Testing the temperature
Jackson Carlaw, deputy leader and health spokesman for the Scottish Conservatives, was attracted to the party by Margaret Thatcher. He has her portrait on his office wall. “I’ll defend Margaret Thatcher to my dying day,” he says.
One wonders what the Iron Lady would have thought when, during the recent debate on the NHS in the Scottish Parliament, his speech talked of “a collective plan” for “accepting Scotland’s wish to have a publicly funded, publicly owned, publicly run Scottish health service.”
The language differs from his London counterpart, Health Minister Jeremy Hunt, and Labour’s UK health spokesman, Andy Burnham, who told Holyrood last year devolution needed to enter a new phase of “UK-wide policy.”
“I think Andy Burnham is wrong,” Carlaw tells Holyrood. “That’s why I’ve talked about whether we should start calling it the Scottish Health Service, which is a national health service for Scotland, rather than NHS Scotland. Because I think we can be very proud of what we ourselves fashion and create if we are not embarrassed to say we have a different health service.”
Is this a rebranding of the Scottish Conservatives on health?
“I don’t know that it is. I’ve come to recognise, frankly, there is a kind of common understanding about a lot of this, but that the old party political game has been one of the biggest obstacles to a sensible discussion,” he says. While there are many things dividing the Scottish Conservatives from Labour and the SNP such as welfare, according to Carlaw, the issue of health is different. With cross-party support on so many health issues, Carlaw believes point-scoring between Labour and the SNP and accusations such as “if the Tories were in they would privatise the health service in Scotland” is a “narrow plastic agenda” that stands in the way of dealing with the challenge of an ageing population. New treatments and procedures “almost on a monthly basis for illnesses that have bedevilled us for generations”, and new challenges “which would never have been contemplated a generation ago – things like obesity and the ever increasing cost of addictions, whether alcohol or drugs, a greater appreciation now of mental health as an area which has really not received the priority or treatment or demand it required.”
The health service in England has seen some of the most radical reforms in its history under a coalition government led by the Conservatives, most notably, the expansion of a market model of competing services with an emphasis on choice rather than collaboration. Don’t the Scottish Conservatives see such a model working in Scotland?
“At the margins, I see a place for the independent sector in support, and I also look to the reforms that have taken place in England or different approaches in Wales and say that Scotland should not, on a wholesale basis, dismiss everything that’s been done as being of no value,” says Carlaw.
What can Scotland learn from the English reforms, then? “I’m delighted that the Scottish Government has now looked to a method to fund end-of-life and rare medicines, but the government at Westminster, I think, was the catalyst on that, because it made doing nothing no longer acceptable.”
Carlaw also believes the Scottish Government has followed Jeremy Hunt’s lead on 24/7 access to services. There is, however, a rejection of the market solutions which have come out of the political system at Westminster: “Frankly, between Blair and whoever, because there has been no cross-party support for anything that’s ultimately been done, we’ve ended up with something of a dog’s breakfast, of things being established, things being unpicked, things modified then things being altered yet again.”
Although the committee system at Holyrood has led to greater agreement on Scottish health strategy, Carlaw believes the current arrangements are unsustainable. “There will need to be real centres of specialisation and excellence in Scotland, and that means that a sort of Southern General Hospital-type model will have to be established in various other parts of Scotland, and the current health board structure simply makes that infeasible,” he suggests. Past pushes toward centralised specialist hospitals met with some resistance, with public campaigns to keep open maternity services and accident and emergency departments in rural parts of the country. “They have to be services that can be accessible to the community,” he says.
Providing services 24/7 will be a challenge too, he says, because it will require “pretty bold discussion” on pay structure with the BMA and others, while ensuring “that we attract and retain the very best staff in Scotland.”
Probably the biggest issue that sets the Scottish Conservatives apart in health is what Carlaw calls the responsibility agenda: “I do think it’s outrageous, frankly, that so many clinical appointments are lost because people simply do not attend. I’ve been on the receiving end of that where the notice of my appointment has arrived the day I’m supposed to be going. There is an obligation on us if we’re not going to attend an appointment to say so, to make that appointment available to others.”
