Policy responses and statements

Name of organisation:: Commission on Scottish Devolution
Name of policy document:: Evidence to the Commission on Scottish Devolution
Deadline for response:: 8 September 2008

Background: Sir Kenneth Calman has written to the President to say that the Commission on Scottish Devolution, which he chairs, is now seeking detailed input from the College into its work. The Commission's remit is:

"To review the provisions of the Scotland Act 1998 in the light of experience and to recommend any changes to the present constitutional arrangements that would enable the Scottish Parliament to better serve the people of Scotland, that would improve the financial accountability of the Scottish Parliament and that would continue to secure the position of Scotland within the United Kingdom".

Since the membership was announced on 28 April, the Commission has had 2 full and constructive meetings. Five "task groups" have been established to take forward key elements of its work, together with an independent expert groups to advise it on financial accountability. Some significant work is therefore underway on a number of fronts.

Public engagement will be central to the Commission's work. The Commission is committed to taking an evidence-based approach, and to listening to as wide a range of views as possible from across Scotland and the wider UK.

On 22 May, I invited initial suggestions for topics on which the Commission should focus its attention. The responses received have enabled the Commission to develop a clearer sense of where it needs more detailed information.

It is in that context that Sir Kenneth is now writing to invite the College to make a formal submission to the Commission. Submission may be on any matter within the Commission's remit, but it would be particularly helpful if they could be structured by references to the questions that are attached to this letter (although he appreciates that each organisation will wish to focus on those questions that are closest to its areas of expertise).

The questions on the attachment are supplemented by a list of some aspects of the 1998 Act, including some of the matters reserved by Schedule 5, on which the Commission would welcome views. This list has been compiled by reference to suggestions made to the Commission in response to Sir Kenneth's earlier letter, and does not represent the preliminary view of the Commission itself. In particular, the Commission has not yet taken a view on which matters (if any) that are currently reserved should be recommended for further devolution.

COMMENTS ON

COMMISSION ON SCOTTISH DEVOLUTION

EVIDENCE TO THE COMMISSION ON SCOTTISH DEVOLUTION

The Royal College of Physicians of Edinburgh is pleased to respond to the Commission on Scottish Devolution on Evidence to the Commission on Scottish Devolution.

The RCPE is an international professional association based in Edinburgh, supporting physicians and related medical professionals to maintain the highest standards of medical practice wherever they work. Outside Scotland, it has particularly strong representation from Northern Ireland, Northern England and areas of the English-speaking world. As such, it relates to several health systems and, although this can create tensions in relations with Scotland-only institutions, it also has the potential to create a richness of debate that pays dividends to Scottish policy making and health care.
The following comments are restricted to the impact of devolution on health and the standards of medicine as practiced in Scotland for the benefit of patients in Scotland.

General Comments

Policy and strategic development in health has benefited from closer attention to Scotland’s problems, freed from the dominant effect of English priorities and political imperatives, e.g. polyclinics or foundation hospitals. One such example is the new focus on remote and rural medicine and which brings the challenge of new models of professional support and care delivery to sustain high quality services in remote communities.
However the College is concerned that devolution could lead to isolation if mechanisms for mature discussion and shared policy making between administrations on health related issues are weak. Greer and Trench in their recent short report for the Nuffield Trust comment about the inefficiencies of devolution resulting from failed or minimal negotiations between administrations (Greer and Trench, Nuffield, 2008). Any perceived imbalance of power or authority between the Scottish devolved administration and their UK counterparts, particularly in Westminster, may impede effective working. This may be exacerbated when the political flavour of governments is different, as now with a SNP government at Holyrood negotiating with a Labour administration in Westminster.

Comments on the impact of devolution on specific health issues

Public Health Measures

Devolved powers in health policy and implementation have enabled Scotland to consider the particular public health challenges facing Scots and to take effective action independent of the timelines and priorities of the rest of the UK. Health risk behaviours such as heavy alcohol intake and smoking are historically more prevalent within the Scottish population and it is right that Scotland can make policy that is proportionate and culturally appropriate to Scottish health needs. Two clear examples are strategies to combat smoking levels and ambitious plans to address dangerous levels of alcohol consumption:

The focus on smoking in public places has allowed Scotland to lead the way to the wider benefit of the UK. Future plans to introduce local positive licensing schemes to enforce the newly increased age limits for purchasing tobacco may also have earlier success in Scotland.
Strategies to combat dangerous levels of alcohol consumption through new (minimum) pricing policies, reduced drink drive levels, and courageous plans to lift the minimum age for off sales are all under discussion in Scotland.
Limited legislative powers for the devolved Scottish Parliament, e.g. lack of freedom to raise excise duty or to make change under health and safety legislation, may be impeding enforcement measures to support these important health policies.

However, freedom to legislate and develop public health policy within a devolved Scotland has to be balanced against the need for a coordinated approach to UK wide problems such as the control of infectious disease either through immunisation or under emergency circumstances in response to pandemics or terrorist activity. Recent examples include the disproportionate effect of vCJD on North Britain compared with the South and the much higher incidence of E.coli 0157 in Scotland compared with England.
The different UK administrations must develop a mature approach to shared policy making on key devolved issues and Westminster must take account of expert evidence from the devolved administrations on reserved matters.

