Interview: Can Shona Robison heal NHS wounds?

Shona Robison - photo credit: David Anderson

No one talks about any other public sector institution like they do the NHS. Politicians from all sides queue up to heap praise on those that work within it, dipping into a seemingly endless stock of superlatives that would never see the light of day when describing, for instance, bin men, prison officers or even the police.

But then the NHS, with its work quite literally being a matter of life and death, is the one public service that inevitably touches us all and so it is little wonder that the emotion invested in it spills over into politics. And no surprise, then, that the politician charged with its smooth running should be at the forefront of any criticism when things go wrong.

And certainly, recent headlines would suggest something is going very wrong.

Pregnant women in labour turned away from maternity hospitals, operations cancelled, treatments postponed, cancer drugs denied, targets being missed, health and social care stalling and health boards facing a future funding black hole.

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Both the bigger picture painted in official reports and the details of individual patients’ horror stories have become the regular fodder of First Minister’s Questions, as not a week goes by without some new revelation exposing an NHS creaking under the strain.

And 2017 had only just begun when one of the most dramatic exposés focused on figures released through Freedom of Information requests by the Scottish Labour Party that revealed nearly 700 people had died in hospital while waiting to be discharged.

And while it would be a gross exaggeration to say that being in hospital alone had killed what were, in the main, elderly people, the figures shone a spotlight on the failure of one of the SNP’s stated priorities which was to tackle bed-blocking.

In February 2015, Health Secretary, Shona Robison said that she wanted to “eradicate delayed discharge out of the system” over the course of that year, but 18 months on, last October’s statistics told a different story.

And while the facts behind these delays are undoubtedly complex, Robison accepts that no one should die in hospital when it is not the most appropriate place for them to be.

But how should she respond to headlines that imply that 700 patients died simply because they were stuck in hospital as a result of delayed discharge? Did the NHS kill these people?

“Well, of course that isn’t the case, they were well looked after into their last few days and hours and the reality is that, in the main, we are talking about very, very frail people. It’s not right, though, that they should spend their last few days and hours in a hospital setting when their end of life would be better cared for either at home or in a homely setting.

“But whether it’s end of life care – and we have a big programme of work making sure that people have choices, or whether it’s those very complex patients  who have incapacity issues and where the courts are deciding upon these matters and it therefore wouldn’t be fair to blame the NHS or our care system for delays when actually, no one has the authority about where that person should go, there’s a complexity here that’s not unreasonable for politicians to recognise.

“But then we have patients who are absolutely ready for discharge and should be and when I look around the [health and]social care partnerships who have delayed discharge numbers in single figures, where they’ve put things in place that have dramatically reduced those numbers to the point that they can name the people who are delayed within their area, then what we need is the other 20 or so partnerships to follow suit.

“There’s nothing rocket science about what those ten have done, it’s just that they’ve put in place things that work and that are evidence based and what my officials are doing is working with the other 20, 22 to say, ‘look, these are the things we know work’.

“Some of it is about relationships locally, some of it’s about leadership, but we need to see them delivering those same things because if all of those partnerships were working at the level of the top 25 per cent, we would halve overnight the number of delays, just by doing what the best performing partnerships do.

“So there is work that can be done, there is more resource going in, and we expect to see further progress being made to get those delays down. We want to get delay out of the system, and that has turned out to be more challenging than even I thought it was going to be. It’s been hard, it’s been slower than I would like it to be, but we’ve absolutely got to keep that aim, that momentum and the focus of where we want to be.”

However, some of the sticking points regarding progress around health and social care were laid bare in a damning Audit Scotland report on the NHS published in October last year. The public finances watchdog made the point that while the Scottish Government had had a policy to shift the balance of care from hospitals to the community for over a decade, the funding had, largely, not changed course. 

It said the NHS was underfunded, had been unable to reform and faced unprecedented savings targets as it tried to keep pace with increasing demand, rising costs and the needs of an ageing population.

Kezia Dugdale, the leader of Scottish Labour, described the report as a “grim diagnosis” and blamed it on “a decade of mismanagement of the NHS” by the SNP.

Nicola Sturgeon responded at FMQs by defending the SNP’s record (much of which with her as health minister) and suggesting that the NHS will always be in difficulty until some fundamental changes are approved cross-party.

And therein lies the dilemma. While all parties recognise that the NHS needs to change and that resource needs to be redirected from costly hospital-based care to community-based care, when it comes to a choice between keeping a hospital open or not so that funds can be used elsewhere, any rational debate disappears in favour of local political expediency.

Equally, and for too long, criticism of the Scottish Government for any failings in the service has been shut down with a sharp rebuff that ‘you are talking down the NHS’.

However, two days before I sit down with the Health Secretary, Peter Bennie, chair of the British Medical Association in Scotland, and one of the country’s most senior doctors, warned that the service was at “breaking point”. He accused the Scottish Government of being in denial and said the health service was nearing the time when some services could not be provided for patients. When this happened, he said, there would be a “system breakdown”.

I ask Shona Robison whether she agrees that the NHS in Scotland is in crisis.

