Guest Blog by Stuart Carroll, Senior Health Economist and Epidemiologist
In under a month’s time, the Scottish people will decide their fate: stay within the United Kingdom or go it alone as an independent country and carve up the Act of Union of 1707. As we saw from the first TV debate (regrettably, only highlights due to STV prohibiting ITV and Sky from broadcasting across the rest of the UK), it is increasingly possible to distinguish between SNP stated policy (romantic fluff and guff) and the consequences of that policy (the real world perspective). Apart from having no currency Plan A, no currency Plan B, no currency Plan C (yes, there is a trend emerging here around no currency plan full stop!), no “independent” monetary policy, no influence over Bank of England interest rates, no clue on financial regulation, no membership of the EU and no NATO, the case for Scottish independence is in a full flow (I obviously say this with some irony!). Alistair Darling 1, Alex Salmond 0 at half time. Indeed, Scottish independence makes about as much sense as Del Boy speaking French. Bonnet de douche Alex!!
However, there is a long way still to go and the “Better Together” campaign should avoid hubris as this referendum is as much about emotion as it could ever be about the hard, cold and real world facts. Moreover, Salmond is a strong communicator despite alleged briefings against him by his deputy, Nicola Sturgeon. His Horlicks of a performance the other night, although fundamentally a consequence of bad and, quite literally, unbelievable policy, is likely to improve in coming weeks, and underestimating the SNP would be foolish.
To be fair to the Scottish First Minister, one area where there is no particular need for an “independence plan” per se is health policy. Following devolution in 1999, Scotland has had its own fully politically independent NHS. Holyrood is already responsible for legislative and operational matters with its own Cabinet Secretary for Health and Wellbeing, Alex Neil, and other organisational arrangements. However, there is one area of health policy, or more to the point public health policy, that remains unclear and ill-considered should Scotland vote for independence. That is, the business of vaccination policy.
In the case of other health technologies, namely drugs, medicines and medical devices, it is the Scottish Medicines Consortium (SMC) that handles decisions pertaining to their approval and recommendation for use on the Scottish NHS. Following assessment criteria analogous, albeit not exactly the same, to that of the National Institute for Health and Care Excellence (NICE) in England, including assessments of cost-effectiveness and budget impact, the SMC has become a widely respected health technology assessment (HTA) body.
However, recommendation decisions for vaccinations still sits with the UK-wide Joint Committee on Vaccination and Immunisation (JCVI); an executive expert advisory body whose secretariat is Public Health England (PHE) and, despite nowhere near the same levels of transparency and process of NICE (more blogs on this topic to come), a committee that broadly speaking follows the same HTA criteria as that of the Institute. The JCVI makes it recommendations to the Secretary of State for Health (currently Jeremy Hunt) based on clinical review and cost-effectiveness, which are then subject to, in most cases, national tenders. Some vaccines such as flu and pnuemo are procured locally by Clinical Commissioning Groups (CCGs) and follow slightly different arrangements in the devolved nations. National tenders, however, are conducted on behalf of the whole UK and procured by the Department of Health with assistance from the Commercial Medicines Unit (CMU), which is considered favourable for “bulk purchasing” and negotiating better price and volume agreements with manufacturers versus higher official list prices. The devolved nations then agree to payback the Exchequer in proportion to their populations and the numbers receiving vaccines.
Technically, the devolved nations of Scotland, Wales and Northern Ireland can do their own thing, reject JCVI advice, make their own recommendations and, in theory, run their own tenders. However, this has so far never happened and can be considered most unlikely under current arrangements. It would make little sense to duplicate the work of the JCVI and would add an extra unnecessary expense in terms of procurement. Representatives of the SMC often appear on JCVI minutes as “observers” and have so far been happy to follow JCVI recommendation decisions in their entirety. Moreover, given that vaccination is a population wide intervention designed to control infectious disease, cross nation coordination and a consistent vaccination policy are desirable, particularly in light of equity considerations and cross border movements. In short, and arguably for very sensible reasons, Scotland does not have an “independent” vaccination policy.
Having read through “Scotland’s Future” – the SNP’s “plan” for an independent Scotland – there is no mention of vaccination and what Scotland would do in the event of a UK divorce. As with everything else, the SNP would be wrong to assume that in the case of independence, JCVI advice would automatically be “handed over”, SMC representatives would still be invited in as “observers”, or the English taxpayer would happily go on paying for the administration of national tenders; the results from which go on to form vaccination policy and UK wide immunisation schedules. After all, when you divorce you divorce.
So, would Scotland have its own JCVI? Would responsibility for policy shift to the SMC? Who would conduct the tendering process? Would Health Protection Scotland undertake the very complicated and intricate infectious disease modelling to ascertain epidemiological trends and cost-effectiveness? If so, what is the “human resource” plan to recruit people from what is already a very limited pool of experts? All of this is on top of questions concerning how Scotland would handle the licensing of healthcare technologies given that the Medicines and Healthcare product Regulatory Agency (MHRA) is also a UK body. Even the European Medicines Agency (EMA), which supersedes the MHRA, belongs to the EU and, regardless of SNP rhetoric, membership is not a “slam dunk” raising additional uncertainties regarding independence. There might be reasonably practical and straightforward answers to all these questions, but as with so many other things around Scottish independence nobody in the “Yes” campaign has properly thought it through. Fluff and guff might be contagious, but it is also potently dangerous in the context of infectious disease and advancing a serious vaccination policy.
This might not be the foremost consideration, or immediate area of policy, that Scottish citizens may cogitate over, worry about or indeed lose sleep over when contemplating the merits of independence. Also, against the backdrop of gargantuan questions such as the entire fate of the Scottish economy, its membership of the EU and future defence policy, there are obviously bigger political fish to fry. Nonetheless, public health is important in its own right. It is something the SNP has sought to emphasise in government and its blueprint for independence (Scotland’s Future) when considering obesity, alcoholism, drug addiction and smoking cessation (admittedly, only in six pages of largely rhetorical prose and pseudo English NHS bashing!). More pertinently, it is another area of policy which the “Yes” campaign has completely neglected to consider. Despite his bluster and guster and extraordinary “Braveheart” rhetoric, not even Mr. Salmond is “immune” from these small but important details. #Better Together.