Failing health: The NHS is broken, so how do we fix it?

Later this year, the NHS will celebrate its 75th birthday and a lifetime of providing cradle-to-grave care. But like many of those who grew up alongside it, the health service is ailing. Once the envy of the world, it is now bedevilled by staff shortages, lengthening waiting lists, and industrial disputes. Delays in cancer screening mean survival rates in the UK lag behind many other European countries, while recent research has shown that patients in some parts of Scotland face waits of up to three years for routine procedures like knee and hip replacements. 

When Scotland’s NHS hit crisis point in the early weeks of January, many experts agreed it was a situation a long time in the making. The cumulative impact of austerity and the huge toll exacted by the pandemic has left the health service considerably diminished and struggling to meet winter demands. Add to that the pay disputes of nurses and ambulance staff, and the doctors leaving the profession due to controversial pension changes, and the NHS is in its most unhealthy state since its creation.

It’s become a cliché to describe the health service as a victim of its own success, an institution so well regarded by the public that it’s problematic for politicians even to discuss reform. So, it’s a brave, or misguided, individual who proposes anything other than modest interventions or anything that threatens the NHS’s founding principle of being free at the point of use.

Both Prime Minister Rishi Sunak and former health secretary Sajid Javid have faced opprobrium in recent months for suggesting that patients in England – where the health service is run by the UK Government – could face charges for missing, or even attending, a GP appointment. During the Tory leadership race last summer, Liz Truss was forced to quickly backtrack on a plan that would have seen public sector workers such as nurses receive a different level of pay depending on what part of the country they lived in.

But while the health service is organised differently in Scotland – there is far less private sector involvement, for example – many of the challenges are remarkably similar to those being experienced elsewhere in the UK: long waits at A&E; difficulties recruiting and retaining social care staff; rows over pay deals for nursing staff and ambulance crews; and problems accessing general practice. 

Alex Neil, who was health secretary in the Scottish Government from 2012 to 2014, says the ongoing crises in primary care, acute care, and social care are all linked, and all have their roots in the austerity agenda followed by then Chancellor George Osborne following the financial crash of the late 2000s.

“It was the case for many years prior to [David] Cameron and Osborne that the budget for the NHS went up by, on average, about four per cent a year, which is what’s needed to stay ahead of the game in terms of inflation.

“We’ve now had a long period across the UK when the NHS has been absolutely starved of the resources it needs. The austerity programme has been the main trigger for this super-crisis that we’re all facing at the moment.”

According to the most recent figures, there are currently more than 470,000 people waiting for an outpatient appointment in Scotland, and a further 140,000 waiting to be admitted as an inpatient. The second figure has increased by 35 per cent in a year. In England, more than seven million people are waiting for hospital treatment.

While the pandemic had a profound effect on the health service, causing the cancellation of millions of operations, waiting lists were increasing long before Covid came along. Indeed, there’s good evidence that overall population health has declined over the past few years. Data from Public Health Scotland shows life expectancy has fallen for both men and women, with a gap of almost 14 years between males living in the most deprived areas compared with those in the least deprived.

Last year, the think tank Reform published a report calling for a radical reimagining of the health service. It argued that an overly centralised system dominated by GP surgeries and large hospitals is no longer the right model to meet the challenges we currently face.

Sebastian Rees, one of the report’s authors, says the conversation around reform is too often dominated by discussion of acute care when budgets cuts elsewhere at the time of austerity are likely to have had an impact on the population’s health, ultimately bringing more pressure to the front door of the NHS.

“There’s a lack of acknowledgement that in the entire period of austerity, government was raiding the budgets of other social services in order to keep healthcare spending relatively constant,” he says. “Reductions in welfare spending or education spending could, in principle, have a large impact on the health of the population.

“Budgets for adult social, at least in England, have decreased in real terms over time, and the funding given to local authorities for public health has been very significantly cut. Those are the kind of services which would most directly contribute to keeping people out of the GP surgery and keeping people out of hospital.” 

But if the problems of the NHS are relatively straightforward to diagnose, finding the cure is much more difficult. Its size and lumbering bureaucracy mean innovation and improvement can take place in one area of the country without being adopted, or even recognised, elsewhere.

One example is Hospital at Home, an initiative which allows patient to receive acute, hospital-level care in their own homes from medical professionals. A practice which is routinely undertaken in other parts of the world, it is seen as an important tool in reducing pressure on hospitals. But despite being in operation in NHS Lanarkshire since 2011 and subsequently adopted elsewhere, a survey of NHS boards in 2019 (before the pandemic) found that coverage across Scotland was “limited and uneven”. 

Jeane Freeman, who was health secretary until she stood down as an MSP at the 2021 election, says the health service has to be quicker at recognising good innovation and rolling it out across the country. 

“One of areas of reform that has been long talked about, ever since I chaired a health board myself, is the need for innovation that proves itself to be effective to be adopted without delay across the whole of the country,” she says.

“We’re still struggling with a situation where individual health boards can [choose] not to adopt good evidence-based practice that we see elsewhere. My personal view is that individual health boards perceive themselves to be autonomous units and I don’t believe they are – they are part of a national service.

“Where there is a clinically evidenced pathway that improves a patient’s outcomes, that is faster, and improves the patient’s experience, then there should be no question about that being adopted across the rest of the country. I’m afraid we’re stuck in too much process and too much bureaucracy.” 

One major innovation which will be carried out at a Scotland-wide level is the creation of the new National Care Service, which has variously been described as both the biggest policy intervention since devolution and a “power grab” on behalf of central government. Freeman says it’s of critical importance, while Neil describes it as “ill thought-out”.

One of the few SNP politicians to openly admit voting for Brexit, Neil says the challenges in the social care sector could be ameliorated by paying staff a minimum of £15 an hour, helping to put an end to the high numbers who are leaving the profession for better-paid positions in retail and hospitality.

As pressure mounted on the health service in the early weeks of the new year, health secretary Humza Yousaf faced almost daily calls for his resignation. At First Minister’s Questions, the Tories raised the case of an 80-year-old man who waited over 12 hours for an ambulance after he broke his neck at Hogmanay. The Lib Dems said 22-year-old Maria, a Ukrainian refugee, had returned to Kyiv for medical attention because it was “less daunting” to see a doctor there than wait on the NHS.

Both Freeman and Neil know the demands of the job and are sympathetic towards the current incumbent, having faced calls for their own resignations in the past. Despite obvious failings under Yousaf’s watch, it’s clear the NHS faces similar challenges in England under the Tories and in Wales under Labour. 

“Without in any way commenting on Humza particularly, I think the problem under successive administrations, both at Holyrood and Westminster, is that we’ve had too many health secretaries in for too short a period,” Neil says. 

“We need money, staff, and bed capacity to be able to deliver. Until we do that, we’re going to continue to stumble from crisis to crisis.”