Associate feature: The lessons we can learn for NHS reform from 100 years ago

More than a century ago, there was huge concern around the provision of medical services in the Highlands and Islands. Poverty levels were high, there was a shortage of doctors to cover vast areas and a lack of hospital provision. A then newly established system of health insurance (National Insurance) relied on employer contributions and so did not cover much of the population who were crofters and therefore self-employed. 

To address these issues, a committee was formed to explore the challenges and solutions, headed by MP, Sir John Dewar. The steps taken included questionnaires being sent to doctors in the areas and visits to various locations, from Oban to Lerwick to investigate the problem and take oral evidence “on the spot”. 

A report was duly published and resulted in the establishment of the Highlands and Islands Medical Service (HIMS), which received government funding and provided better conditions for doctors. This included a guaranteed minimum salary for GPs which allowed them to charge lower fees to patients, mileage for their cars and later the provision of houses. That HIMS is now considered to have established many of the principles of the NHS when it was founded in 1948. 

Decades later, there is no doubt that the NHS is in crisis, and that is acutely felt in our remote and rural areas. Already long waiting lists are getting ever longer forcing those who can pay for it to go private, leading to a two-tier health service and putting the founding principle of the NHS, remaining free at the point of need, at risk. 

Meanwhile doctors are frustrated and disillusioned, working tirelessly to try to meet often crippling demand without feeling properly valued.  

Our modern healthcare system is of course very different from the time of the Dewar report. It did not solve all the problems of remote and rural healthcare, but arguably, there are lessons that can be learned from it. Not least, that the vision for the HIMS came from an informed discussion. 

BMA Scotland has long been calling for an inclusive and wide ranging National Conversation on the future of the NHS. For the long-term reforms and culture change that are needed for today’s modern-day NHS, we need an honest, open and in-depth conversation on how to address the challenges. There has been a commitment to a series of engagements by the Scottish Government, but we still await further crucial details on engagement. While the Scottish Government must commission the conversation, it remains our view that someone independent of government should oversee and manage it. 

Any reforms which come out of this must be implemented swiftly. In the case of HIMS, necessary legislation was in place a year after publication of the report. With today’s NHS now facing a year-round crisis, our doctors, health and social care professionals and most importantly patients cannot wait indefinitely for solutions.  

The need to value our medical workforce is as vital now as it was then. That means investing in doctors’ pay, properly supporting our medical students, the doctors of the future and substantial, direct and immediate investment into our GP practices.  

We also have huge concerns about the role and deployment of medical associate professionals (MAPS) in Scotland, which should not be seen as a potential alternative workforce option to address shortages of doctors. 

More than one hundred years ago, it was recognised that proper investment in doctors would result in improved care for patients. That remains the only solution to our workforce crisis today.  

This article is sponsored by BMA Scotland

www.bma.org.uk