Regulation

The regulation of doctors and of postgraduate medical education remains reserved and is managed across the UK by the GMC and PMETB for which England carries most influence. The College is concerned that Scotland may be tempted to seek to extend devolved powers to regulation, believing that this will support implementation of appropriate (different) health policy in Scotland. The College believes that any fragmentation of standards through devolved regulation will not be in the best interests of patients.
The challenge for a devolved Scotland is to maintain and strengthen the distinctiveness of Scotland’s high quality medical education and the international reputation of Scottish medicine within a regulatory system that assures high standards of care.

Training , Education and Revalidation

A devolved Scotland should never underestimate the benefits of its international reputation in medicine that stem from education and training and high standards of medical practice. This may come at a premium but, in the long term, is of great benefit to a small and vibrant country.

Medical School Numbers

Scotland has traditionally been a net exporter of graduates in medicine, with many moving south into junior training posts in the NHS in England. This, combined with the reputation for centres of excellence in postgraduate medical education brings significant benefits to Scotland and thus to the UK. Overseas medical students return home imbued with the Scottish way of delivering care with consequent benefit to the UK and to its various healthcare industries. New medical schools in England are reducing the NHS dependency on doctors from outside the UK and immigration changes decided in Westminster and will encourage other countries to look elsewhere for support. Medical schools in Scotland may see a change in application numbers or in the calibre of applicants with consequent risk to their international reputation.

Post Graduate Training

The market for medical staff is global and if Scotland is to retain high quality medical staff, the quality and flexibility of training must remain consistent across the UK. At a time when post graduate medical education is undergoing great change, it is critical that Scottish solutions remain fixed firmly within a UK regulatory and training systems. This will ensure qualifications are transferable and standards are maintained.
Devolution has made England more defensive about ensuring post-graduate training posts for its own graduates and is expecting Scotland to do the same. This is already having an effect on Scottish medical schools and in the long term is likely to drive down Scottish medical school numbers. It will also decrease the influence that Scottish medicine has had for centuries on medicine in the rest of the UK and the world.
There is early evidence that even minor differences in training regimes can influence cross border flow of trainees to Scotland’s detriment. For example the decision to retain “run through” training opportunities in Scotland provides much sought after job security for the small number of young doctors fortunate to achieve a training post in their preferred specialty. For many others, the prospect of time limited training roles is encouraging a move south to the more flexible system emerging in England. This risks significant service gaps in Scotland and the loss of many high quality candidates.
Professional input into training standards is coordinated at a UK level and Scotland has always contributed extensively through the Colleges and other networks. It makes no economic sense to move away from a UK approach in terms of curricula, assessment methodologies and certification.

Revalidation of doctors

Revalidation of doctors becomes a reality from 2010 and the College supports strongly a UK wide approach to the regulation of the profession. This may be challenging as standards of practice for professionals are key components of clinical governance systems, and which, for Scotland, are now devolved. Nevertheless the College believes it is critical that Scottish doctors remain within the UK regulatory and training systems. No-one underestimates the challenge of delivering a cost effective, acceptable system of regulation and revalidation and it makes good economic sense for this to operate as a standardised system across all specialties and all employers in the UK.

Quality of Care

Scotland has a strong track record in innovative quality of care initiatives. Regretfully devolution has failed to export these with any real success to England. For example, the Scottish Intercollegiate Guidelines Network (SIGN) has been developing evidence-based guidelines for 15 years but, whilst significantly more cost-efficient than the much younger yet larger National Institute for Health and Clinical Excellence (NICE), it is comparatively under-resourced.
With the separate health care systems which have developed in Scotland, England and Wales respectively, there are practical (methodological) but mainly political barriers to full cooperation to prevent duplication of guideline development: commissioners in England and Wales will only follow NICE guidelines and these have no formal status in Scotland (although some have been considered on an ‘ad hoc’ basis).
The Scottish Medicines Consortium (SMC) has been much lauded for its more efficient and effective approach to drug approval in comparison with NICE and it remains to be seen whether a similar model will be adopted in England.
The College supports initiatives to foster innovation but believes that devolution can lead to inefficient and unnecessary duplication of work and create barriers to the adoption of best practice across the UK as a whole.

Health Data

Data systems in the NHS in Scotland have evolved quite separately from the rest of the UK and in many ways are much envied by clinicians and planners outside Scotland. This pre dates devolution but as the NHS moves towards greater reliance on IT solutions for data transfer and remote working, it is important that systems are compatible across the UK. This will be critical to the effective and safe delivery of some tertiary services, emergency care and cross border patient flow in the south of Scotland.

Inequalities

The College, as an organisation supporting Fellows and members across the UK, is also concerned about UK postcode lotteries resulting from differences in policy between the administrations and which influence access to care. A devolved Scotland will need to reconcile variations across borders and within borders relating to decisions on healthcare.

European Effect

Much of our UK health legislation is now initiated in Europe, where although Scotland has MEPs , discussions in the Council with member states are led by Westminster on behalf of the UK. On going examples of the impact of Europe on health include the free movement of professionals and patients across EU states, the European Working Time Directive and measures to control the research industry. The College is unclear about the influence of the Scottish Parliament over Westminster on health issues and would encourage the Commission to explore these in more detail.
It will be important for Scotland to extend influence into Europe. In several respects UK health policy has been caught out over the past two decades by failures to identify the effects of wider policy making in Europe on healthcare and the healthcare workforce. Scotland’s approach to the cross border market in health are is rather different to that of England, owing to its relative geographical distance, the strength of it’s health care and medical research reputation, the modest size of it’s private sector and the integrity of it’s public health system.

Copies of this response are available from:

Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.

Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939

[8 September 2008]