NHS at 70: Q&A with former Scottish health secretaries on carrying responsibility for the nation's health

Scotland's health secretaries then and now

Given the place the NHS has in the nation’s psyche, how daunting was it to take over the health brief?

Alex Neil (2012-14): The NHS is probably the most important institution in the life of the nation. Therefore, managing this brief well is key to having a successful Scotland, as well as being very personal to every one of our citizens. Furthermore, the health brief means you control over 40 per cent of the Scottish Government’s entire budget so it is a huge responsibility.

Nicola Sturgeon (2007-12): The NHS is our most treasured institution as well as being the biggest public service, so of course I felt an enormous sense of responsibility when I took on the brief. I had shadowed the health portfolio for some time in opposition, so when I came into the government I couldn’t wait to get started. I also felt tremendously privileged to be able to work with NHS staff and to see their incredible work on a daily basis. When you see their compassion and skill it becomes abundantly clear why the NHS is held in such high esteem. 

Andy Kerr (2004-07): I would not describe it as daunting in that sense. It was a daunting political brief due to the performance pressures and profile. The finance brief [which Kerr had held from 2001] was pretty pressured and high profile too. Once I had established that it was not a ‘hospital’ pass by Jack, I was good to go but I did make it a condition that I got to take my private office team and special advisor with me so I could hit the street running. They were key to the deal and the success. (It was not popular with some, though!)

Malcolm Chisholm (2001-04): It was certainly daunting, because there were enormous challenges at the end of 2001 and no quick solutions.

Susan Deacon (1999-2001): Being asked by Donald Dewar to be the first health minister in the first Cabinet, in the first Scottish parliament for 300 years, was one of the proudest – if not one of the most terrifying – moments of my life. I just had to take a deep breath and throw myself into the job.

What was your main priority?

AN: Improving the quality and range of services available is the top priority. Twenty-five conditions account for about 70 per cent of all the NHS does in Scotland. Diabetes alone takes up about 9 per cent of all NHS resources. If we get the treatment of these conditions right then we are a long way towards getting the whole system in top gear.

NS: It is impossible to pick just one single priority – I had many. Patient safety has been the key to driving improvement and as a result we’ve seen huge reductions in hospital acquired infections. But we also face deeply-ingrained health inequalities across Scotland. They were never going to be solved overnight, but I was keen to ensure that tackling them was at the forefront of everything we did. I also wanted to have a health service in which the views and feelings of patients were genuinely listened to.

AK: I wanted to focus on the key killers: coronary heart disease, stroke and cancer alongside improving mental health services but had to deal with waiting times first. I was also aware of the looming need for reform and restructuring of the service which could only be tackled once waiting times were not the issue.

MC: There were several priorities and it was important not just to focus on one, although cancer services, especially at the Beatson, were an immediate priority and getting down waiting times was another. Improving the quality of care and bringing about a more patient-focused health service were other key priorities, as well as the whole health improvement agenda.

SD: I was determined to try and work across party boundaries to use the new devolved powers to rid Scotland of its ‘sick man of Europe’ tag, so my focus was on public health, prevention and health improvement. I was really pleased that the very first debate, on the first full business day of the Scottish Parliament, on 1 September 1999, was on public health – and I was gutted when it was completely overshadowed by a row over commemorative medals for MSPs which cost £56 each!

Unlike many other government briefs, you really do have life and death embedded in your responsibilities, how heavy does that responsibility feel?

AN: A good example of this was when the Scottish Medicines Consortium decided not to make a new drug, Kyladaco, generally available on the NHS. This drug was designed to extend the lifespan of some children by up to 16 years. There was no way I was going to allow these children to die because they couldn’t access this drug. Alex Salmond agreed with me and we set up the Special Drugs Fund to ensure the money was available for this and other similar drugs. I still get updates from some of these children’s parents telling me how well they are doing. They’re not only alive, they are living their lives to the full. Now new drugs available for dealing with cystic fibrosis are so powerful that we are on the edge of eliminating CF as a condition which limits the lifespan of the sufferer. That fills me full of pride and pleasure.

NS: In any role in public life you feel a sense of duty, but of course the health service comes with its unique responsibilities. There is an obligation to patients, and also to the NHS staff. I found that sense of responsibility to be a very positive thing, because it keeps you grounded and ensures you remain focused on the people who are being affected by your decisions.

AK: It didn’t. My mantra was to follow the evidence and on that basis, make the decisions. It hurt to the core when faced with individual cases but as long as the evidence was solid, rational rather than emotional, decisions had to be made. Remember, an irrational or political decision meant that people, expertise and finances were pointed in the wrong direction – that would have felt heavier.

