NHS needs intensive care after 18 months of unprecedented pressure

Exhausted doctors. Six-hour ambulance waits. Hospitals on ‘Code Black’. Months-long waiting lists. Elective procedures on hold. Cancelled appointments. Growing patient backlogs.

Problems are mounting on the NHS. And the Scottish Government faces a huge challenge in getting services back on track. Even before the pandemic, the NHS was not on sustainable footing. But after 18 months of Covid-19, things are reaching breaking point.

Against this backdrop, the government published its NHS Recovery Plan. Health secretary Humza Yousaf described it as “ambitious” but “realistic”; a plan to “drive the recovery of our NHS, not just to its pre-pandemic level but beyond.”

Its key pledge is to increase capacity “by at least 10 per cent as quickly as possible”. Central to this is the network of national treatment centres, two of which will open in Inverness and Forth Valley next year, to increase planned care capacity. But other centres are not set to open until 2026, a concern given the amount of unmet – and currently unknown – need caused by Covid delays. Such concerns are leading some to question whether the plan is enough.

BMA Scotland has said it was a “good starting point”, but the body has raised particular concerns about staffing. At no point does the document mention the staff shortages across the health service, despite high vacancy levels even before March 2020.

“We need real workforce planning,” says Dr Patricia Moultrie, deputy chair of BMA Scotland. “We’ve been calling for that for some time and obviously it would have been more helpful if that had been in place earlier on, but we are where we are.”

She emphasises this is not just about raw staff numbers. Better workforce planning would also mean making good use of the resource the NHS currently has, partly recognising the time it takes to train up new doctors and the difficulty of recruiting in the midst of a global pandemic.

As well as altering patient pathways to allow the burden to be shared across healthcare professionals, Moultrie speaks positively about technology. She explains: “We need to make as much use as we can of technology, being careful that it doesn’t disadvantage any sections of the population. Working with patients and enabling them through technology will be useful. And I think in particular, with regard to hospital services, it’s important that we look at facilities for monitoring in the community.”

This can include things like ambulatory blood pressure monitoring or patients keeping track of their symptoms through an app. Moultrie adds: “I think [the pandemic] probably has accelerated the enabling of many patients to be partners in managing their condition, and I think that’s an important public health aspect to progress. It fits really with people self-managing on occasions when that’s appropriate and knowing which parts of the system to contact when they do need assistance.”

Including patients in their own health planning has long been a key ask of public health experts, including former chief medical officer Sir Harry Burns.

He tells Holyrood: “My whole thing has been about, you do things to people and that’s less helpful than doing things with them. Ask them what they need and then help them get it.

“One of the things we’ve learned from the pandemic is that when you support people – as the chancellor did with his various financial supports for folks having to isolate and stay off work and so on – then you get a lot of compliance.”

It’s an important element of the prevention agenda. Making it easier for people to choose to live better, healthier lives will ultimately save lives, as well as reduce the strain on the NHS. Tackling these health inequalities – which has led to men and women in Scotland’s most deprived communities dying 13 and 10 years earlier, respectively, than their wealthier counterparts – will help improve the health of the population as a whole.

Having conventional approaches like banning advertising of high calorie foods before the evening watershed – that’s just fiddling with things

But as a recent report produced by the LSE-Lancet Commission on the future of the NHS – a project launched to mark the NHS’s 70th anniversary before having to pivot in response to the Covid crisis – highlighted, “treatment continues to be prioritised over prevention, with funding for public health continuing to decrease relative to NHS funding.”

Asked what the major barrier is to improving Scotland’s health, Sir Harry replies: “Lack of a sense of control; the feeling of helplessness in people.

“I always start my talks by telling the story of a guy who had come in three or four times with a serious alcohol-related problem and I said to him, ‘look, this is the fourth time you’ve been in here with us. If you keep on drinking, you’re going to die.’ His response was, ‘I know, I’m not stupid, but I don’t care because life is crap and the booze is the only pleasure I’ve got.’

“And it’s that kind of learned helplessness and hopelessness that makes it very, very difficult to turn people’s lives around. Having conventional approaches like banning advertising of high calorie foods before the evening watershed – that’s just fiddling with things. It’s about giving people a sense of control and a sense of hope for the future.”

His advice to politicians battling with these issues is to admit they don’t have the answers. He encourages them instead to listen to people with lived experience and those who work with them. “Some politicians are quite humble about this, they will admit that they don’t know what the answers are. There are some politicians – and I’ll leave you to speculate who they might be – who just stand up and say, oh we must do X, we must do Y and all that kind of thing.

