Michael Matheson: I’m not optimistic about a change of government at Westminster

When First Minister Humza Yousaf was appointing his first Cabinet, it was vital that his former portfolio – health – went to a safe pair of hands. The task for the next person to take on that role would be enormous, given the mounting pressures on the National Health Service and the need for wide-ranging reforms.

And so it was no surprise when Yousaf handed that task to Michael Matheson, an experienced parliamentarian who has sat in Holyrood since 1999, has held a number of government briefs, and was in a former life an occupational therapist. Along with the new portfolio, Yousaf gave Matheson a new title that emphasised the expectations being placed on him: Cabinet Secretary for NHS Recovery, Health and Social Care.

Matheson agrees the slight adjustment to the job title is a sign of the times. Putting the NHS back onto sustainable footing will be key, and part of that, he says, is reducing the backlog which resulted from the coronavirus pandemic.

The decision to “pause or restrict access to services” during the pandemic had “inevitably” led to patients’ deteriorating and needing greater levels of care, he explains. “We’re seeing higher levels of acuity in those who are entering into hospital which very often means they require a greater level of intervention. In some cases, they’ll end up spending longer within the healthcare system as well and possibly a longer stay within the hospital setting.”

One of the things that I'm giving more consideration to is: what should the future shape of our National Health Service be?

But he’s also aware the problems go beyond backlogs. He points to an ageing population, a higher burden of disease, recruitment challenges and issues with capacity in social care. It’s a conversation being had across the UK, with broad recognition that the NHS won’t survive by just pumping more money its way. Ways of working need to change too.

Matheson says: “That combination of built-up demand, higher levels of acuity, combined with increasing burden of disease, alongside the staffing challenges which we face all create huge pressures on the system.

“Part of my role is not only to help to support the recovery of our NHS, one of the things that I’m giving more consideration to is what the future shape of our National Health Service should be. How should our health and social care system operate in the next five, 10, 15 years? Given the size of the organisation and the way in which it works, it takes time for us to change our approach in some areas.

“One of the things that I am looking at is how we can make sure that we start to put in place the building blocks to shape our healthcare system for the future. I’ve got some clear views around how I think that should be taken forward. But it’s important that we have a proper level of engagement with stakeholders within the health and social care system and looking to see how we should shape that going forward.

“That will be critically important to make sure that we are able to meet the future demands our healthcare system will face and the changing nature of how healthcare will be delivered alongside social care in the future. We need to make sure that we are taking an approach that helps to make sure the health care and social care system are sustainable in the medium to longer term.”

But it will be difficult implementing large-scale reforms while also combating existing pressures. Matheson, though, believes it’s all part of the same piece. “It’s not a case of one or the other, we’ve got to do all of these things – help to support the recovery, make sure we’re maximising capacity within the existing system, supporting it as much as we can to be as efficient and effective as possible, looking at where there are opportunities to scale up some additional capacity where that’s possible and to bring some new capacity on stream, alongside also looking at what we need to put in place to help to support the medium- to long-term future of our health and social care system. I don’t see these as being competing demands; I see them as all being necessary and critical.”

The National Care Service is critical to making sure that we have a sustainable health and social care system

One of the biggest areas of reform is in social care. Matheson says: “The challenges around integration of health and social care go back many decades. I remember when I first qualified and was working in the system, the integration of health and social care was one of the key issues. The various iterations we’ve had of it over the years have made progress, but not sufficient progress. And there’s a lack of consistency in how that type of integration works, and how we make sure that we align the health and social care system much more effectively, which is why we need to make a real step-change to try to deliver that.”

But efforts started by former first minister Nicola Sturgeon to establish a National Care Service have been hindered by concerns about centralisation, governance, and funding. The bill drawn up to create it is currently on pause and is not set to complete stage one until the end of January, 18 months after it was introduced. So, despite its problems and serious opposition, is it still the right approach?

“I think the National Care Service is critical to making sure that we have a sustainable health and social care system. Both systems are completely interdependent on one another. We need to make sure that they are much more aligned and there is a much greater consistency of approach. The creation of a National Care Service will help us to achieve that,” Matheson argues.