Unsurprisingly, she doesn’t. “The NHS has a challenging time during winter every year and every winter brings its challenges not just in Scotland but everywhere,” she says. “The reason for that is that you have more demand on the system because of more illness. Frail, elderly patients quite often get sicker in the winter and then you have festive holidays where the NHS and care systems are not working to full capacity, sometimes because of staff being off on holiday and GP surgeries being closed, so it all comes together to create real demands and strains on the system. However, what we’ve done in Scotland to prepare for this is showing results, that despite those challenges, our performance compared to elsewhere in the UK, is holding up. So, for example, we are 10 points ahead of England’s A&E waiting times, 15 points ahead of Wales A&E, we’ve also integrated health and social care this year and you can see delayed discharge, albeit I’d like for it to be coming down quicker, it is going in the right direction.

“We’ve seen further progress over the festive season through the unscheduled care work and we’ve made a lot of changes in our A&E departments and the way they work. All of that has led to a position that in that first week back in January, despite the four per cent increase in demand over the numbers last year, we’ve actually seen a similar performance to last year. So, big demands on the system and yes, the system is sometimes under pressure, but I think Scotland’s ability, as Professor Bell [president of the Royal College of Physicians of Edinburgh] has said, to cope with those pressures and to have the resilience in the system, is better than elsewhere in these islands.”

I ask her if it is good enough, particularly from a politician who believes in independence, to simply compare Scotland with other parts of the UK to illustrate that despite all the problems, the NHS in Scotland is doing better than elsewhere?

“Whether it’s comparing England, Wales, Northern Island or elsewhere in Europe, I suppose our near neighbours are our best comparison, because our NHS systems are more similar than you would have elsewhere. Therefore, I don’t think it’s unreasonable to compare and additionally, it is our political opponents that are in charge of those systems and yet they don’t seem to see the irony that those systems are under the same pressure and yet their ability to cope doesn’t seem to be as strong as it is here in Scotland.

“But we are not complacent and that’s why this week I announced the review of the public holiday closures. It is absolutely the case that you got the perfect storm back in January where people had been holding onto their illnesses, if you like, and managing, but they were not well. They suddenly appear at our A&E departments rather than wait for a GP appointment. Some of that is driven by limited access to services over the festive period, so the review that we’ve kicked off is going to look at how we put together, across the health and care system, better coverage over that holiday period, focusing on the festive season, but of course, it has applicability to Easter and beyond. If we can improve that bit of the service, then we will avoid that spike in demand that we see in the first week in January on A&E that leads to additional pressures that then lead to a drop in performance.

“But if you look at the figures, most people, for example, in A&E, get treated within the four-hour target and most people get a good quality of care. I get letters all the time, actually, from people who praise staff. Those letters are not going to make front-page headlines, but I tell you what, they are well appreciated by the staff and I always pass on each and every one of those letters to the staff concerned so that they can see what patients are saying about their service.

“I think where the constant criticism does have an impact is on staff morale. I am in hospitals week in, week out, in winter particularly, and where staff do see negative headlines that they believe are unfair, then that does affect morale and it can be quite difficult for staff who know they are doing a really, really good job, in difficult circumstances in the winter and actually are delivering a good quality service. But sometimes a headline will be grabbed by a particular day, by a particular patient and absolutely, if they didn’t get the right treatment and care, I’m the first to apologise for that but you have to look at the whole system and how the whole system is working. And it is working well.

“What we are laying out is a direction of travel that talks about investing more money in primary and community services and less money in hospitals – shifting that balance so that over half the spend goes into primary and community health services over the course of this parliament. That’s pretty radical. Now the opposition say, ‘yeah, yeah, we agree with that’ but then when it comes down to the detail of service changes they are the first to say, ‘oh, well, wait a minute’.

“So yes, we do need an honest debate but that’s not just from the government, it has to come from the opposition as well. When, for example, the Tories called for the 11 per cent share of spend to go on primary care, we agreed and are delivering that because that’s the right thing to do. But then they criticise any other changes that are obviously going to be required to release those resources into primary care so that debate has to happen but that’s not just from government.

“I have had opposition members sitting in the very chair that you’re sitting in and I’ve put these issues to them and they’ll sit in here and agree with me but on the floor of parliament you get into a different territory and they’ll say something entirely different. That’s part of the theatre of parliament, I guess, but what I need to do is keep my eye on the ball and focused on helping a system that is very complex and very detailed and very large to change direction. That’s not easy but I think we’ve got the right plans and we’ve got enthusiasm among the staff.

“If we make the changes, we can actually keep a lot of these frail, elderly people out of hospital where it’s the last place they should be and give them a good quality of care and treatment within their own home or in a homely setting and that’s the big prize.

“We’ve talked about doing these things for a long time and the delivery plan sets out the blueprint and road map about how it’s going to happen and I hope the opposition will come on board, not just with the principles of it but with the detail of it too.

“Of course, this is politics and while I don’t expect that to change any time soon, all I would ask for is maybe for us all to come together to try to agree the parameters so, yes, we will disagree about this and that but if we could get agreement on the direction of travel, that would be very helpful because it means that we have a continuity and we can focus with getting on with the transformation.