“No. Be quiet and listen. And the critical thing is, test the ideas and the things that work, put them into practice.”

He points to the Sure Start
programme in England as an example of politicians getting in the way. That programme, introduced by Labour in 1999, was targeted at families with children under five living in deprived areas. It brought together health services, parenting support and access to childcare and early education. But since 2010, Sure Start has had its budget cut by 60 per cent.

Sir Harry says: “It went on and on and on, and the politicians got a bit fed up with it. What they were saying was, well, we’ve done this, we’ll just stop this and do something else… [But] we now know that the kids that went through the Sure Start programme are significantly healthier in adolescence than the ones that didn’t.”

Vittal Katikireddi, a professor of public health, is familiar with the problem Sir Harry describes. He says: “There’s often this paradox we talk about in public health where if someone gets a treatment for something, and gets cured of the specific disease, then there’ll often be vocal support for that treatment. Whereas in contrast, if you actually prevent someone getting a disease, because the benefits are less visible it’s much more difficult to find that level of support.”

But finding that support is vital if we want to improve the health of the nation. The latest National Records of Scotland report on demographic trends found the death rate in the most deprived communities is almost double the death rate of people in the least deprived areas.

It’s going to take a number of years before we even achieve back to where we were before we went into this

And the pandemic specifically has sharpened some of those inequalities. Not only has the death rate from Covid been higher in deprived neighbourhoods, but Katikireddi’s research has found a disproportionate impact on routine healthcare. He says: “Clearly the NHS and the social care systems have been under a lot of strain over the last 18 months or so. There’s undoubtedly a lot of unmet need, with people waiting for elective procedures. Also, there are indications that there’s quite likely to be a lot of kind of undiagnosed cancer that would have been diagnosed, and heart disease and so forth. Delays to treatments are likely to worsen the prognosis of those conditions. So, there’s a need to invest in health systems to try and address that. From a health inequalities perspective, there’s also some evidence, partly from our work, partly from others, that actually it’s been more socioeconomically disadvantaged groups have been hit hardest by the healthcare disruption, and also ethnic minority groups as well.”

But he also believes the pandemic has provided an opportunity to shift the narrative and try a different approach. Katikireddi says: “Firstly, I think we can certainly be more bold in addressing some of those, what I would see as more downstream drivers of health – things like obesity, smoking, physical inactivity and so forth, all of which are very, very important.

“But also, the fundamental drivers of health inequalities are more upstream than that. Many of the big drivers are more about things like the working conditions and employment and income that people have that then make it easier or more difficult for them to pursue that healthy lifestyle.

“One of the really striking things in the pandemic has been actually how we’ve been able to change things like the welfare system in a way that I don’t think anyone would have really anticipated beforehand. So, yes, I think it does illustrate that there’s real potential for governments to respond to public health threats in a far more kind of urgent and holistic way than often has been the case.”

The LSE-Lancet report agrees. It concluded that, “after the Covid-19 pandemic and leaving the EU, the UK faces a once-in-a-generation opportunity to invest in the health of all its population and secure the long-term future of the NHS.

“Failure to re-lay the foundations of the NHS… risks a continued deterioration in service provision, worsening health outcomes and inequalities, and an NHS that is poorly equipped to respond to future major threats to health.”

It made several recommendations for how to do this. Firstly, and most importantly, was increasing investment. It said yearly funding increases of four per cent up until 2030 would help deliver many of its other recommendations. Crucially, this increase should be spread across the NHS, social care and public health rather than solely focused on the frontline.

The other six recommendations were to improve resource management, develop the workforce, strengthen prevention, improve diagnostic times, make use of data and improve integration between healthcare, social care and public health – all calls which have long been made by experts in the field for years.

However, achieving all of this will take time and the road to recovery for the NHS is long. Dr Moultrie is particularly concerned that public messaging will increase expectations beyond what is possible.

She says: “It’s going to take a number of years before we even achieve back to where we were before we went into this, so I think probably one of our concerns would be that the public understand what a long road to recovery this is going to be.

“And we really hope that there’s not the temptation to try and push the workforce too fast, to ask them to do the impossible, because ultimately that’s obviously not going to be helpful.

“It’s having an honest discussion with the public about expectations and how long it is going to take the NHS to recover, even if we enable all bits of it to work as effectively as possible.”