First published in Health Service Journal on 11 September 2014: http://bit.ly/WN8RX
And so the unthinkable has happened: One week to go until the Scottish independence referendum and the polls suggest the rival Yes and No campaigns are neck and neck.
Such alarm has this created in Westminster, that on Wednesday we witnessed the undignified spectacle of David Cameron, Ed Milliband and Nick Clegg jetting to Edinburgh in a desperate bid to inject some life into the flagging Better Together campaign, which wants Scots to vote ‘No’.
How has it gone so disastrously wrong for Better Together, which a year ago enjoyed what seemed like an unassailable lead? There is no simple answer. But almost since the starting gun fired, the campaign to save the Union has been dogged by accusations that it amounts to ‘Project Fear’ – an endless litany of ever more shrill and dire warnings on everything from currency to pensions, mortgages to EU membership. It’s clear this has been a turn-off for many voters.
But Yes Scotland, and the SNP Scottish Government, have also slipped up, not least in their insistence that Scotland will be able to form a currency union with the remaining UK, in spite of the Westminster parties’ refusal and warnings from the Bank of England’s boss Mark Carney that this would be undesirable.
So why has Yes Scotland ostensibly made up so much ground, so quickly, and in spite of near-universal media hostility (with the notable exception of the Sunday Herald)?
Arguably, it’s all down to the NHS.
Most people in England are totally in the dark about the changes in Scotland brought about by devolution. But since 1999 Scotland has had a legislatively, as well as administratively (this had been the case since its foundation in 1948), separate NHS to England.
The practical effect of this is that the health services of the two nations have diverged widely in the intervening period.
The English NHS has undergone a transformation into a more market-orientated body, particularly since the Coalition came to power in 2010 and perhaps best exemplified in legislation by the Health and Social Care Act 2012, which transformed the commissioning landscape in England and created opportunities for private healthcare providers to deliver certain NHS services.
In stark contrast, successive Holyrood governments have resisted almost all involvement by the private sector. The Scottish Government has presented this as a preservation of the original ethos of the NHS.
At the same time, NHS Scotland has been the subject of key populist policies such as Free Personal Care for the elderly, scrapping prescription charges, free eye tests and eliminating hospital car parking fees.
It’s no coincidence that one of the leaders of the Yes campaign – the SNP’s Nicola Sturgeon – is also a former health secretary. Sturgeon is a formidable operator, one of the SNP’s leading lights and effectively a ‘vice-president’ figure next to Salmond. There can be little doubt that she has masterminded much of the rhetoric from the Yes campaign on the NHS.
This has entailed a simple presentational contrast between an increasingly fragmented English NHS – which even critics in England fear is in the process of being dismantled – and a still-centralised and resolutely public Scottish NHS.
By doing so, the Yes campaign has been able to appeal simultaneously to Scots’ pride in their NHS – the most tangible remaining example of a common national asset – and their deep distrust of the Tories and their motives.
Alex Salmond even went as far as holding a carefully stage-managed photocall at Arbroath Abbey – where the famous declaration setting out Scotland’s original independence was drafted in 1320 – where he promised that a Scottish NHS free from the “Westminster privatisation drive” would be written into an independent Scotland’s constitution.
For many Scots, public ownership of state assets is an expression of Scottish belief in the ‘common weal’, a direct link with historical firsts such as universal state education and a philosophical bond with Rabbie Burns’ egalitarian poems and even the ideals penned in the Declaration of Arbroath. So this cleverly orchestrated connection between a medieval document and Scotland’s modern health service has deep appeal in the Scottish psyche.
For its part, the Westminster government has hit back, with David Cameron accusing Salmond of being a “desperate man with a desperate argument”, saying that because health is a devolved matter, only Salmond has the power to privatise health services.
But the nationalists’ oft-repeated mantra that eventual cuts to the NHS in England will lead to knock-on effects on the £11.6bn Scottish health budget via the Barnett Formula appears to be worrying sufficient numbers of undecided voters into opting for Yes. Of course, it’s hard to say exactly how many of these voters see the NHS as a prime motivation, but it is striking how the upswing in Yes fortunes coincides neatly with the debate focusing on the health service.
We are now squarely into the endgame. On social media, Scots are nailing their colours to the mast in the form of a rash of Yes and No twibbons and profile pictures. We can expect an exhilarating final week.
But if we do wake up on September 19th to a Yes victory, and people are still scratching their heads as to why, we probably don’t need to look much further than three little letters.
by James Tout