MC: It’s a very heavy responsibility that is all absorbing and displaces almost everything else.

SD: I was always acutely aware of that responsibility – and there were times where the job was really very emotionally draining. Equally though, that was what kept me going. To be able to do something to support the people who work in the NHS, as well as those who rely on it, was an immense privilege. It’s because people value and care about the NHS that passions on the issue run so deep.

Best piece of advice you were ever given during your time as health secretary?

AN: A friend advised me to pay regular, unannounced visits to hospital wards, surgeries, etc, so I could find out exactly what was going on rather than rely on civil service briefs, which too often paint an over-glossy and sometimes complacent picture of what’s actually happening on the ground. These visits were invaluable to keeping in touch with what life was really like for both patients and staff on the front line.

NS: Sir Harry Burns once said that unless you have evidence all you have is opinion.

AK: I can’t think of any.

MC: Focus on patients and learn from their experiences. I collected around myself a group of key health people in Scotland, apart from the civil service, and we met once a month or so. One of them, Professor Nora Kearney, was extremely strong on patient experience and always emphasised the importance of listening to patients and learning from their experience.

SD: I got two pieces of advice on the day I was appointed as health minister. From my mum – “just be yourself”, and from a former colleague – “Trust your instincts, because they’re good”. That advice, and that approach, literally carried me through the next few years and since.

What are you most proud of achieving during your time as health secretary?

AN: There is a long list of specific decisions I took of which I am very proud, including the one referred to regarding new drugs for children suffering from CF. More generally, implementing a programme of reform to improve key services and make the NHS more accountable was really important, although the pace and scale of reform needs to be stepped up significantly.

NS: The Detect Cancer Early campaign has gone a long way to change the culture around encouraging people to seek early diagnosis for cancer symptoms. I was also proud to have initiated the Penrose Inquiry, which meant that Scotland was the first nation in the UK to properly address the historic issue of infected blood products. One piece of work that has had a particular impact, and continues to this day, is the Scottish Patient Safety Programme, which I launched ten years ago. This programme has made some profound changes to the way the health service operates and has made Scotland’s NHS one of the safest in the world - saving around 25,000 lives and reducing the rate of infections by around 90 per cent, which is a huge achievement.

AK: Lots of things. Building a team for change and to do the right things; getting a grip of waiting times; using support and investment allowing a focus on the big killers and mental health; reducing bed blocking to a minimum, using ring-fenced resources to do the sexual health strategy and delivering for health reform strategy founded in the review by Professor David Kerr – sadly still relevant today; taking the health board annual review process from civil servants and from inside St Andrew’s House to the minister and on the road into local communities; and involving patients and the workforce. I have not mentioned the smoking ban. In my view, that was a collective effort. My task was to continue to follow the evidence, get it implemented and undertake a post-implementation study to help others as we had been helped by those who had gone before.

MC: I was pleased there was a quite a bit of progress on cancer services, including the provision of a new Beatson Centre for the West of Scotland.

SD: Establishing real partnership working with NHS staff and putting in place a new national identity for NHS Scotland across all NHS organisations, facilities and services. People forget this now, but at the time these were really important measures to redress the fragmentation of the internal market. Partnership working is now at the core of NHS Scotland and the national ‘brand’ is embedded across all NHS services and facilities. I’m really proud of that.

Do you think you did anything to actually improve the health of Scotland?

AN: Absolutely. A good example was in overruling official advice not to replace cochlear ear implants for deaf children every two years instead of every eight years.

NS: There were many improvements to the health service which I think have had a positive impact on the health of the nation. Introducing the various waiting time targets and the treatment time guarantee has helped to reduce some of the very long waits for treatment that used to be commonplace. Diagnosis rates for dementia improved, meaning people were able to get appropriate treatment more quickly. There were public health measures such as the Childsmile programme, which has led to great improvements in the oral health of children. Of course over many years I argued that we should have a minimum unit price for alcohol and I am pleased that parliament eventually agreed with me and that minimum unit pricing was finally introduced in May this year. The evidence shows it will play a significant part in reducing the harm caused by the strongest and cheapest alcohol over the next few years in a way that could save lives. The legal challenge meant that it took longer to implement than we would have liked, but now that it is in force I believe we will start to see some real benefits.

AK: The smoking ban is the obvious one, people still remind me of the impact on their lives. Many chose it as quit day and have not smoked since, it bolstered efforts by others to keep off and workers loved it for the positive impact on them. Likewise, I am reminded by others of the positive outcomes from the sexual health strategy. We started tackling diet in schools, with positive outcomes and changed attitudes towards mental health. Overall, the positive impact was improving the performance of our NHS using targets wisely, for example, cataract and bed-blocking targets as well as the big ones. This kept faith in the service and delivered high quality outcomes. Coronary heart disease, stroke and cancer outcomes are in a better place.

