Scots have a reputation for being pretty touchy when the word English is used to mean British.
For those working in the health service north of the border, there are few more annoying things than the Department of Health making announcements from Whitehall about initiatives portrayed as being UK-wide despite having no direct relevance in a devolved Scotland.
One of the worst offenders is the National Institute for Clinical Excellence - not so much the body itself, but the impression given that its advice applies not only to England and Wales, but to the rest of the UK as well.
It is difficult for doctors and managers in Scotland to know what to make of NICE advice, and the relative slowness of its Scottish near-equivalent to get off the ground has left what some perceive as a vacuum.
From this month, however, this could be changing. There are signs of a growing co-operation between the two bodies - in one direction at least. Last week, the Health Technology Board for Scotland published the first of many 'Scottish' responses to NICE rulings. The idea is that HTBS, in addition to the 10 or so assessments which it aims to carry out each year, will also examine the 30 NICE judgements and decide whether they will do for Scotland as they are or if they need to be modified.
'All NICE recommendations will be considered in a Scottish context to see how they should be used, ' says Dr Karen Facey, director of HTBS. 'In most cases the advice will be equally applicable to Scotland and we will take it on board. But there might be some areas where we have to take a closer look. This could include looking at geographical differences or cases where there are differences in disease pattern in Scotland.'
The first comment, on drugs for Alzheimer's, is a case in point.
NICE recommended that these drugs should be prescribed only in specialist clinics. That would provide huge challenges for Scotland's more remote populations, where GPs have had to build up an expertise, under strict protocols, in diagnosis and treatment of dementia.
'This is particularly an issue in the islands, ' says Dr Facey. 'So we have said that the drugs can be prescribed by an old-age specialist or a GP experienced in the diagnosis of Alzheimer's.'
That comment took six weeks to prepare and involved setting up an ad hoc expert group to consider the issue. Normally the process should take three to four weeks, Dr Facey believes, although, depending on the topic, it could be longer.
'Publication can take time and I find the most challenging thing is getting a group of experts in the one room together, ' she says.
This system has the obvious advantage of minimising the risk of duplication of effort because, after all, what is suitable south of the border will in most cases be fine in Scotland.
But whether NICE will return the compliment and adopt - with relevant modifications, of course - the Scottish guidance remains to be seen. One HTBS insider reckons NICE is waiting to see the quality before committing to a reciprocal system. A NICE spokesperson is more tactful. 'It is not really come up yet because the first piece of guidance is quite a long time away, ' she says. 'But we have a very good relationship with HTBS and the two organisations do talk to each other.'
For all the two bodies are both working within the UK, there are fundamental differences in their approaches. Unlike NICE, whose agenda is set by the DoH, HTBS comes up with its own selection of technologies to assess. These can be suggested by anyone, including patient groups, doctors, nurses or anyone with an interest in the NHS.
The first topics - PET scanning for cancer, diabetic retinopathy and interventions for alcoholism - have been chosen, however, with an eye to the Scottish Executive's priorities and timetables.
For example, a national framework on diabetes is in the pipeline.
HTBS will not have NICE's responsibility for drawing up guidelines - that is already fulfilled in Scotland by the Scottish Intercollegiate Guidelines Network (SIGN), although the two bodies do communicate.
Again, unlike NICE, which has one appraisals committee, HTBS will involve short-life groups of experts who will work on each assessment, although the management board will see all assessments as a way of giving a broader quality assurance, ' says Dr Facey.
Views of anyone expected to have an interest, including drug companies and patient groups, will be actively sought.
The HTBS's slow-but-sure approach has had frustrations. In Scotland new treatments are still assessed on a health board-byhealth board basis, by each area drugs and therapeutics committee, which inevitably work to different timetables.
Those waiting for specific appraisals, such as the longawaited ruling on beta interferon, cynically say all it will mean for Scotland is having to wait an extra few months before the patients can get the drugs, if the judgement should go that way.
Time will tell.