The Commission on the Future Delivery on Public Services in Scotland has reported. In a time of major cuts in public services, the Commission’s reponse is an unreflective recitation of all the things that Scottish public services have been trying to do for the last few years anyway: partnership working, holistic responses, personalisation and early intervention. And, just because we have been doing them for years, we know what is wrong with all of them. Partnership working is all very well, but services need a division of labour to work effectively. The main impact of partnership has been to refocus attention on the boundaries – often issues of that affect the interfaces between services (such as the environment or community safety) rather than the things which most matter (like health, education and housing). The problem with everyone trying to be holistic is that is means that everyone is responsible for everything; services duplicate effort and spend time dancing on each other’s feet. One of the silliest proposals in the report is that public agencies should all have the power of welfare: so the local NHS trust will have legal power to build a railway? Be serious. Personalisation is administratively cumbersome and wasteful; it depends on there being choices and options, which are drying up; it individualises responses (like employment provision) which should be generalised. And early intervention, which has been tried repeatedly for nearly fifty years, is fuelled by a myth of integenerational continuity, something that doesn’t happen; depends on us having effective models of development, which we don’t have; and assumes that early gains are maintained, which they’re not. The fundamental problem is not continuity, but long-term insecurity; and the route to a secure social framework is not focused early intervention, but a continuing framework of access to the services and support people need.
Is “rural Scotland” the right focus for policy? The OECD report on rural Scotland lumps three different parts of Scotland together. Part is the urban hinterland, described as “accessible” rural space. Part – the smallest part, in terms of the population – is the kind of area that is most often represented as “rural”, rooted in agriculture and the activities associated with the countryside. But in terms of the distribution of population and communities, the largest part of what the OECD is treating as “rural” is not agricultural, but coastal. Scotland’s coastal areas face a complex set of economic and environmental issues, that have little to do with conventional understandings of the rural environment. They take in issues like energy, mineral extraction, tourism, cultural activity, military activity and the ports. The largest single industry is the distribution network.
The key problems relate to isolation. The services and facilities in many coastal areas are often desperately inadequate. Communities need enough population to support basic services. People want access to shops, banks, post offices, schools and medical facilities; these facilities can only survive if there are enough people to keep them going.
However, development, which is difficult enough in isolated areas for practical reasons, is locked by a combination of opposition from landowners, exclusionary communities and planners. Much of Scotland is radically underdeveloped. The high cost of housing reflects a market in scarce supply – and where supply will always be scarce unless we take the fetters off. Where there is not enough housing, there are not enough people. We all want sustainable communities, but no community is sustainable if it is not also viable. If the coast is not built up, the communities will die.
I submitted a response to the Government Economic Strategy: a copy is available here, in PDF format.
Having made the effort to respond to the consultation, I was interested to see how the report on the consultation would represent the answers. I was surprised to see the statement that everyone had approved the government’s priorities, when I had written that I did not; so I went back to the original submissions and compared the comments with the report on the consultation.
There were three significant differences. First, the report claimed that everyone had approved the priorities; it was clear that many, like myself, did not. Second, the government had asked whether it had the balance of prevention and response right, and the report claimed that it did. I had argued against the fashion for preventative work, but I was very much in a minority; the majority of other respondents took the opposite view, and felt the government had put too little emphasis on prevention. Third, the report claimed that respondents favoured the government taking a leading role. Most respondents argued against that, believing that change had to come from the bottom up.
The Scottish Government have announced legislative proposals to reform the law of rape. In particular, they intend to make it inadmissible in court to raise the issue of whether a women was drunk. The problem with rape trials is that they often become trials of the victims rather than of the perpetrators; this proposal is a small step to help with that problem.
It is only, however, a very small step. The central problem with the law of rape is that the definition of the offence depends on the issue of consent, and so on the state of mind of the victim, rather than the actions of the perpetrator. As long as that remains true, it is inevitable that the victims will be put on trial. And the recent proposals to investigate rape as if it was murder will only make things worse: a more extended, detailed, thoroughgoing investigation and legal process will bend most victims until they crack.
There is an alternative. Rape is only part of a general class of serious sexual assaults. Many are at least as bad as rape. (This comment is likely to surprise people who think that rape means “very bad”, but some of these other actions are much worse, even if they typically carry a lesser sentence than rape itself. Unfortunately, I cannot explain the comment fully in a public forum – they are so appalling that I am not prepared to describe them explicitly. I can only suggest that people consult a law book and see what sort of thing is classed as “indecent assault”.) If the nature of the offence was redefined in terms of the general class of assaults, the issue to be considered in court should be whether or not the actions of the perpetrator (male or female) fell into that class – and, regardless of consent, physical evidence of force would stand as evidence of such assault.
The NHS in Scotland has been blighted by creeping centralisation. Hospital services have been progressively been sucked into the large, university-based hospitals in the major cities. The result has been growing problems with accessibility and equity, and a sense of alienation from the population that these hospitals serve. People do not simply want the best medical care possible – especially not if if means they have to travel away from their communities and their families in order to receive it. There are now many parts of Scotland where there is no cover on evenings and weekends, and over an hour’s travelling is needed to get help. Health care is all about social protection, and the first, basic rule is to make sure that people are covered when they need it. The resistance to the closure of Accident and Emergency (A&E) facilities in Monklands and Ayr is symptomatic of this. The understandable fear that people have is that the services will not be there when they need them, and they will have to travel long distances to get essential cover. One of the first actions of the new SNP executive has been to refer the issue back to the health boards for reconsideration.
The reform of A&E is not, however, just another example of centralisation. On the contrary, the development of A&E is itself an example of over-centralisation – formed in the belief that a unit can only function adequately if it has a critical mass, and all the bells and whistles that might be needed. The current arrangements don’t work – it’s not very long since A&E in Lanarkshire was virtually overwhelmed by the number of people reporting with a respiratory virus.
The Kerr report, Building a health service fit for the future, argues that the problems of A&E can be dealt with by more decentralised, local services. The report makes a crucial distinction between Casualty and Emergency services. Kerr proposes a network of casualty units, each with the capacity to deal with lesser injuries and to stabilise life-threatening conditions. Kerr suggested that “as a rule of thumb, each current hospital offering A&E services should be able to sustain services for urgent care.” Emergency services, by contrast, will be more specialised, typically serving about a quarter of those who currently come into A&E.
The NHS boards in Lanarkshire and Ayrshire and Arran proposed, in line with the Kerr report, to replace A&E with a split between Casualty and Emergency units. In Lanarkshire, the plan would have increased the number of units dealing with casualities from three to five, with new units in Cumbernauld and Lanark. These 5 units were to cover 70%-80% of the load currently done in three places. Each, then, wouldl have only half the load of current A&E provision. Two further Emergency units, at Hairmyres and Wishaw, were to act as specialised backup. A&E in Monklands was to be downgraded – not closed – as part of a process which would have redistributed staff and facilities across seven units in five locations. The same pattern was proposed by NHS Ayrshire and Arran. Instead of two A&E departments there were to be five causalty departments and one emergency unit. A&E in Ayr would therefore be downgraded.
The purpose of these plans was to make services more local, less centralised, more accessible and much less overburdened. That is what people are now opposing. An attempt to decentralise is at risk of unravelling because of a demand to keep things as they are.