GPs braced for Scottish independence vote

As Scotland prepares to decide its future at the polls, David Millett looks at how independence could change the face of UK general practice.

A few weeks from now, the people of Scotland could decide not only the future of their country, but also of UK general practice.

While some GPs in the country champion a Yes vote as a means to shield Scottish practices from the market-led reforms in England, senior GP leaders are increasingly concerned that independence could exacerbate the difficulties facing general practice south of the border.

The consequences of a Yes vote on 18 September for GPs across the four UK nations would be far-reaching and complicated.

Although the economy has dominated the debate, the potential impact on the NHS has not gone unnoticed. Both sides have promised a vote in their favour will put the healthcare system in a better position (see box).

The NHS debate:

How both sides of the independence debate claim a vote their way would benefit the NHS in Scotland

Although surveys of voting intentions among the public consistently place the No vote ahead of the Yes campaign, the margin is slender and many voters remain undecided (see box below). Scottish independence remains a real possibility.

A vision for healthcare

Glasgow GP Dr John Ip believes the debate has lacked a clear vision for what general practice would look like in an independent Scotland, and this could hinder the Yes campaign.

'I would like to know how it will change my day-to-day life, how it will affect the services I provide, how the interface with hospital and social care colleagues will change,' he says. 'That's the level of detail needed, but it's not out there.'

Dr Dean Marshall, UK GPC negotiator and former chairman of the Scottish GPC, shares this view. 'As ever with politicians, it's not how they can do it, it's what they will do. The Scottish government has only said what it doesn't like about what's happening in England, not what it will do in Scotland. We have the same problems in Scotland, so I say they're shying away from saying how to solve those problems.'

Dr Anne Mullin, a Glasgow GP and member of campaign group NHS for Yes, says although independence would open the doors to great change, it would take many years for this to be visible. 'I think it's more a question for how the future vision of general practice could change in the event of independence,' she says.

But change is already happening. Healthcare is devolved in Scotland and the government has already followed a different path with the GP contract. Just last month, the Scottish GPC confirmed the current deal would roll over until 2017, to return some stability to practices. This contrasts with the picture for the rest of UK general practice.

Some believe the widening policy gap between Scotland and England means independence would not lead to dramatic change in primary care.

A GP in Grampian, who wishes to remain anonymous, tells GP: 'While the structure of these contracts may be likely to continue to diverge further with or without independence, the fundamental care we have to offer our patients will remain similar. So even with independence, I suspect there is a limit to how divergent the arrangements could become.'

But Dr Mullin disagrees and says the current contract, in her view, 'isn't really fit for purpose'. She hopes the contract would be 'completely re-imagined' under independence.

Dr Mullin believes starting from scratch would grant GPs in Scotland a valuable opportunity to be much more involved in the process of collaboratively devising a contract that best suits them, rather than being written by distant committees.

Cause for concern

GPC deputy chairman Dr Richard Vautrey says independence could be a cause for concern for the future of practices south of the border.

'I think the concern that GPs in England have is that it's the health service in England that's moving away from the three Celtic countries in a way that is not what patients would want to see,' he says.

'If there was a clear separation between Scotland and England, it may be that those who want to see a greater development of the market and greater involvement of private companies would have more of an opportunity.'

However, some view independence as a way of protecting the NHS in Scotland against what critics argue is increasing privatisation and fragmentation in England.

Dr Ip says that although he is undecided on how to vote, promises from Yes campaigners to preserve and prioritise the changes Scotland wants are 'an attractive argument for going independent'.

Dr Mullin asserts that independence is essential to preserve 'the NHS and its principles'.

'It's not scaremongering to say the NHS is no longer "national" south of the border, now that the state doesn't have responsibility for it. Up here in Scotland, we still have a national health service. It has been protected under devolution, but now there are financial and constitutional risks to the health service if we don't have independence,' she adds.

Others worry that Scotland may not have the available capital to improve healthcare as promised by the Yes camp if independence were to go ahead.

As the Grampian GP explains: 'One of the main decisions we have to make is whether we think Scotland will be richer or poorer under independence, and both sides have statistics and expectations which contradict the other.'

The Yes camp claims the UK 'drains wealth from Scotland'. 'All that money we wouldn't be spending, we would bring back into our own economy,' says Dr Mullin.

Increased funding

Dr Marshall insists there is only one way an independent Scotland could increase funding to the health service: raising taxes, something he says the Scottish government would not do.

A split between Scotland and its neighbours would also have ramifications for national membership and governance bodies for GPs.

The BMA has already begun considering how it would reorganise internally should a split occur, and despite the Scottish government's insistence that it would try to keep the GMC, some GPs in Scotland are not convinced.

Dr Ip warns: 'If Scotland becomes an independent country, we would need our own regulatory body.'

Dr Marshall says: 'There would be huge problems if Scotland had to provide its own medical education and governance of education. I get the impression people are hoping we won't have to be presented with these problems. It would take years and years to resolve these issues.'

With so much uncertainty, the road to independence could be long, even if the Yes vote triumphs. Moreover, there seems no clear-cut answer for which outcome would best serve general practice in Scotland.

'I think both camps are relying on people to vote with their hearts, rather than facts,' Dr Ip says.

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