MC: There was a lot of emphasis on health improvement, particularly on diet and smoking, including the consultation paper that set us down the path of banning smoking in public places. I think that has helped to improve health, as well as some of the service developments on, for example, heart disease and stroke.

SD: I think I laid some important foundations ,such as Scotland’s first national health plan, establishing the NHS as a national ‘health’ not just ‘illness’ service; the first national health improvement fund; a national public health institute for Scotland; an increased focus on health inequalities and investment in children, families and communities. That said, if I had my time over, I’d place much less emphasis on ‘top-down’ approaches to change – and I believe strongly that successive governments in a devolved Scotland have been too focused on the letter of policy and strategy, rather than on getting behind the people who really make things happen – in our NHS and in our communities.

Any regrets about work unfinished?

AN: Loads. I was really disappointed at leaving the health portfolio as I loved the job – even although it was working 24/7!

NS: The NHS has been constantly evolving throughout its 70 year history, and that journey of change will continue through the next 70 years and beyond. There is always more you feel you can do, but I don’t think anyone will ever leave that post thinking ‘job done’.  As First Minister I’m able to see the work that is underway now to adapt the NHS for changes in population and in the way services are delivered, for example, through the integration of health and social care, the creation of elective centres, the work to end the stigma of mental health and the increased investment going into mental health services.

AK: My major regret is that the painful, controversial, difficult but vital reforms set out by Professor David Kerr and the strategy, ‘Delivering for Health’, were not completed. Part of that process was an unconvincing report by a tame academic whose name escapes me which was used to undermine years of work commissioned by Malcolm Chisholm and undertaken by Professor Kerr in concert with a very wide stakeholders’ group. And today we are still talking about the same issues well over a decade later. All political parties are shying away from reform, all political parties are treating the NHS with misplaced kindness, putting political self-interest first, leading to a collective political establishment failure to make the decisions that will shift the balance of care, make the evidence-led changes that are required for a sustainable health and social care service going forward. Until we shut the gate at the top of the cliff by investing in prevention and health improvement and care at a community level, we will continue to pick up people at the bottom of the cliff, make emergency interventions only for them to fall off again. I also regret not getting round to reforming the board structure. We set up three regional boards to co-operate in key areas and the follow-through should have been three boards from 14 and two specialist boards.

MC: I was very sorry that I could not be there for the publication and implementation of the Kerr Report, which I had commissioned, and for the waiting-time progress which we had planned.

SD: Change in the NHS takes time and improving health in Scotland takes a generation. I don’t do ‘regrets’ but I would have liked a bit longer to finish what I’d started in the health brief, but that wasn’t to be. When Jack McConnell became first minister, he wanted me to take on another cabinet role. By then I was pregnant with my second child and it just wasn’t the right thing for me to do. I’ve never regretted leaving government at that point – I went on to have the most wonderful six months of my life – with my first child starting school, a new baby, and time with my mum, who in fact passed away six months later. It really confirmed to me that power and position isn’t everything in life!

Do you think the NHS in Scotland is now in crisis and what advice would you give to the current health secretary?

AN: It’s not in crisis, but it could be if we don’t dramatically step up the pace and scale of reform as well as invest significantly more money in the NHS. If the UK NHS got allocated the same percentage of GDP as happens in Germany and France, then the NHS in Scotland would have up to an additional £2bn a year to invest. We need to step up the pressure on the UK Government to fund this scale of expansion, otherwise, we will never be able to keep pace with demand.

NS: That is simply not a description I recognise. As with all health systems across the world, there are challenges we face, not least adapting to meet the needs of an ageing population. But Scotland’s NHS is performing well, on many measures better than the rest of the UK. We have record numbers of staff and levels of investment and we are changing the way we deliver care so we can make sure the NHS continues to evolve to meet the needs of patients.

AK: Everyone loves and respects our NHS and it is difficult to change because of that love, but I do believe that it is a silent crisis, it is not sustainable in its current form, it cannot go on like this. I recall the introduction to ‘Delivering for Health’ as stating that we are not in a crisis, but as our needs change so must the service, and that was 15 years ago. All the evidence is there, but so are all the barriers, so there is no need for advice.

MC: There are big challenges, but I would not say it is in crisis. I would say don’t worry too much about the media, or even opposition politicians, but listen to patients and clinicians.

SD: Crisis is one of the most overused words in the political lexicon – and I really tire of politicians and journalists overusing it. There is, though, a need for a long overdue and grown-up debate on how we sustain and fund the NHS in the future. I think ministers need to acknowledge there are real pressures on the system and to be more honest, bold and radical. Opposition politicians need to step into that space too. Both the public and NHS staff deserve that.

