Robin McAlpine – 17th November 2022
You can’t have missed a dark, ominous drumbeat surrounding the health service in Scotland. It is really important to be aware of what this does mean – and what it doesn’t mean. The future of our Scottish NHS could depend on it.
The almost constant stream of really bad data about the state of health services and very worried people warning about it is all very real indeed. Sometimes these kinds of warnings are a bit of a gambit to get attention or to lobby over funding. That is not what is happening here; the NHS really does face a very severe risk.
What none of this means is that it is impossible to fix it in Scotland or that we have to accept that the NHS as we have known it is coming to its natural end and what we get next will be much more austere and limited, an emergency service only. That is just another example of right wing politicians cynically using a crisis.
None of this is happening purely because we’re not spending enough on health. Scotland (well rather the UK) spends a greater proportion of GDP on health than does Denmark, and Denmark has a truly gold-standard health service in which everyone gets a diagnosis in a maximum of four weeks and begins treatment not less than four weeks after that.
So when the Scottish Government asks for more Westminster funding for heath there is no question that the NHS needs it – but that is very different from saying that the Scottish Government can’t do anything at all.
The Scottish Government claims that health services in Scotland are doing better than in England and that it is providing ‘record funding’ for health. This latter claim really annoys me – there has never been a cash-terms cut in health spending year-on-year so every year since the NHS was created has seen ‘record funding’. It is the worst kind of sophistry to make that claim.
And yes, it is certainly true that things are worse in England. But let’s put that in perspective – one very knowledgeable health expert I spoke to phrased it as “the NHS in Scotland will collapse within the next two or three years if something isn’t done while the NHS in England could collapse at any minute”.
So unless the epitaph for this Scottish Government is to be ‘slightly delayed the collapse of the NHS’ it very much needs to get its act together. It needs to dedicate an awful lot more effort into fixing the problem and rather a lot less on spinning it.
Obviously there is much more to be said than I have space for here. Common Weal now has a Health Policy Group which has been meeting weekly for a number of months. That work is coming towards completion and we will publish it soon. But it is urgent that we all understand what is happening and why.
The first problem is that Scotland’s health service is under massive strain because Scotland’s public health is poor. Scotland has a dreadful record on poverty and it is getting worse. Poverty and its impacts are by far the biggest indicator of ill health.
This is the first message Common Weal wants you to take – health is primarily social not individual. The impact of your genes and life decisions you make of course make a big difference. But not as much as social factors.
Scotland’s public health is dreadful. Lots of our housing stock is substandard, damp and draughty. Our economic inequality is of developing nation proportions. We work far too many hours and face continual stress and anxiety. Our entire food system is run by supermarkets and fast food chains. We do just about everything we can to make ourselves ill.
And public health policy in Scotland is really just about messaging – we don’t fix damp housing, we give money to advertising agencies. The Scottish Government had the chance to do something about our food system with the Good Food Nation Bill – but just shrugged.
Denmark doesn’t have magical doctors who can treat you for less money than Scottish doctors, Denmark just doesn’t accept the social failure that we accept as routine in Scotland. Until that ends, its always going to be an uphill battle.
But that doesn’t help us in the very short term nor does it explain the rapidity of the downwards spiral in Scottish health services. And a lot of the blame for that does indeed lie directly with the Scottish Government. Here’s why.
In Scotland health services are bureaucratically-led. Health is planned not by doctors and nurses but by finance directors and political place people. The management culture actively disempowers clinical staff, deliberately making them afraid to step up or to step forward because it is fundamentally risk-averse.
This makes it woefully wasteful, spending money doing things that don’t need to be done in a constant orgy of back-covering. The British Medical Journal has conclusively shown that there is no greater infection risk of irrigating a wound with tap water than with sterile saline, and yet tending to your wound will involve those little expensive plastic bags of saline. Hospital bosses listen to lawyers not medical journals.
The management culture and ‘internal market’ tipped the NHS into that downwards spiral. A finance director looked at a spreadsheet, said ‘oh look, we’re running at 90 per cent capacity on average and so we need to get that up to 95 per cent’. Except there is no ‘average’ in health. Do you know what 95 per cent capacity in June is? It’s 110 per cent capacity in January.
The Scottish Government slashed beds (more than 4,000 cut in the last ten years), then faced cyclical crises because it didn’t have the capacity to deal with spikes. When was the last time you remember entering January and not being told that flu season could tip hospitals over the edge? A decade? Two? And yet the Scottish Government just kept cutting capacity.
Then to stop the whole system falling over it effectively bribed medics to work dreadful hours. Doctors and nurses were expected to cover the capacity problem by… working more. The doctors negotiated big payments for this, the nurses got squeezed. And the Scottish Government kept cutting, so they kept squeezing, so it got worse and worse.
So health care workers started to leave the service. When they discovered they could join an agency and get the same pay but for fewer hours, that’s what many did. The NHS uses locum nurses to deal with capacity shortages, which costs twice as much as just hiring the nurses, requiring more ‘efficiency gains’, round and round.
The patches to stop the system falling over now are the system. Junior doctors don’t work unsafe lengths of shift while the problem gets fixed, they just do. To stop them leaving we pay them more and to pay them more we cut capacity and to deal with cut capacity we make them work more and to stop them leaving we pay them more…
The bureaucratic burden means GPs have insufficient patient contact time, the poor quality of workforce planning limits the workforce, Scotland builds insane ‘mega hospitals’, commercial vested interests dominate (big pharmaceutical companies are all over the NHS and lawyer are the fourth biggest area of expenditure in Scotland’s NHS.)
But above all it is management culture which is the issue. To give you an idea of what this means, NHS Lothian has an ‘innovation team’ of six people, of which only one has any medical expertise and the other five are marketing graduates and an anthropologist. The following sentence tells you what you need to know: “having worked up the NHS Lothian corporate ladder, she eventually became a Business and Administration Manager”.
If we want to save the NHS we need to reverse almost all of this. Health must be clinically led, not politically led, not Master of Business Administration led. Governance should be democratised so the workforce chooses its leaders based on delivering the best health, not the best political outcomes.
We must set the health workforce free, breaking the rigid hierarchies of the NHS “corporate ladder”, empowering staff and enabling them to step up and step forward. Staff with managers hovering over their shoulder will absorb the risk aversion of the managers and simply bump problems up the hierarchy even though they could easily resolve them on the spot.
Capacity must be expanded and in doing it must be relocalised. Specialisms that people use rarely should be concentrated in purpose-designed facilities so that hospitals can focus on the medical generalism that is what most people need from a hospital. We need to get workforce planning right and solve the insane bottlenecks that slow down the qualification of new staff.
We need to shift health into communities by training local people to become Community Health Supporter Workers who can intervene early with simple things that stop them escalating. Training medical staff takes a long time but we can quickly train Doctors’ Assistants and Nurses’ Assistants to release capacity from medical professionals.
But above all we need to make a working life in the NHS something people actually want. The failure in the NHS is leading to a staff exodus and there is no escaping the downwards spiral for as long as we treat staff as if they are consumables.
We need to believe the NHS can be saved or it will die. It can be saved. We can’t turn it round this winter but if the kinds of approaches proposed above are taken over the next two years then we can avoid the collapse and start to turn things around. And then we need to take seriously the social failure which leads to our terrible public health.
At the moment the Scottish Government is simply doing more of what got us into this mess in the first place. If it doesn’t stop and change course, it risks becoming the gravedigger of Scotland’s most beloved institution.