“Everybody wants more money in primary care but that means changes in the acute sector. In order to resource that, you can’t just resource that with new money and although new money is going in, it’s not enough to make that big change, that has to come from a shift of resource. I would like to see if we could have a more mature debate that gets us into some level of agreement, even with some of the opposition, I think some of them are maybe beyond that point but I think there are some that are not unreasonable people who are saying exactly the same as I am, but it’s not just enough to say it, you actually have got to set out how it would happen. That’s my job, all I would ask for is a fair hearing.”

Robison is no stranger to the ministerial health brief. First elected to represent Dundee East in 2003, having been a list MSP for the North-East region since 1999, she served as Minister for Public Health in 2007 and in 2009 was given the extra responsibility for sport. Government then decided it needed a dedicated minister for sport and the Commonwealth Games and Robison was the obvious choice. In 2014 she was promoted to Cabinet Secretary for the Commonwealth Games, Sport, Equalities and Pensioners’ Rights before being made Secretary for Health, Wellbeing and Sport in November, the same year when Nicola Sturgeon – one of her predecessors in the Health Secretary role – became First Minister. Like Sturgeon, she has embraced the role with a passion but she also remains realistic about its flaws and the challenges.

“The NHS is an institution that is held very close to people’s hearts, because very few people, if any, won’t have had the services from the NHS for themselves or members of their family. Whether it’s giving birth, whether it’s caring for an elderly relative, whether it’s a child at A&E, we will all have had experiences of using the NHS and sometimes in life-saving situations – there’s really no other service that does that, that’s so close to family and that’s critically important, so I do appreciate the language that has developed around the NHS because of its unique position in people’s hearts. I don’t think that in itself is an issue but I don’t think emotional attachment should stop us from taking quite a hard look at what works well and what doesn’t work so well.

“I have the same insight into NHS care services as everyone else through family need, ageing parents, a teenage daughter and so on. I see it as a mum and as a daughter and in the same way as others, I see the strengths and sometimes the weaknesses of the system and that helps me see why we need to deliver the changes.”

Articulating her passion for what she wants to do to transform the health service, Robison suddenly hits an emotional bump as she reflects on her own personal NHS journey of last year.

“I lost my mum back in September,” she says, apologising for the tears. “She got hugely positive care at the Royal Victoria, just down the road from Ninewells. She was 91 and in there for a long time and we had to come to the realisation that she wasn’t going to come out as her body was basically shutting down. That is hard for a family because she was a real anchor for us and you have expectations that even though she was 91, you still think they are going to go on forever.

“The care at the Royal Victoria was so fantastic and the way the staff worked with us as a family to help us come to the realisation that she was very ill and to face what the prospects were going to be was just amazing.

“Having gone through that, I appreciate how difficult it is for mums and dads when you are juggling caring for ageing parents and childcare responsibilities.

“I was also trying to see my dad who is in a dementia unit and trying to find the time to visit him. It is never as much time as you want and you carry that guilt around. I know I am not unique in this because others will rack themselves over the same things. It is just trying to juggle life.

“When Mum did die, I got some lovely messages from across politics and one, in particular, from Kezia Dugdale because she remembered I had talked at some event we were both at about my mum being an inspiration to me and in the cut and thrust of politics, something like that shows the humanity of folks and it reminds you that we are all just people with families and with feelings. It’s good to remember that.”

It’s fair to say, 2016 was not the kindest of years for Robison. On top of her mother’s death and her father’s descent into dementia, she also faced the breakdown of her marriage. In May, after 20 years of being married to fellow SNP politician Stewart Hosie, MP for Dundee East, they separated following lurid headlines which exposed his affair with a political journalist. It was clearly a shock to Robison and one that she was anxious to protect their teenage daughter from.

“I wasn’t sorry to see the end of 2016,” she says wryly. “It was mixed and there were some good things but generally it was a tough year.

“For anyone to go through a marriage breakdown, in any walk of life, is difficult but when it is on the front page of every newspaper and you have press outside your door, it is hard.

“You are also trying to protect family from that as well but you know, it is character building. It can make you stronger and you do come through the other side of it. I have met a new person in my life, which was very unexpected, I have to say, but my life has moved on in a way I didn’t expect.

“I have also found out things about myself that I didn’t know I had. I have a resilience that I didn’t know was there and while you don’t come into politics if you are a shrinking violet, so there is a strength there, I think you dig deep and you find pockets of resilience that you perhaps even surprise yourself with and you manage to find coping mechanisms.

“I think politicians are always a little cautious about opening up because it shows a vulnerability and that can be seen as a weakness and yet we are all human and our lives have ups and downs but as a politician, you are expected to just get on with the job.

“I did just get on with the job and actually found that helpful because I have a job I love and I found it was the stable thing in my life during what was a turbulent time. It helped me keep focused.

“I think the public are sometimes surprised that with a politician when you peel back the layers, they are just the same as everyone else. I don’t know why that should surprise but it does.”