Bus with Thank you NHS on rear in Dumfries

The NHS can be saved

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.

8 thoughts on “The NHS can be saved”

  1. I am puzzled as to why the G.P. service has virtually disappeared. The G.P.s say they are overwhelmed yet their waiting rooms are empty. Capitation Fees are still ticking away for the absentee patients.
    I am waiting to consult a G.P. face-to-face. When I do see her, it will have been 6 weeks since my initial request.
    This is a three Stage Process;
    1) A rather too-personal call to an unqualified Receptionist.
    2) A two-week wait for a telephone chat.
    3) A further four weeks wait before I can enter the holy of holies.
    I hear similar stories from relatives and friends all over the Country. I am so old that I remember a time when G.P.s made home visits and treated emergencies at weekends. Dentistry and Podiatry seem to be working normally.
    We do have a problem, the failure of Primary Care inevitably knocks over the rest of the Health Service dominoes.
    Sam Purdie, Perth.

    1. I agree with your comments regarding GPs. I’m not sure what they are doing these days, but it isn’t seeing patients the way they used to. Our health service waiting room is always almost empty, and yet getting a face -to-face appointment is nigh on impossible. Ours sends you to the pharmacy first. I see pharmacists ‘consulting’ with patients – minor ailments, medication reviews etc – to the detriment of their own jobs. You used to get a repeat presription filled in three days, now it takes eight. But I disagree that dentistry seems to be working normally. Many dentists in some areas across Scotland have either closed their doors to NHS patients, and gone private, or are still only seeing ’emergency’ patients.

  2. This is great and should be read by all. It’s not rocket science is it? In fact it mirrors exactly the discussions I’ve been having with others about the NHS in Scotland. This week I’ve used the service for a routine checkup for a heart condition that involved passing 2 hospitals near to where I live to get to one that is probably the most difficult to reach. The place was earily empty of patients. After 72 hours I had to repeat the journey to hand back the heart monitor.
    This could have all been done in my GP surgery by a technician. God knows when I will get the results. I’m in my 70s and love the NHS but we do need to get over the nostalgia and the “clapping” and call out our politicians for allowing what you have so eloquently described to happen. I’m not as optimistic as you Robin but I do sincerely hope that you are right that the health service can be saved. And it’s a national disgrace that poverty and social factors are destroying our citizens health.

  3. Ian Davidson

    Agreed! The fault lines were there pre covid. Eg: the NHS “convalescent” hospital that allowed my aunt and uncle to live together under medical care in the last few weeks of their lives was closed a year later. The sleepover service added to my mum’s innovative sheltered housing with care service was closed, just before she really needed that night-time on site staff presence, resulting in expensive hospitalisation and then 24/7 nursing care. The NHS hospital where my mother-in-law died had one (exhausted) junior doctor to cover 250 patients over each weekend.
    One example of a “health bureaucrat” is the NHS Clinical Director Jason Leitch. He is a qualified dentist and has a masters degree in Public Health. This does not make him qualified in dealing with complex mutating viruses. He is not a micro biologist. He is a good PR communicator. Nothing against him personally but the fact that a dentist is the clinical lead in our NHS during a time of a fatal virus tells its own story. A qualified psychologist with a Phd can be called “Dr” but that does not make them medically qualified; they can’t prescribe medicine, they can’t operate, they don’t know how to manage a ward or a GP surgery etc etc. It would be nonsensical to have such a person as the National Clinical Lead for the whole NHS.
    Far too much time, energy and (our) money is spent daily in hospitals “managing beds”: Lots of qualified folks and managers meeting several times each day to squeeze out the last drop of bed capacity as if they were managing a hotel chain during a festival! As you say, you cannot run hospitals on this “efficiency, just in time basis” esp for older people who take longer to heal (rarely to 100% of previous physical/mental capacity) and may needs lots of support, re-jigged housing etc when they get home. I know this, you know this, so why do our political leaders act as if they do not know this?

  4. florian albert

    Robin McAlpine avoids the most important question about the NHS; is it the most effective way of deliivering health care ?
    The fact that other countries have chosen not to create an NHS replica suggests not.
    With regard to his specific comments;
    I am far from convinced that having doctors as managers would make a radical difference. A system as big and complex as the NHS requires a massive bureaucracy. Most doctors do not want to be bureaucrats. Within medicine, the failure to
    give sufficient resources to mental health has been tolerated by doctors for decades.
    Staff shortages have been factored into the NHS for decades. Instead of training sufficient doctors and nurses, we have poached them from abroad – overwhelmingly from poorer countries which needed their skills even more than we do.
    For all Robin McAlpine’s comment about how badly NHS staff are treated, their conditions of service, pay and pensions are
    significantly better than most in the private sector. In Scotland, GPs work, on average, a three and a half day week.
    If Scotland is, as Robin McAlpine writes a less healthy country than Denmark, we will need to pay more for health care than the Danes. Does this mean – as I assume it would – higher taxes ? In such a case, health professionals would be amongst those having to pay more.

  5. Almuth Ernsting

    One thing missing from the article is the impact that wave after wave of unmitigated Covid is having on the NHS in Scotland, too: Waves of staff sickness and peaking admissions, more and more staff chronically ill with Long Covid, and post-Covid heart attacks, strokes and other ill health. Of course, the fact that Scotland (like England) has less hospital beds per 1,000 people than almost any country in Europe means that the healthcare system cannot possibly cope with a steep increase in ill health. However, there are reports of serious problems with an exodus of healthcare staff, staff shortages and delays to treatment in Denmark, too. And in Germany, which has seven times as many hospital beds per 1,000 people as the UK, excess deaths stood at 19% in October. Hard to see how we can protect NHS Scotland without reviving public health and striving to reduce Covid (and at the same time other airborne virus infections) which we now know can be done with a combination of ventilation, air filters and good quality masks in particular (including in hospitals).

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