One country, two systems was the formula the Chinese Government once used to explain how the rampant capitalism of Hong Kong could coexist within the ambit of a communist regime. That description can now be applied to Britain – not to its economy, but to its health service.

The NHS north and south of the Border has come to differ so markedly that it has been attacked for operating what one commentator describes as “medical apartheid”. If you are ill, old, infirm and English, you will ask, in vain, for the following benefits: free prescriptions for the chronically ill, free personal care for the elderly, free access to drugs that treat advanced lung cancer, multiple myeloma, Alzheimer’s and some forms of brain tumour.

If you fall down and break your leg, you may find that your local A&E unit has been closed under the Government’s programme for centralising hospital services, and if you are judged to be an out-patient, you could find yourself on a three-day waiting list for your local GP. If you are a doctor, you will grapple with the intricacies of foundation hospitals, primary care trusts and a whole array of market-based systems presenting you with a series of targets in the name of patient choice. None of these applies in Scotland.

This Anglo-Scottish gap is about to get wider. And as it does so, a picture emerges of two healthcare systems that are ideologically poles apart. One is the market-orientated, target-driven, management-dominated approach, in which the private sector plays a critical role. The other is the more traditional version – state-funded, centrally directed, collaborative, slower-moving and with fewer management targets. It might perhaps be described as the Dr Finlay’s Casebook model.

There is no doubt which is the more popular. The Scottish model has the comforting feel of the deeply familiar: this is the health service as most people like to think of it, paid for by the State, freely available, with minimal involvement of the private sector. It has its own version of the National Institute for Health and Clinic Excellence, which determines whether new drugs should be paid for by the NHS or not, and as a result has approved a range of prescriptions, such as Tarceva, which is used to treat advanced lung cancer, and Velcade, which has helped patients suffering from multiple myeloma. Neither is judged to be cost-effective in England, and are therefore not available on the NHS south of the Border.

None of this comes cheap. The NHS in Scotland is costing about £10 billion a year, with the annual bill for free personal care already approaching £200 million. Approving the two new drugs has added some £2 million a year. Nobody has even begun to quantify the cost to the taxpayer of rejecting the private sector approach to health provision.

The new Scottish Nationalist Executive is untroubled by this. Not only has it set its face against such Blairite reforms as foundation hospitals and outsourcing of medical services, it has promised to phase out private finance initiatives, extend free care for the elderly and abolish all prescription charges within the next four years. It has kept open accident and emergency units that the previous government believed were inefficient, and has announced that it will match the ambitious English target for reducing waiting times from the GP’s diagnosis to the hospital bed to 18½ weeks.

It is easy (and lazy) to say, with certain Tory MPs, that all this is an example of Scottish profligacy, paid for by English taxes. For one thing, Scottish taxpayers have shouldered their burden in equal part; for another, the funding advantage that Scotland has enjoyed over the past 20 years thanks to the Barnett formula has been steadily shrinking and will, within the next decade, have virtually disappeared. The decision to invest a large and growing proportion of the Scottish budget in health has been a direct consequence of devolution, reflecting Scotland’s appalling health record, and the agreement across all parties that something has to be done to tackle it. If that has resulted in a policy division between Scotland and England, then that is what devolution was meant to be all about.

The more pertinent point, however, is to question how the present administration in Edinburgh intends to pay for the NHS as its costs escalate and the funding diminishes. Thus far, ministers in Scotland have not had to worry too much about their share of the national cake, because the cake has expanded so dramatically. Twenty years ago the Scottish budget was around £12 billion a year. Within the next two years it will have reached £30 billion – an increase of 150 per cent. That has allowed spending commitments that would otherwise have been inconceivable.

Alistair Darling’s Comprehensive Spending Review has put a brake on that. The SNP has not hesitated to condemn a parsimonious increase and will use it as an excuse for future cutbacks. But they know that, sooner or later, they will have to confront the reality of government: to cut their coat according to the cloth available.

Ironically, that would happen very rapidly, and very drastically, if they won their goal of independence and found themselves having to raise their own taxes in Scotland. At a stroke their budget would be reduced, their spending targets curtailed and their accountability ruthlessly exposed.

SNP ministers may even now be wondering if the independence game is worth the candle.

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