After the election, what's the prognosis for the NHS and public health in Scotland?

The main result was never in doubt. With such a comfortable lead in the polls, Nicola Sturgeon was virtually guaranteed to continue as first minister after the 5 May elections. But there were surprises. First, the Scottish National Party (SNP) narrowly missed out on a much-anticipated majority, leaving Sturgeon at the helm of a minority SNP government. Second, and despite being virtually wiped out in Scotland at the 2015 UK general election, the Scottish Conservatives overtook Scottish Labour as the leading opposition party in Holyrood. So are the NHS and public health safe in the SNP’s hands? And what will the other parties be fighting for?

The main message of the SNP’s campaign was its intention to enhance the financial sustainability of the NHS. The very first pledge in the manifesto was that the revenue budget of the NHS will increase by £500m – an emphasis intended to address an area of comparative weakness for the SNP.

In the context of rising health care prices and a growing population, the constraints on NHS funding - between 2010 and 2016, health spending in Scotland fell by 1.2% in real terms while in England, under Conservative-led administrations, it increased by 4.4% - have had consequences. There have been damaging headlines, often at sensitive times. For example, an internal NHS memo calling for greater rationing of services and estate closures hit the newspapers last September - just days before the independence referendum.

So what does £500m of extra cash mean for the NHS? It implies a real-terms increase of around 1% per year to 2021 – similar to that envisaged by NHS England. Under the ‘Barnett Formula’ that determines what the devolved administrations receive from Westminster, every £1 change in public spending per person in England triggers a £1 per person change in the Scottish budget. This commitment implies that, for the first time in five years, the Scottish government will allocate most of the additional money it receives on the back of increased NHS funding in England to the NHS in Scotland. It is less clear, though, what this means for other areas of spending. In this respect, there is a contrast to Labour’s position, which is that stopping cuts to public services requires new sources of income: its manifesto pledged to introduce a new 50p tax rate for the richest 1%.

It appears that the SNP’s funding plans could attract support from the Scottish Conservatives, whose manifesto proposed a ‘health guarantee’ – ensuring the NHS budget rises every year by at least the amount reflected in the block budget provided by Westminster. The Scottish Conservatives suggest that this would mean an additional £1.5bn – in nominal terms - for the NHS by the end of the parliament, which is probably equivalent to the SNP’s real terms proposal.

The second major SNP pledge is to take forward what the party calls ‘the most significant reform in health and care since the creation of the NHS in Scotland in 1948’. This rather bold claim - one that politicians in England might be wary of making, given the magnitude of recent reforms - relates to a long-standing ambition to expand and integrate health and social care services.

The new health and social care partnerships, which came into effect this April and are due to pool £8bn in funding, represent a distinctly Scottish attempt to encourage NHS and social care services to work together. Yet the experience to date with such inter-sectoral action is not wholly positive. A recent Audit Scotland report argued that the scale of change is too modest to address the financial challenges facing the NHS. Assessing this aspect of the SNP’s agenda will be important in understanding Scotland’s NHS at the turn of the decade.

The other major strand of health policy is public health, with policies on smoking, alcohol and diet, having major implications for the health of the Scottish population. In government, the SNP has previously taken some bold measures, including supporting a minimum unit price for alcohol. They have also placed a strong emphasis on the need to address the wider social determinants of health to reduce Scotland’s marked health inequalities. In contrast, the SNP’s 2016 manifesto says very little about new public health measures, beyond a commitment to a strategy for improving diets and tackling obesity.

None of the other main parties said much about public health in their manifestos either, raising the prospect of Scotland losing its international reputation as a leader in this area. The Scottish Greens offered the only innovative public health proposal, outlining a levy on retailers and caterers of unhealthy foods and bans on price-promotions for sugary foods and youth advertising of unhealthy food and drink. But while the Greens managed to beat the Scottish Liberal Democrats to fourth place, these proposals are unlikely to get far unless they are successful in challenging the apparent ambivalence to public health among the other Scottish parties.

Mark Hellowell is Senior Lecturer, Global Public Health Unit, University of Edinburgh. You can follow Mark on Twitter @mhellowe.

This blog was co-authored by Katherine Smith, Reader, Global Public Health Unit, University of Edinburgh. You can follow Katherine on Twitter @KatSmithInEd.