I don’t usually discussed politics at all in my blog, unless absolutely essential to make a point. However, politics is now intruding on almost every aspect of our lives, all over the world.

In the UK, Brexit is affecting the NHS for the worse, and we haven’t even left yet. The lies told in the referendum about the Brexit dividend for the NHS have quickly been rebutted, and the service is haemorrhaging staff from the EU, resulting in shortages in all parts of the health service. In the USA Donald Trump has withdrawn financial support for women’s health services all over the world, and has his eyes on taking over the British NHS by buying up privatised services to make a profit. The right wing Brexiteers in the Conservative party want to turn the UK into a Singapore style free market economy, in so doing lowering standards in food, services and finance.

I haven’t yet met a doctor who supports a hard Brexit. There may be some out there, but on the whole doctors are aghast at what is happening. But the change in people’s political choices has meant that in England at least, there has been a Tory majority, albeit small, for quite a few years now, and there is not much evidence that a left wing government, even a coalition of different parties, will be elected next time round.

I spent my career in general practice and medical management in Wales, and I now live in Scotland, so I don’t have an Anglo-centric view of health services in the UK. Although all countries of the UK have similar problems, brought about by austerity, and a disinclination of the Westminster government to invest in health for ideological reasons, health is a devolved matter and each country can put a different emphasis on its priorities. For instance, the privatization mantra has not really been supported outside England

Recently Labour has warned that the UK Government’s agenda of privatising the NHS has come one step closer, after the Tories tendered £35m in new contracts to private companies in just six weeks since mid-February. Further analysis reveals that a total of 21 NHS contracts, worth a staggering £127 million, are currently out to tender. Some people believe the mantra that private companies are more efficient than public bodies. But many people in medicine, and I am one, believe that you lose too much – the goodwill of those who now see profits being syphoned off, the lack of morale in a low paid workforce, and the potential for decisions being made that are antithetical to public service.
So one big concern I have is how far devolution will allow Scotland, Wales and Northern Ireland to diverge from this nightmare scenario of the NHS being sold off to American firms after Brexit.
I recently read an article about how the republic of Ireland has managed to influence the Brexit debate. It seems that over a year before the 2016 referendum, the Irish government, appalled by the way things were going, set up a task force to see how Ireland would be affected. They soon saw that Ireland would be affected almost as much as the UK, and that the border with Northern Ireland would be real problem. So they started planning how to respond even before the referendum, and made sure that the important players in the EU were well briefed. It seems that intense lobbying went on so that all countries in the EU were aware of Ireland’s position, and that all supported the joint effort to make sure that the EU was on the side of Ireland, the state that was staying, not the UK that was leaving. Certainly, smaller states on Russia’s border appreciated the benefit of having the EU on their side. Since the beginning therefore the EU has been clear that it would make preventing a hard border a priority. It seems that none of the UK negotiators ever believed that this would be the case, thinking that the EU would give in at the last minute.

This gives us an insight into the situation that we are all in. If England doesn’t consider the position of Ireland, its biggest trading partner, to be important when negotiating with the EU, what hope is there for Wales or Scotland?

I think the Union is on the ropes. The most pressing problem is Northern Ireland, as it would suffer most from Brexit whatever form it takes, and is highly likely to join southern Ireland after Brexit because of the effect it will have. And the people there voted to remain. But after that, Scotland would likely want to consider its position. I voted in the Scottish referendum and I voted for Scotland to stay in the UK, at least partly because if Scotland left it might have to leave the EU. I have put remaining EU as a priority, because my mindset is that of subsidiarity – that powers should be devolved downwards as far as possible. I would support a completely federal union within the EU, because that way smaller regions can get the support of the EU when larger ones are bullying them. But to my horror, when Scotland voted to stay in the EU, the Westminster government ignored the vote completely and is still committed to taking Scotland out of the EU against the will of its people.

For Wales, which voted to leave, the situation is dire.
The following table shows the difference between May’s Stronger Town Fund and the EU structural Funds per region, so this is how much each region is losing out on because of Brexit.
Scotland -£895m
Wales -£2413m
South West – £1462
North West – £851
North East- £634
Yorks & Cumberland £597
South East £249.

The Welsh people were promised by the Leave campaign many times that Westminster would make up the money Wales would lose from EU funds. People who believed that were very gullible – the Tories have never invested in Wales, at least partly because the Welsh people never vote for them. It is a vicious circle of course.
Wales is rich in energy – it is the fifth largest exporter of electricity in the world. In 2016 Wales generated 38.8 TWh of electricity and only consumed 16.1 TWh. This means that we exported 22.7 TWh – that’s just less than what the whole of Scotland consumes in a year. But profits from these assets – water, hydroelectric, wind energy, nuclear, don’t go to Wales. Further investment, could increase this wealth, but it will never come from Westminster. The tidal lagoon in Swansea, and electrification of the rail network come to mind, as examples of investment that never happened.

