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I was the Head of Policy and Public Affairs at UNISON Scotland until my retirement in September 2018. I now work on several policy development projects, so all views are very definitely my own. You can also follow me on Twitter. I hope you find this blog interesting and I would welcome your comments.

Friday, 17 January 2020

Passing on the Scottish healthcare experience

I am in Stockholm this week talking about health and care systems. Sweden has a healthcare system which is generally free at the point of use. However, there is greater local autonomy at the regional level than in the NHS and is increasingly adopting market-based systems with private sector providers, particularly in Stockholm.

Privatisation is being challenged in Stockholm, and I was invited to speak at a seminar to explain the Scottish experience. We moved from a command and control NHS model, to the internal market and now to a collaborative system. Having tried the market for around 15 years, they are interested in our experience and why we changed in the years after devolution. And why we have retained the model despite privatisation in England.

International comparisons in healthcare are notoriously difficult, and my approach is to explain the Scottish system, rather than suggest it should or could be copied directly. While Sweden starts with universal health care, the health challenges are very different to Scotland with our massive health inequalities. If only we had their more equal society, even if they are rightly concerned that the post-war gains are being eroded.

On systems, we can offer some relevant experience. The local newspaper was interviewing me outside a large new hospital built with private finance. Unsurprisingly, they have already discovered the cost of these projects and the creeping privatisation that comes with them. Scotland didn't have the cheap borrowing powers when most of our PPP hospitals were built. So why a country like Sweden, which can borrow for next to nothing would want to pay private sector rates is difficult to understand. Even the Tories have largely abandoned this model.

My interview in the main daily newspaper
I outlined our experience of market-based systems in healthcare and the benefits of collaboration over competition. The key points include:

·       The private sector brings extra costs through private finance, profits and dividends.
·       To work, they need to create surplus capacity, which in a universal healthcare system has to be financed by the taxpayer.
·       Markets also have administrative and other costs. Prioritising marketing managers over nurses seems a poor choice at a time of scarce resources.
·       Collaboration enables the sharing of best practice. If one hospital innovates that is shared in a collaborative system, rather than patented in a private sector one.
·       National and local planning is difficult when hospitals and other care systems are competing. Not to mention the considerable procurement savings in an integrated system, most notably on drugs.

From a workplace perspective, partnership working has brought stable industrial relations and better staff engagement in service design. The private sector approach brought expensive management consultants, with their 'Blue Peter' method, 'here is one I prepared earlier'!

That is not to say that despite high user satisfaction there are no problems with NHS Scotland. Performance under budgetary, workforce and demand pressures are rightly highlighted in Parliament and elsewhere. We are not achieving a meaningful shift in resources from acute to primary care, and community engagement is limited, not least because of limited local democratic accountability. However, none of these issues would be addressed in a market-based system.

I also spent some time explaining the problems we face integrating health and social care. Ironically, many of these exist because we retain the use of market mechanisms in social care. Most Scandinavian countries have fewer problems with this because these services are integrated with primary care in local government. 


So, while the Scottish healthcare system is far from perfect, it does at least avoid the disaster that marketisation brings. It is up to the Swedes to make their own decisions, but at least they can learn from those who have been there and won’t be returning anytime soon.

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