No Magic Pill: After Covid, how are Scotland's health & care services?

This time next year, the NHS will have entered its 75th year.

The special anniversary will follow the most intense and sustained period of public health crisis in the life of the service; one that has led to soul-searching about what can and should be done for public health.

This parliamentary year has been about rebuilding and looking to the future of services.
And throughout it, the Scottish Government has grappled with the questions the pandemic has asked – and continues to ask – on budgets, staffing, prioritisation, and on top of the existing health inequalities that have widened throughout the coronavirus crisis, can the NHS cope with it all? There’s no magic pill for any of it. 

While the Covid vaccination programme is at an advanced stage, and jags have now been provided to children aged five to 12, overall case numbers rose to an estimated one in 15 as school summer holidays began, applying yet more pressure on a wounded service as hospital staff pushed for action to fill workforce gaps and on better pay.

Political pressure ramped up too as cancer waiting times fell to a decade low. Just one quarter of those being referred with urgent suspicion of cancer waited longer than the 62-day target for their first treatment, according to Public Health Scotland. Performance against that target was under 77 per cent in the first three months of 2022 and Scottish Conservative health spokesman Dr Sandesh Gulhane said that was “truly terrifying”. “When a patient comes to see me with signs of cancer, I act quickly because time is vital to their survival,” the GP said.

“Limiting the impact of Covid-19 on cancer patients has remained a top priority throughout the pandemic,” the Scottish Government said when the figures emerged. 

“The 62-day standard remains challenging for this quarter,” the administration admitted, saying “we must do more”. That would mean up-skilling nurses and putting more money into diagnostic tests to reduce backlogs, it was claimed.

Reversing the trend would be an easier battle if the waiting times target was only an issue for cancer treatments, but it is not. Take A&E waiting times, which hit another unwelcome record recently, with the number of patients waiting longer than four hours increasing to its highest-ever level in late June.

Health secretary Humza Yousaf has announced new measures on the matter, including an end to two-year waits for outpatient appointments in most specialities. As of the end of March, 10,613 people had been waiting that long and Yousaf called the new targets “some of the most ambitious” in the UK.

Money for the work will come from the £1bn allocated for the NHS in the Scottish Government’s Covid Recovery Plan. Yousaf said the pandemic had exacerbated the backlog and that there has been an effort to attract more people into the healthcare workforce and accelerate their route into the field. This includes through the digital Preparing for Work in Health and Social Care Programme from the NHS Scotland Academy, which has been accessed by more than 1,200 learners since launching in December. That was followed in June by the Accelerated National Innovation Adoption pathway, which aims to speed up the development, assessment and roll out of tech innovations to healthcare workers to further improve services.

Meanwhile, mental wellbeing minister Kevin Stewart recently announced the recruitment of almost 960 whole-time equivalent mental health workers for hospitals, GP practices, police station custody suites and prisons – 160 more than pledged in the Scottish Government’s Mental Health Strategy 2017-27.

All that, though, has been overshadowed by the threat of industrial action this summer, when members of four unions – the Royal College of Nursing Scotland, Unison, Unite and GMB Scotland – rejected the Scottish Government’s five per cent pay offer. The decision opened the door for a ballot of healthcare staff on industrial action in a further bid to put pressure on the SNP-Green administration.

That is despite an offer that the same administration says is the largest single-year deal in the history of devolution and more generous than offered elsewhere in the UK.

Unions have been highlighting the difficulties facing healthcare staff for some time, raising issues of low morale and heavy workload as well as financial pressures. Yousaf says medics have “worked tirelessly to keep us safe during the course of the pandemic” and “we value our NHS staff”.

The social care workforce was also key during Covid, and the blueprint for the promised National Care Service (NCS) has now been published. The policy has been described as the biggest reform to public services since the birth of the NHS in 1948 and would transfer responsibility for the running of social care services from councils to care boards, which would be similar to NHS health boards. Costing up to £527m to set up, the NCS could be operational by 2026, it is claimed, and would also bring in a new complaints process, help for unpaid carers and visiting rights for adults in residential care homes, with a National Social Work Agency established to monitor standards.

Ministers say the plan would also improve accountability because the Scottish Government would ultimately be responsible for performance. But unions have called this a “recipe for disaster” and argue care workers have been sidelined in the planning.

“The Scottish Government could not have drafted a more incomprehensible, incoherent and dreadful Bill,” Unite union general secretary Sharon Graham said, calling the proposal “an all-out assault on local democracy”. Meanwhile, Keir Greenaway of the GMB union said it was “unclear” how staff would benefit from the “fag packet plans” and claimed the Scottish Government is “in danger of overpromising”.

