Scotland, Independence, and Pharma

As an American, asking a Scottish academic or biopharma industry executive about the health implications of an independent Scotland will get you quiet smiles that are difficult to interpret. The Scottish themselves (not to mention the English) seem a bit surprised about the rise of the Scottish National Party (SNP) led by First Minister of Scotland Alex Salmond, who, in January, announced that the Scottish Government would hold a referendum vote on Scottish independence in the fall of 2014. Whether or not the government has the power to declare independence is up for debate, and a public consultation period is currently ongoing, with plans to introduce the referendum bill to the Scottish Parliament in early 2013. The precise wording of the referendum question (or questions)-to be answered yay or nay-is still being determined.

But Scotland already has an independent education system, legal system, and health system (NHS Scotland), the latter a single-payer that provides health services to the Scottish public for free at the point of access. And the Scots are way ahead of many other nations (including the U.S.) with respect to electronic record keeping. "Scotland has excelled at collecting data and tissue for years, which means we have outcomes data without additional studies," says Rhian Touyz, director of the Institute of Cardiovascular & Medical Sciences at the University of Glasgow. "For every patient admitted to a hospital in Scotland since the 1970s, we get their data." Pharmaceutical companies looking to conduct clinical trials are given access to a fully phenotyped population of over 5.1 million.

Indeed, clinical research is a source of national pride in Scotland; last November, the Edinburgh BioQuarter cut the ribbon on a £60 million ($95 million) Centre for Regenerative Medicine, heralded as a leading institute for the study of stem cells. Generation Scotland, a large-scale collaboration between the Scottish university medical schools, biomedical research institutes, and NHS Scotland, aims to create more effective treatments based on genetic knowledge. Its banner project—the Scottish Family Health Study—involves an "intensively phenotyped, family-based cohort with which to study the genetic basis of common complex diseases and response to treatment." The program has already enrolled its target 25,000 family members.

Despite world-class strength in early stage clinical research, and a country-wide EHR network—made possible at least in part by the absence of multiple and competing healthcare providers—Scotland has some of the steepest health inequities by socio-economic status in all of Europe, as well as a disturbingly high incidence of cardiovascular disease and percentage of cigarette smokers. These are expensive problems, and so the question becomes: What, if anything, in terms of resources, would be lost or jeopardized if Scotland decides to go it alone in 2014?

Making that determination is about as difficult as reading the faces of the individuals to which the question was posed. Most responses were circumspect. Andrew Henderson, manager of life sciences at Scottish Development International (a joint venture between the Scottish Government and industrial policy and commerce groups), and founder and director of the Scottish Stem Cell Network, declined to comment on "political issues" given his role as part of a government agency. Sandosh Padmanabhan, an academic at the University of Glasgow who is working on a British Heart Foundation fellowship, was a little more forthcoming: "The SNP could present problems." For example, the British Heart Foundation is a charity—a British charity—and "the Medical Research Council's (MRC) remit [decreed by Royal Charter] is to improve cardiovascular health in the UK," he says. This could result in a loss of funds for these crucial health intermediary organziations. Scotland, in fact, has been more successful in securing MRC funds than any other part of the UK; Scotland represents only 8.5% of the total UK population, but received over $1 billion in funding—or 11.5% of MRC's total investment—in 2009.

The 2014 vote is Scotland's "most important decision in 300 years," Alex Salmond wrote in a paper explaining the referendum. "Our politics should be judged on the health of our people, the welfare of young and old, and the strength of our economy." Quoting poet Robert Burns in a speech on independence in Edinburgh last month, Prime Minister David Cameron urged all citizens to "see ourselves as others see us,"—that is to say, united. If the people of Scotland opt instead for disunion, will the country be able to use its small size and interconnectedness to its advantage in an increasingly competitive global marketplace?