Scotland under the searchlight as executive begins its reforms

'Measurable progress' is demonstrated in delivering a 'smar- ter, greener, healthier, wealthier and fairer, safer and stronger Scotland', trumpets the press release. 'More spin than Torvill and Dean' harrumph the Liberal Democrats, who, along with the other opposition parties, were less than impressed. So who is right?

It is undeniable that many of the Scottish Executive's announcements since the SNP formed a minority government have been hugely popular with some.

Take one of its earliest health moves after the May Scottish Parliament election, where the party won just one seat more than Labour.

Fulfilling a manifesto pledge, new cabinet secretary for health and well-being Nicola Sturgeon overturned reconfiguration plans which would have closed accident and emergency units in Ayr and Monklands hospitals.

Although it was welcomed by campaigners, the move understandably threw plans for service change in the two NHS board areas of Lanarkshire and Ayrshire & Arran into disarray.

Last week both boards were putting a brave face on it, saying that revised plans would be published by the end of the month.

But NHS managers in Ayrshire have already hit back, albeit in a subtle way. While resolutely not criticising the SNP's decision to reverse the A&E closure at Ayr Hospital, the board has said that it will be possible to reverse the move but other plans - such as a new cancer unit - may be affected.

However, the public seemed happy with the move and to further bolster the SNP's practical credentials Ms Sturgeon announced that 'independent scrutiny panels' were to be set up to look at incoming reconfigurations.

With a clear dig at Labour's record on patient and public involvement, she said last month: 'Any proposals for significant service change in the Scottish NHS will now be subject to rigorous independent scrutiny before public consultation can take place.'

Further practical changes to health policy followed. The government has pledged to phase out prescription charges, reinstated the full pay award for NHS workers to 2.5 per cent and promised a consultation on the idea of directly elected health boards.

But chair of the British Medical Association in Scotland Peter Terry says the SNP is fundamentally in keeping with the previous government, as it has backed a 2005 report commissioned by it on the future of the NHS in Scotland. That document, Building a Health Service Fit for the Future, by David Kerr, urged a shift from hospital to community care and a greater focus on long-term conditions.

Dr Terry said: 'They backed the Kerr Report and are still following that direction, although they have to make it fit with their manifesto pledges.

'What they are trying to do is implement Kerr but more quickly, more dynamically. That makes it very difficult for Scottish Labour to oppose because it's policy that they introduced in the first place.'

Unquestionably there's a sigh of relief from Scottish Labour's ranks. Malcolm Chisholm, a former health minister for the party and now a member of the executive's health scrutiny committee, was responsible for commissioning the Kerr Report.

He says: 'The Kerr Report was based on extensive consultation and engagement with clinicians and the public. The SNP backed it at the time and I'm pleased to see that they are still doing so.'

It could be argued that in calling for a 'bare-knuckle fight' on the NHS and highlighting 'at-risk' A&E units, Tory leader David Cameron is following the SNP's successful pre-election strategy.

Ironically, in a tail-chasing kind of way, it could well be that Scottish Labour now emulates Mr Cameron in trying to out-local the SNP. Back-bench Labour MSPs are keeping a close eye on various reconfiguration hot spots, ready to pounce on any appearance of inconsistency.

One such combustible area is the Vale of Leven, where reconfiguration plans are being scrutinised before going to the health secretary for a decision.

In Scotland, there is a real enmity between the SNP and Labour - some MSPs won't even speak to each other. Nevertheless, Dr Terry thinks that Scottish Labour probably has more areas of agreement with the SNP than with Labour in London, particularly around the health service.

'The Scottish Labour Party has not been given credit for resisting considerable pressure from within its own party to change the health service in Scotland in the way it has in England. I think Scottish Labour was right to resist and that while things aren't perfect, the current approach is right for Scotland.'

Veteran Conservative MSP and health spokeswoman Mary Scanlon is less impressed, however, and sees a more tribal motivation behind its announcements so far.

