant paying for services directly rather than outsourcing service provision.
Both staffing and funding of health will now need to be addressed—in the run up to the referendum, no decisions were taken that could upset anyone. Soon after the vote, national headlines highlighted how Aberdeen Royal Infirmary had paid expenses for a locum in A&E to travel from India for two 12-hour weekend shifts.3 The Health Board chairman has now resigned but opponents blame our soon-to-be First Minister for failing to address a funding disparity, by not implementing the 2007 recommendations of the National Resource Allocation Committee Report.
In the short term general practice continues to have to deal with rising patient demand, medical complexity, and government initiatives of dubious benefit to patient outcomes. The Scottish negotiators have in recent years gone along with a ‘tartanisation’ of the quality and outcomes framework but this year the Scottish Local Medical Committee conference voted effectively to withdraw from the UK national contract negotiations. Following a period of ‘stability’ but with ‘early changes’, the Scottish General Practitioners Committee will look to develop a Scottish contract from 1 April 2017. Dean Marshall, a UK GP negotiator, again warned of the dangers of going it alone but his persuasive powers of the previous 3 years did not prevail this time. After the No vote, our negotiators may be the Scottish Government’s ‘new best friends’ but we wait expectantly to see if there are any benefits for practices and patient care.
In Scotland there is now likely to be a state of ‘neverendum’ and the resulting instability will cause firms in the financial sector to consider again whether it is worth being based north of the border. Once again we will all lose but if the next vote (when it comes) is against the context of the UK having voted to leave the European Union (EU), then the result may be very different.
- McCartney M. For Scotland, the real winner is democracy. BMJ 2014; 349: g5773.
- Institute for Fiscal Studies website. The Scottish NHS—more financially secure outside the UK? www.ifs.org.uk/publications/7366 (accessed 3 November 2014).
- BBC website. Health board defends flying locum doctor from India. www.bbc.co.uk/news/uk-scotland-north-east-orkney-shetland-29392449 (accessed 3 November 2014).