For the NHS as a whole, we know that staff shortages and lack of investment is damaging the NHS. The private sector is growing and is now as big in proportion as in many other European countries with an insurance-based system. Staff shortages are worse in Wales and Scotland; they both depend on immigration, even more than England does, to support the NHS and other industries. Depopulation has long been a concern in Scotland, not overpopulation as in England. Wales loses many of its young people each year – often the most talented, because of lack of opportunities. The cost of their education has been born by the Welsh Government, as education is devolved, and the countries that receive them, mostly England, get a free gift. But a large proportion of immigrants to Wales – from Birmingham, London, Europe or wherever are elderly retirees, who expect (rightly) to use the NHS and to get the same service they would have got in England. This means that the Welsh health service gets a double whammy – it loses the young people who don’t need health services so much and imports the elderly who do. Sadly there is no extra bonus to Wales – the basis of health service funding is per head, with a small addition for the elderly which does not cover the huge extra cost of looking after them. Culturally, the effect on Welsh speaking communities of a huge influx of people from outside Wales has been much worse than having a lot of Polish speaking immigrating to English towns – at least English is not likely to ever be a threatened language!

This all pre-dates Brexit, but when you then add up the loss to Wales of EU funding, then Wales is stuffed.

So, post devolution, how will the health services of Scotland, Wales and Northern Ireland fare? Up to now, they have been able to avoid the worst of the English drive for competition and privatization. PFI is hardly known in Wales, and happened much less in Scotland than in England. Outright privatisation is much less; for instance the GP back-services (which deal with their pay, premises, staff reimbursements and patient records) which were handled extremely badly by Capita, have remained in house, much to the relief of GPs. Where possible both devolved governments have tried to keep the ethos of the NHS as a public service.

The future does not look bright. One of the first acts of the conservatives after Brexit was to take back powers of devolution to Westminster in order to have a “UK –wide” system of funding after Brexit. Both devolved governments objected (NI doesn’t have a government at all at the moment) and protested fiercely. Wales eventually caved in given certain reassurances that the powers would be “given back” after 7 years (by which time everything important will have been sold off, with none of the benefit going to Wales and Scotland). Scotland has never agreed to this and a court case has now indicated that the Conservatives have acted illegally. So the battle for Wales and Scotland to run their services the way they want is not over yet. But if there is either a deal such as Mrs. May’s or no deal then the aim of the Westminster government is to allow further privatization, and we can be sure that this will result in Scotland and Wales having no control over privatization, and devolution going out of the window.

As a result of Brexit, many people believe that Northern Ireland will get a plebiscite on whether to join the republic of Ireland (as is their right under the Good Friday agreement) and may well do so. Scotland will then certainly want another referendum. I, voting in Scotland, and many like me, would definitely vote to leave the UK this time, rather than stay with England. England always was more right wing, and seems to be becoming more hard right and controlling. Wales may not get a choice and its views may be ignored, resulting in it becoming just an appendage of England, getting poorer and poorer and losing its rich culture and language which goes back to Brythonic times. Survey after survey shows that people in Wales want more powers devolved to the Welsh Government; a Federal state is popular and the NHS is even more of an iconic establishment than in England. As with Brexit, youth also favours one side. The BBC’s recent St David’s day poll showed that 63% of 18-34-year-olds wanted either independence or more powers, compared to a measly 7% who wanted to abolish the Welsh Parliament. If Brexit doesn’t happen it will likely inflame the far right throughout the UK, and their representation in the Senedd could increase. The Welsh language and culture are fighting back hard, especially in places where it had previously been almost dead, and nobody wants to get poorer. Plaid Cymru is now openly asking for independence, and its support is growing. So who knows?

I would hate to see the UK break up, although if truth is told I think that ultimately Northern Ireland must join the Irish republic, because of demographic trends and the fact that immigrants are unlikely to join either group of the religious divide. But I have heard that the NHS is a big attraction for Northern Irish people to continue their membership of the UK. Ireland does not have an NHS such as exists in the UK. You have to pay to see a GP and for many hospital services, and it can cost €100 for a visit to the Accident and Emergency department. (People receiving welfare payments, low earners, and with certain other diseases do receive free care). GPs are often single-handed and can charge quite a lot for visits, so many people have private insurance. Brexit could change everything for Northern Ireland.

For me, living in Scotland, and travelling to Wales frequently would be a nightmare if Scotland left the Union. But the thought of creeping Americanization of our Health service is equally horrifying. While American healthcare can be the best in the world, it is the most inefficient system in the world on a population basis, and for Scotland with a long history of poor health outcomes this would be a disaster for those who care about everyone’s health, not just the wealthy. If England really does leave the EU without a deal or a very poor one, and we continue with a hard right wing government I think there is no doubt that the NHS would be dismantled.

I believe in meaningful devolution, and would very much support a more Federal solution. Whether Scotland could rejoin the EU after Brexit is an open question –its health system could continue to develop separately as it has been doing if so.

Whatever happens to Brexit now a lot of damage has already been done to our country’s social cohesion. Who knows what the future will bring?