'I think the SNP are trying to woo the Scottish people into voting for independence,' she says.

'In the first 100 days they've been going for easy wins and making decisions - such as reversing the A&E closures - for reasons of political opportunism, as opposed to well thought-out health policy. We'll wait and see whether that will come back to haunt them.'

Ms Scanlon concedes that there is one major policy difference between the SNP and Labour in NHS use of the private sector.

Ms Sturgeon told the NHS Confederation's annual conference in June: 'We reject the very idea that markets in healthcare are the route to improvement.

'We believe, instead, that it comes through the collective energy and ideas of committed staff, working with patients, and the communities they serve.'

Ms Scanlon says: 'The previous Labour-led executive was quite happy to utilise the private sector to achieve waiting targets, so in that way it was more patient-focused.

'The SNP, however, is vehemently opposed to the private sector and has totally rejected public private partnerships and the private finance initiative.'

She adds: 'It will be interesting to see where they will find the capital for projects, especially with tight budgets ahead.'

Institute for Public Policy Research Joe Farrington-Douglas, gives a mixed assessment of the SNP so far: 'I'm interested in the SNP's emphasis on patient and community involvement, because that's been seen as a bit of a blind spot in England.

'If Scotland does more towards directly elected health boards - which is something Alan Milburn [former health secretary in England] and others have recommended for primary care trusts - then I think we'd be watching that with interest.'

Yet this could see boards politicised and dominated by special interest groups with the loudest voices, he says.

And while the abolition of prescription charges may be a wise political move, in reality the benefit to the NHS is small change.

'Prescription charges don't raise a significant amount of funding, but there would be short-term costs in abolishing them.

'The policy rationale for charges is also to prevent people frivolously consuming healthcare. So would free prescriptions mean a big increase in demand from the worried well?'

The creation of independent scrutiny panels raises questions about the government's role in local decision-making, Mr Farrington-Douglas says.

'Looking at what the SNP has said so far, there is a real tension between centralism and localism,' he observes.

'While on the one hand they are saying they want more local decision-making, on the other hand they are setting national targets. What if a locally elected NHS board says it doesn't want to concentrate on cutting waiting times to 18 weeks, it wants to improve access to GPs instead?

Last week the executive made no bones in taking a decision that would affect managers on the ground by reversing a commitment to move the headquarters of three special health boards from Edinburgh to Glasgow.

Such a move would cost around£22m, warned public health minister Shona Robison.

HSJ also understands senior managers have been told to expect an inflation-only uplift in the next financial year, which is causing finance directors to rethink their sums more radically.

A Scottish Executive spokesperson denies this, but Ms Robison does not mince words on the topic: 'We have shown we are ready to take tough decisions and will continue to do so as we strive to make Scotland healthier.'

Yet Scotland still receives a disproportionately high financial settlement when compared with England through the Barnett formula, which calculates government funding for Scotland, Wales and Northern Ireland.

Could this now be set for a shake-up, perhaps securing extra cash for services in England? Joe Farrington-Douglas thinks so: 'If Scotland has a different stripe of administration then that will push questions about the financial settlement up the agenda.

'England has had to make tougher decisions than Scotland, but how long will that last?'

The SNP's main health moves so far

• Announced reversal of decisions to close accident and emergency unitss at Monklands and Ayr Hospitals.

• Promised independent scrutiny of all service change proposals.

• Published consultation, Better Health, Better Care, ahead of a new health action plan, due by end of the year.

• Announced a review into free personal care by Lord Sutherland, and pledged increase in payments for nursing and personal care from next April.

• Promised plans to phase out prescription charges will be before the Scottish Parliament by this autumn.

• Announced commitment to 18-week waiting time guarantee.

• Promised proposals by autumn for a Local Healthcare Bill including direct elections to boards.

• Implemented NHS pay award in full.

• Opposed funding private sector to help it compete with the NHS.

• Reversed plans to relocate headquarters of three special health boards from Edinburgh to Glasgow.