Do party politics make the job of the health secretary impossible because while everyone may agree on the general direction of travel, individual health cases will always frustrate progress and make headlines?

AN: I tried to get a cross-party consensus on the way forward, but Labour at that time scuppered it. However, I continued to work with Jackson Carlaw and Jim Hume, both of whom were excellent in working collaboratively with me on major initiatives. For example, the Tories worked with me to get an extra 500 health visitors recruited and we worked with Jim Hume to help get his bill on child safety in cars passed.

NS: On the rare occasions where the standard of care has fallen short, then it is right that those issues are raised and properly investigated. That is something I always acknowledged during my time as health secretary. More generally, robust interrogation of how the NHS operates is essential to ensure it is working to the highest standard. However, I think we should all recognise that in the overwhelming majority of cases the level of care and treatment that people receive throughout our health service is very high indeed. I think most people realise that fact.

AK: Yes, but the job is to lead not to follow.

MC: Oppositions have a job to do in putting forward the concerns of the public, but there is too much inappropriate party politics in health and that doesn’t help mature discussion of health challenges. It will always be possible to find individuals who have had a bad deal from the health service but it must be kept in perspective because the majority of patients are full of praise for the health service.

SD: In my view, one of the adverse, unintended consequences of devolution is that the debate on the NHS – and indeed other public services – has become too politicised. I’d love to see a more open and searching debate, both within and between political parties, about how we build an NHS that is fit for the future and on how we improve the health of people in Scotland. Party politics gets in the way of taking some of the difficult decisions that need to be made.

Did your attitude to your own health change while in charge of the nation’s health?

AN: Absolutely. I no longer eat a fish supper every day!

NS: Working in this role really brought home how relatively small changes in lifestyle – whether it is regular exercise or healthier eating – can bring significant health benefits. That is a lesson that has stayed with me and something I have tried to adopt in my own life. 

AK: To a degree, yes, I ate a wee bit better and drank less, I learned more about my health and took appropriate action, I walked a lot more and left the ministerial car when I could and kept up my running. When I was caught out in the parliament canteen by the occasional journalist or a snide remark, it was always nice to challenge them to a half marathon. They tended not to make comment again.

MC: I don’t think so.

SD: Seeing what some individuals and families were going through really made me value the good health that I and most of my immediate family had. Though, to be honest, I never had a less healthy lifestyle than when I was health minister. Doing that job while bringing up a toddler at the same time was a recipe for unhealthy eating and extreme sleep deprivation!

What has the NHS ever done for you?

AN: A great deal, the most important of which was saving my son’s life when he nearly died from septicaemia.

NS: There can’t be a single person who hasn’t benefitted from NHS treatment in one way or another – either themselves or through care given to their loved ones. I am no different, and like most people I am extremely grateful for all the care my family and I have received from the NHS.

AK: A lot. Susan and I have three daughters so there’s a big call on the NHS already. We have had our own life events too, as have family and friends, and the NHS has been there for us.

MC: I have been lucky up till now and it has been through GPs that I have mainly experienced the health service, and excellent GPs at that.

SD: Bringing my children into the world, taking care of my mum in her later years, saving my partner’s life, looking after cousins, aunties, uncles – where do you start or end? We are so very, very lucky to have our NHS, and yet I feel that too often, we take it for granted. Knowing that we can get sick or injured without someone asking to see the colour of our money is a truly wonderful thing. All the more reason we need to be willing to think about how we sustain our NHS into the future.

Was there anything you learnt from your time in health that you carried forward into your next role?

AN: The importance of making a comprehensive and properly funded attack on the levels of poverty in our society as so many of our problems of poor health emanate from the grinding levels of poverty and deprivation we have in Scotland.

NS: I learned an enormous amount during the five years in which I was privileged to work as health secretary – much of it from meeting patients and NHS staff. I think most of all the role taught me about the importance of never losing sight of the human impact of the decisions we make as ministers.

AK: Yes, that the right things don’t always get done, that for a combination of rational and irrational reasons, we take easier options and store problems up. That the political process is flawed and that political self-interest gets in the way.

MC: The main problem is that health spoils you for every other job in government. It was the best of my 24 years in parliament and it took me at least a year to get over not doing it anymore! But listen to those who know what they are talking about, I would say for any job in government, and in the context of health, that means patients and clinicians.

SD: That it is people not process that makes a difference. And that, as a leader, it is possible to take tough and unpopular decisions if you are prepared to explain your case openly, consistently and authentically. I think that politicians across all parties too often forget that.