There have been many other developments too during this busy year, such as the passing of legislation for the reimbursement of women who have travelled abroad for surgery to remove harmful transvaginal mesh implants. Hundreds of patients underwent the procedure to treat issues including post-childbirth incontinence, but were left with chronic pain and other debilitating symptoms. Agreements are now in place with centres in Missouri and Bristol, with travel and accommodation costs covered for patients.  

But much remains to be done. As the next parliamentary year begins, health is likely to remain one of the most pressurised portfolios.

Q&A: Humza Yousaf: Cabinet Secretary for Health and Social Care

Holyrood: How do we ensure the infection prevention lessons of 2020 like wearing face masks are not forgotten, and are you worried about what is coming?

HY: Covid has not gone away, which is why we continue to ask people and businesses to take sensible precautions to protect themselves and other people. This does include continuing to wear face coverings where appropriate – such as in crowded, poorly ventilated places – and following the latest advice on hygiene.

We are in a good place, with a highly vaccinated population and high levels of natural immunity. But, of course, we continue to keep an eye on case numbers and we are working with Public Health Scotland to continue to identify new threats as early as possible. In addition, we encourage everyone to receive the vaccine doses they are eligible for as and when they become available.

Cancer treatment reached a record low in July. How will you turn this around, and how long will that take?

HY: Overall, the 31-day standard has been consistently met throughout the Covid-19 pandemic with a median wait of four days to treatment from a decision to treat. However, the 62-day standard remains challenging.

A new Early Diagnosis Vision will be developed as part of the new Scottish Government Cancer Strategy we will publish next year. We are currently working with clinical and non-clinical groups to influence the development of this strategy, which will set out a 10-year strategic approach to cancer services, supported by three-year action plans.

The pandemic brought a new emphasis on mental health. How can we ensure that focus is retained and built-upon? 

HY: The impacts the pandemic has had on people’s mental health and wellbeing are still emerging – and those impacts will not be evenly felt. However, the pandemic also saw huge progress in how we talk about mental health. 

We will build on everything we have learned and achieved over the pandemic when we publish our new Mental Health and Wellbeing Strategy later in 2022. It will set out a vision and framework for improving mental health and wellbeing for all people in Scotland over the coming years. We have an opportunity to build on some of the creative things that people, communities and services have done, both before and during the pandemic. 

The health brief brings with it a range of challenges, competing priorities and no shortage of criticism, which can often be personal. How do you deal with that and stay focused on the job?

HY: In any role that I’ve ever been given in government I always aim to focus on the task at hand. I absolutely take criticism where it is constructive and from people that I respect. I have taken steps to protect myself from the abuse I often get on social media, because frankly the Twittersphere is not real life and the noise, verging on abuse, can be an absolute distraction. 

Notwithstanding the pressures of the job, I make time to dedicate to the things that make me the happiest, which are my wife and kids and my family. I am making an attempt at a better work-life balance than I have maybe had in previous ministerial roles.  

You’ve been in post for approaching 18 months, starting slap-bang in the middle of a pandemic; what do you wish you’d known when you took the job on?

HY: I knew the job of health secretary would be demanding, but if you allow it to, it could become completely all-consuming. 

When I first took the role, we were not long after the initial waves and during my first period in the role we went straight into the Delta Wave. I let it become all-consuming. 

It will always take a significant proportion of my time, but it is not healthy if you don’t ensure you have that work-life balance for your mental health. The role is so huge, you have to be good at delegating. I have not always been the best at that but my team in health and social care remind me of the need to do it.

Have there been any silver linings that you can take from the pandemic?

HY: It is difficult to talk about silver linings when the pandemic has been such a tragedy for so many people, but there are certainly ways of working that we want to embed for future years. Near Me, for example, was expanded out of necessity but it would be a shame to lose that – it has been revolutionary. We’ve also worked at a pace in government during the pandemic which I think we should try to embed.

What’s your top tip for keeping healthy and do you always manage to stick to it?

HY: In terms of physical health frankly I’m not the best example. In attempting to get back to fitness I suffered a ruptured Achilles and now I will forever do my dynamic warm-ups and cool-downs. 
After that injury and period of rehab I have actually started the Couch to 5k programme, so I have Sanjeev Kohli in my ear urging me to keep going three times a week. It is a really good mix of running and walking and eases you in at a good pace.

In terms of mental health, in any ministerial role, you can burn both ends of the candle until there is just nothing left. Nobody wants any minister or cab sec who is completely burned out. They will not make good decisions and not serve people well. 

For the last six months, I have been very strict about boundaries and don’t disrupt time spent with my wife and kids unless there’s an absolute emergency. It is important to realise that there are other people there who can pick up the reins while you’re taking that vital family time.