Professor James Mitchell writes on how Scotland and England together can evaluate the changes that need to be made regarding public services in the light of the Covid-19 crisis.
STAY HOME. PROTECT THE NHS. STAY ALERT.
Nicola Sturgeon’s message continues to resonate with the public and repeats the consistent political focus on the NHS. The National Health Service has long been a religion in the UK. The NHS is the number one priority and an unquestioned matter of faith. To challenge the sanctity of the NHS is apostasy. But it has become a faith that risks damage to public health.
This is not to denigrate those who work in the National Health Service, quite the opposite. We seem unable to distinguish between those individuals who provide valuable service in the NHS from its institutional structures and NHS policies. Occasional moans about NHS management is as close as is permitted to a serious debate. In order to relieve pressure on NHS staff, we need a broader understanding of public health. We continue to ignore the role played by a wide range of public servants the length and breadth of the country, including, though not only, environmental health staff but also leisure and recreation in maintaining health and wellbeing.
Any politician who is tempted to play the populist card by incanting support for the NHS is, however inadvertently, denigrating those who work across the range of public health services. And though Nicola Sturgeon is quoted above, the same populist messages have come from all political parties over many years across the whole of the UK. This problem dates back decades.
And yet, while the establishment of the NHS is rightly seen as one of the great achievements of the Attlee Government, it was by no means its only achievement. Attlee himself saw the NHS as part of four key measures – the National Insurance, National Injuries, and National Assistance Acts – as representing a comprehensive system of social security. Labour’s ‘Speaker’s Handbook 1945’ reminded aspiring MPs in that year’s election:
‘It must never be forgotten that health is not just a matter of doctors and nurses, hospitals and medicine. We must have the best health service we can achieve. But housing and food and full employment, and old-age pensions and rural water supplies are no less important in the promotion of the health of the people’.
This holistic, joined-up understanding, informed by an emphasis on prevention, has lately been lost.
During this crisis, there have been constant calls for greater investment in the NHS. What will really be needed is greater investment in public health and wellbeing. Yet, there were those unheard voices who warned that a pandemic was likely or inevitable and argued that a pandemic would have wider implications. In October 2005, Michael Leavitt, former US Health Secretary under President George W Bush, became convinced that a pandemic was all but inevitable after the outbreak of avian flu and warned:
‘If a pandemic hits our shores, it will affect almost every sector of our society, not just health care, but transportation systems, workplaces, schools, public safety and more. It will require a coordinated government-wide response, including federal, state and local governments, and it will require the private sector and all of us as individuals to be ready.’
The response during the pandemic and in its aftermath demands both horizontal and vertical collaboration, and genuine respect and acknowledgement of the roles from our local communities through to global governance. Local government’s role tends to be ignored, as evidenced by the slow and inadequate response to requests for support from the top-down approach adopted by London and Edinburgh. The pressures on service delivery and local government finances have been immense with additional spending on social services and emergency support for vulnerable people while income from charges for services has suffered. Without the borrowing capacity or powers of UK central government, local authorities have had to plead for more support. An account will need to be taken of the uneven impact that the virus has had across our communities. It has hit many already vulnerable people hard. Many of those who have avoided the virus itself will be adversely affected by the inevitable economic aftershocks.
In Scotland, local authorities made the same demands as colleagues in England. The priority attached to local government by Scottish Government was evident in Finance Secretary Kate Forbes’ ‘storm in a teacup’ comment. This was all part and parcel of the tendency to view health as the remit of the NHS and a failure to appreciate the public health role of local government. Local authorities had demanded and were eventually given, the Barnett consequentials of extra resources being made available to English local authorities. But Scottish local authorities need to be careful. The last thing they need is for the Scottish Government to provide equivalent levels of grant to Scottish local authorities as available south of the border. While local government in Scotland has suffered in real terms relative to public spending across Scottish Government’s field of expenditure, it has not suffered as much as its equivalents in England. The need, north and south of the border, for a major overhaul of local government funding giving local authorities greater fiscal autonomy has been highlighted.
One of the weaknesses of devolution has been the obsession with the focus on divergence with England. It is far more important to focus on the need to diverge from past practice and policy that has given Scotland its poor health record. That will require the kind of thinking and leadership we have not seen in decades.
This crisis has shown, once again, that we need a far more collaborative approach, a fuller appreciation of what is meant by and required for wellbeing and public health and one that places prevention at the heart of our services. The review of local governance has, inevitably, been placed on hold in Scotland but this crisis has highlighted the need for major changes. The ‘respect agenda’ in London’s dealings with devolved government and ‘parity of esteem’ between Edinburgh and Scottish local government has so far proved cheap talk.
STAY HOME. SAVE LIVES.