Part of the problem, he says, is a “misunderstanding and misinterpretation” of the bill, with a tendency to “overly focus on process”. He believes that following engagement with stakeholders and several ‘national conversation’ events, he and social care minister Maree Todd will shortly be able to move it on. “I am confident that we will get to a point where we will get a greater level of consensus on the approach that we take in the bill. What’s critical in achieving that is that we don’t lose the core objectives of what we’re trying to achieve with the National Care Service. And that is, ultimately, to ensure there is greater alignment between health and social care, and there’s a greater consistency of approach in how that’s delivered across the country.”

However, there remains a lack of clarity around the cost of the bill. In December last year, Holyrood’s Finance Committee concluded it was “difficult to assess whether the proposed National Care Service is either affordable or sustainable”. Despite requests made by the committee since then for updated costings, ministers have so far refused to publish this information. Todd argued it was “not usual” to update financial memoranda for a bill before the end of stage two.

Asked whether it’s possible to set up something as wide-ranging as a National Care Service within the confines of the Scottish Government’s budget, Matheson insists it is “perfectly feasible – with the right collective leadership, with a clear focus on what you intend to achieve with it, and to make better use of what is a huge amount of money that presently goes into social care”.

This is the worst Conservative government that we have ever experienced in my time in politics. At times it feels to me like a reckless disregard for social consequences

A benefit of strengthening social care would be shifting some of the burden away from healthcare settings, leaving doctors and other healthcare professionals to support patients who need it. Another part of that equation is improving population health so fewer of us are accessing those services in the first place.

As a former occupational therapist and public health minister, this is an area Matheson says he feels “very passionate” about. “The reality is that when people talk about the health challenges that we face in Scotland, we very often find that our health services are dealing with the consequences of social inequality. A lot of health inequalities are embedded in, and are caused by, social inequality. Our healthcare system has to deal with the consequences that come from that.”

I remind him of an interview he did with Holyrood back in 2011, fresh in the door as public health minister, in which he spoke about the need to deal with these sorts of challenges. He said at the time that there were “no quick solutions” and “it will take governments – that’s plural – years to effectively eradicate many of these problems”. 

His party has now had governments – plural – to take action. So, is he disappointed that some problems, like alcohol and drug abuse, are no closer to being solved and have in some cases got worse?

He argues there are a number of areas where progress has been made, pointing to the expansion of early learning and childcare, free school meals and “good use of the devolution of some of the social security powers, for example the Scottish Child Payment”. He is adamant that the work being done outwith his own portfolio on child poverty will bring about positive long-term health trends.

“We know the evidence demonstrates the benefits that come from that; countries which have got a better track record than us in tackling these long-standing health inequalities are more equal societies, they have lower levels of poverty, child poverty, and they also have a better preschool education provision.

“Now Scotland has made huge steps in improving preschool education for children through the childcare expansion over the course of the last decade, and also the work that we’re doing around tackling child poverty, things like the Scottish Child Payment, which we know is a step-change in helping to reduce child poverty.

“These areas, we will hopefully start to see the benefits in the decades to come because we are building strong foundations that will help to address some of the key areas that we know can have a marked impact in helping to improve population health overall. Can I also say that going forward there are areas where we still need to make further progress.”

But he says that some of these efforts have been “undermined” by the UK Government, and certain policies have “not been as effective as they could have been as a result of decisions that have been taken at UK Government level”.

“I don’t want to dismiss the need for us to do more, although we can’t lose sight of  the fact that we are going through a period of extreme austerity that is being taken forward by the UK Government. That is having a huge impact on our ability to do more and also the ability to sustain some of these critical services.”

But with a general election looming next year, and likely a change of government, I wonder if he’s maybe feeling a little more hopeful about the future. “Look, I think this is the worst Conservative government that we have ever experienced in my time in politics. At times it feels to me like a reckless disregard for the social consequences that go with some of the policy options that have been taken forward; at times it has been quite breathtaking.

“But the reality is that I’m not optimistic about a change of government at Westminster for the very reason that has been demonstrated, I think, over the course of the last four or five weeks alone, where the Labour Party at UK level have confirmed that they will largely follow the fiscal plan that has been set out by the present Conservative government. That to me demonstrates that we are likely to, even with a change in government, still experience a significant period of austerity.

“And if any change of government is not prepared to take a different approach at a UK government level, I think the consequence of that is it runs a danger of exacerbating social and health inequalities, not just in Scotland, but right across the whole of the UK. So, I’m not optimistic.”