If the challenges of no clinical cure for dementia, the increasing number of emergency admissions for over-75s and a need to have the elderly housed in an appropriate community setting are to be met, he says, “then for the rest of the population, on issues like obesity, and on addictions, and general levels of fitness, we have to start being much stronger in the way we talk to people about their responsibility and duty to do for themselves.”
Doesn’t prescribing behaviours sound a little like the ‘nanny state’? “I accept that. I still rail against what I thought was one of the most useless pieces of public expenditure, telling people which was the better curry for them to eat, on which we spent a quarter of a million pounds at the time.” Obesity needs “big decisions”, he says, “whether or not we move to a clinical intervention. In so many respects, that offends sensibilities, but nonetheless it may prove to be more cost-effective than some of the ongoing treatments that simply aren’t making progress. All of that’s very controversial, but if we aren’t prepared to do that then the whole thing is simply going to run into the sand.”
Carlaw recognises obesity and addictions can be symptoms of social disadvantage and poverty. The solution, he argues, lies in universality: “Scottish Conservatives have been advocating for a universal health visiting service up to the age of five. Everything we’ve read says the most proactive way which we can address these issues in the future is to address families with young children because so many core signs, whether it be health, social or even justice, manifest themselves in that age group of around three.”
The 14 health boards all approach it differently, he says, diluting any sense of a national or universal approach. “Look, there is not an argument about whether we will have a national health service, there’s not an argument about whether it will be publicly owned and free at the point of delivery. But if it is going to be focused on delivering successfully then there is part of the contract we all have to embrace.”
A publicly-owned health service could be described as a natural monopoly, something the Conservatives have traditionally been opposed to. Carlaw says he’s “reconciled” to it.
There always has been a unique ‘Scottish Conservatism’, he argues: “We have never been the Tory party in Scotland. We didn’t become the Conservative Party here until the 1950s, but we’re still known as the bloody Tories or worse.”
It wasn’t the shift in economic priorities under Thatcher that broke Scottish Conservative tradition, he argues: “Nobody thought Alec Douglas-Home was London’s man in Scotland, they thought of him as Scotland’s man in London. Nor did they really think of it of George Younger, but I think nonetheless in time what came to be seen as the heart of Scottish Conservatism was a defence of London’s position in Scotland, and the desire to alter the character of justice, education and whatever had been unique in Scotland to fit the London model.”
The closure of Gartcosh steel mill and the implementation of the poll tax compounded the view, he suggests: “The collective impression of all of that was Scottish Conservatives were no longer fighting for Scotland’s interests in the United Kingdom, but were fighting for the United Kingdom’s interests in Scotland. As somebody said to me, ‘perception is the truth, even if it’s not the reality’. Maybe it did stray towards being the reality in the minds of some.”
Ruth Davidson is now the leader of the Scottish Conservative Party, rather than the parliamentary group, and Carlaw says this is a symptom of the change of direction:
“I hope we are embracing the devolutionary process. There’s no hankering any longer for the ancien régime. We understand what the advantages of devolution are. But if we’re actually going to embrace them and give life to them then on areas where we can see a broader measure of agreement, it would be helpful if we took the partisanship out of that.”
Carlaw sees this as “a root challenge to Labour. I understand their sincerity, I do, I’ve worked closely with Jackie Baillie and I see Neil Findlay now. Whatever the sincerity underpinning their concern, and the whole history of the Labour Party and the health service, in the chamber, it comes down to the most unhelpful full-on partisan tribal braying. Too often at the sharp end, we don’t come out of that having really made any productive contribution to the debate at all. That’s not withstanding people like Malcolm Chisholm or Hugh Henry or others who very often make really important contributions to the subject in hand.”
Despite leading the drive for devolution, Carlaw says, none of Labour’s “principle people wanted to come here, or still want to come here.”
He admits, however, Labour’s problem is one he’d like to have: “They have a lot of MPs at Westminster, who are competing with their MSP group at times for influence and the determination of policy. We’re able to be more focused and united than that,” he laughs.