Chronic Condition: Can a 'national conversation' help revitalise Scotland's NHS?

At the start of the pandemic, with people confined to their homes, the weekly Clap for Our Carers ritual allowed the public to show its support for the NHS as it faced the most difficult challenge in its long history. Amid the fear and anxiety of Covid, the health service was a symbol of hope, its logo juxtaposed with a rainbow to remind everyone there would be better times ahead. But while the world has now emerged from the pandemic, the NHS remains in a critical condition, its increasing limitations threatening to erode the goodwill built up not only during the time of Covid-19 but the preceding decades.

If it was once the beloved national institution, the best idea of any post-war British government, and the part of the state romanticised in the opening ceremony of the 2012 London Olympics, then the NHS’s stock has fallen in recent years. While most of us still have experience of world-class care delivered by hard-working staff in increasingly difficult circumstances, there is also growing frustration about the difficulty of obtaining a GP appointment, concern over the state of A&E departments and anger over long waits for surgery. By nearly every metric used to measure performance in Scotland’s NHS, the system is struggling.

Last year’s British Social Attitudes survey recorded the lowest levels of satisfaction with the NHS across the UK since the survey began in 1983. Just under a quarter (24 per cent) of respondents were satisfied with the state of the health service, while the figure fell to 13 per cent for social care. Since 2020, the first year of the pandemic, satisfaction levels have fallen by 29 percentage points. Yet analysis of the findings by the King’s Fund, an independent think tank, found the public do not want a radical overhaul of the NHS, they do not want a different model – they just want the current one to work as it should.

In Scotland, health secretary Neil Gray, who replaced Michael Matheson in February, has called for a “national conversation” about how the health service can be reformed to help meet today’s challenges while remaining free at the point of use. Gray has spoken of trying to find “consensus” and  “a common vision” of what the NHS is there for and what its priorities should be. In England, a rapid review carried out by surgeon and independent peer Lord Darzi, which was published last week, painted a bleak picture of a health service that is in a “critical condition”. Prime Minister Keir Starmer has said the NHS in England is now in an “unforgiveable” state, left “broken” by 14 years of Tory rule.

Darzi’s report said the NHS had been left chronically damaged by the years of austerity under the last government. He highlighted what he called a “staggering” capital spending gap which opened up between the UK and other European countries in the 2010s. He said there would have been £27bn more capital investment had the UK matched other EU nations and an extra £35bn had it matched the spending in Nordic countries. In response, the prime minister promised “the biggest reimagining of the NHS” since it was formed, with a new 10-year plan to be published in the coming months.

Dr Gavin Francis, an Edinburgh GP whose book Free for All: Why the NHS is Worth Saving was published last year, says the health service’s cherished status with the public has been undermined by the previous Westminster government, which was, on occasion, “actively hostile” to the NHS’s founding principles.

“It would be very unfair if the reputation of the NHS crashed because it has been starved of funding by its political masters,” he says. “The primary care budget for this country costs £180 a year per person – that’s less than 50p a day to have access to a GP. The basic distinction between commercialised and socialised healthcare systems is that [in the former] it is in the interests of all the decision-makers to make you more anxious about your health and make them more money.” 

Francis says that if he could make one contribution to the national conversation under way about the health service it would be to highlight that the UK has fallen behind its near neighbours in the amount it spends on health.

“The single biggest thing we need to do is recognise that we need to pay more for it,” he says.

“We don’t spend as much on health in this country as the French do, the Germans do, the Danes… If we want a modern, scientific health service then we are going to have to pay a bit more for it. 

“We’re supposed to be one of the richest countries in the world. I find it a bit baffling that we’re constantly being told we can’t afford a decent health service. The health service is actually very efficient, it gets painted as inefficient in certain sections of the media but that’s not really true.”

While health is fully devolved in Scotland, the amount the government receives in its block grant – and therefore the amount it can allocate to the NHS – is determined by UK Government spending. At the outset of devolution, Scottish health spending per person was approximately 22 per cent higher than health spending in England, equivalent to an extra £297 per person in Scotland, according to research by the Institute for Fiscal Studies (IFS). In the 25 years since, Scotland has continued to spend more per person on health, but the gap with England has fallen over time, and by 2022–23 the two countries spent almost the same on health per person.

Meanwhile, the number of patients on the elective waiting list in Scotland has grown by 87 per cent since the start of the pandemic. The percentages of patients waiting fewer than 18 weeks for elective treatment and fewer than four hours in A&E departments have also fallen substantially since the start of the pandemic. And, according to the Scottish Fiscal Commission, health spending will rise from 35 per cent of the Scottish Government’s budget in 2027-28 to 50 per cent by 2072-73, driven by higher wages for staff and the demographic pressures of an ageing population.

The strain put on the health service by the pandemic has pushed more people to pay for private medical insurance. While to some extent there has always been a two-tier system in the UK for this very reason, it has become more defined over the past few years. 

Since the advent of Covid, the number of people paying for medical care has increased dramatically. Figures from the Private Healthcare Information Network, which monitors activity across the sector, show that 272,000 people paid for an operation or diagnostic procedure in the UK last year – up 37 per cent on 2019. Even for the most serious conditions, such as cancer, patients are funding their own treatment rather than be left at the mercy of NHS waiting lists. At a recent First Minister’s Questions, Scottish Labour leader Anas Sarwar said figures obtained by his party showed 1,000 rounds of chemotherapy were paid for privately in Scotland last year.

But while increasing numbers of people paying for private medical insurance can help relieve pressure on waiting lists it can also have the opposite effect of creating an extra burden for the NHS when patients are seen privately and then pushed back into the NHS for post-operative care or for ongoing consultations with their GP. 

In the short to medium term, it’s difficult to see how the NHS can resume a more stable footing given the ongoing squeeze to the public finances. Chancellor Rachel Reeves will set out her autumn statement next month and could raise taxes to help better fund public services. In February, the Scottish Government put on hold all new NHS building projects, halting construction on at least a dozen projects to save money. Since then, finance secretary Shona Robison has implemented emergency spending controls and announced £500m-worth of cuts at the start of the month as the government in Edinburgh seeks to plug a £1bn funding gap. 

Among the ‘savings’ announced by Robison was a £115.8m cut to the health and social care budget, including an £18.8m reduction in money for mental health services. The cuts are due to public sector pay deals – including for nurses and other healthcare staff – which now account for a significant proportion of the government’s budget. 

Despite the financial constraints, there are some radical suggestions around for how to reform Scotland’s NHS. One put forward by Scottish Labour is to reduce from 14 to three the number of regional health boards. Speaking at a Holyrood fringe event at the SNP conference earlier this month, the health secretary said that while the current system is far from perfect, such an overhaul would likely be expensive and time-consuming.   

“Some of our opponents suggest that the very simple answer is just to reduce the number of health boards,” he said. “That’s a massively expensive, very tortuous and probably very lengthy process to achieve something that we are only going to see the benefit of a number of years down the line.

“If we were setting up the health service from scratch, would we have 14 territorial boards? Probably not. However, we are where we are, we need to recognise that we need to see service improvement now.”

For Francis, someone who continues to work in the NHS, there is room for cautious optimism with the change of government at Westminster, but only if it properly funds the health service. He points to a series of graphs produced by the Financial Times that show how the public’s relationship with the health service fluctuates. 

“When public investment in the NHS is on the way up, so too is public satisfaction,” he says. “When NHS investment drops or flatlines as it did under the Conservative administration, then public satisfaction plummets. It’s quite straightforward.”