Scotland's NHS at 70 - the legacy of care

When Nye Bevan proposed the National Health Service, it was a dream of applied socialism, a universal service in which everyone was treated equally.

Four principles lay at the heart of the vision. It was to be free at the point of use, available to everyone who needed it, paid for out of general taxation, and used responsibly.

Initially, this vision was resisted, not just by the Conservative opposition but also by many in the medical profession.

The idea that general practitioners should give up their autonomy as independent businesses would prove a step too far, and the BMA threatened a doctors’ strike.

Bevan conceded that general practice would remain independent, saying that he had “stuffed their mouths with gold”.  

But there were still dissenting voices. A leading member of the British Medical Association described Bevan’s role as health secretary as the “medical Führer”.

Industrialist Bernard Docker, the chair of private hospitals body the British Hospitals Association, warned the NHS would become a “mechanism in which the patient will get caught and mangled”.

While the NHS has survived 70 years, have Bevan’s four principles endured? And is there any evidence that Docker’s prediction of patients getting stuck in the machinery has come true?

While doctors fought to retain their autonomy in England and Wales, Scotland’s health service has in fact been autonomous since the very beginning. 

It has never been run from Westminster by the UK Health Secretary. A separate piece of legislation, the National Health Service (Scotland) Act 1947, created a Scottish NHS under the ministerial oversight of the Scottish Office as an entirely separate legal entity.

Scotland had its own, established, distinctive medical traditions, steeped in the medical schools and links with the ancient universities. 

Charles Darwin and Arthur Conan Doyle were alumni of Edinburgh University’s medical school, while the pioneering medical school at the University of Glasgow welcomed African-American students before they could study in their own country. James McCune Smith was the first African-American to receive a university medical degree in 1835.

St Andrews medical school, established in 1413, granted the first medical degree from a UK university to an Indian, Pulney Andy, in 1860.

The three colleges were also among the first in the world to train women. Marion Gilchrist was the first woman to graduate as a doctor from a Scottish university in 1894.

Unlike elsewhere in the UK, the early twentieth century had already seen healthcare in Scotland consolidated into a collaborative and centralised structure.

In 1936 – 12 years before the NHS was created – a ground-breaking report, chaired by Edward Cathcart, professor of physiology at Glasgow University, called for the Scottish Health Service to be better integrated and more personalised.

The 404-page Cathcart report advocated a health system steered by national policy but led by general practitioners on the ground. Cathcart’s vision was for a GP to lead a health centre which could provide a number of services. And the system should promote health, rather than just treat sickness.

It all sounds very familiar to anyone with a passing interest in health policy in 2018.

Cathcart said: “Health education should be placed in the forefront of national health policy. It should aim at producing a people who are balanced physically and mentally, who enjoy health and take it largely for granted because, by education and training, their outlook and habits are healthy.”

By 1948, health services in Scotland were already largely a public asset. Many hospitals were run by local authorities and charities, while the state-funded Highlands and Islands Medical Service provided care to half of Scotland’s landmass.

Although care was not yet universal or free at the point of use, treatment was often provided even when people could not afford the small fee.

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In many ways, it could be said the world-famous NHS was piloted in the Highlands, and the fact that well-established relationships existed between the country’s top doctors, civil servants and universities meant the acrimony Bevan faced in London from the medical establishment failed to materialise in Scotland. 

The creation of the NHS in England became a baptism of fire, while in Edinburgh, civil servants were already involved in the day-to-day running of health services, and the medical schools were embedded into the regional structure from the outset.

It is thought PM Clement Attlee preferred the Scottish model. 

Every family in Scotland received a booklet with a foreword by Scottish Secretary Arthur Woodburn outlining their new rights for access to a GP, dentist, eye tests, hospital treatment and prescriptions.

In reality, workforce shortages meant the services would be limited in some areas from the start.

Concessions made by Bevan to the BMA in England meant the Scottish model would include a number of private beds to be allowed in hospitals and GPs would remain in private practice instead of the more integrated, health centre-based approach advocated by Cathcart.

Of course, the NHS proved to be vastly more expensive than Bevan realised. From the beginning, it was under pressure to cut costs and firefighting meant it became more focused on treating the sick than prevention. 

Bevan resigned, along with Harold Wilson, from the UK cabinet in 1951 over charges being introduced for dental treatments, eye tests and prescriptions to help pay for the Korean war arms race. 

These charges would remain across the UK until Scottish devolution. Scottish Labour made eye care universally free in 2006 and a year later, the SNP scrapped prescription charges.

Adding to the pressures on the capacity of the NHS was the fact people steadily lived longer. In 1948, men in the UK were expected to live into their 60s, while women might survive to 70.

In 2018, UK life expectancy is 79.2 years for males and 82.9 years for females, and like the population it serves, the 70-year-old NHS now deals with a plethora of ailments and political prescriptions. 

Although Scotland’s life expectancy rates have lagged behind the UK’s, particularly since 1979, the country’s universities have played an important role in leading research and innovations in medical science that have helped people live longer, thanks to their close relationship with practice.

Ultrasound was pioneered in Glasgow in 1958, unlocking accessible detailed scanning to the world, which has led to much earlier and accurate diagnosis for a range of diseases. Scotland was where the first recognition of the dangers of Thalidomide was made in the 1960s.

Scotland also made pioneering advances in organ transplantation, family planning and harm reduction, particularly when facing the AIDS epidemic in the 1980s.

1989 saw the introduction of the internal market to the NHS across the UK, followed by the use of private finance to modernise the hospital estate and outsource non-clinical services.

This synergy with UK health policy was to be short-lived, however. The internal market would begin to be dismantled in Scotland even before devolution, which brought with it fresh commitment to free personal care and an abolition of the system of trust hospitals. 

The new millennium also brought a newfound commitment to take the preventative approach to public health and mutual relationship with patients first suggested by Cathcart. 

A ban on smoking in public places was to be copied throughout the UK, and minimum pricing on alcohol sales would see the drinks industry fight the Scottish Government in Scottish, UK and international courts, only to fail at the last hurdle.

Health is now the biggest spend of the Scottish Government budget, with around 160,000 staff working across 14 regional health boards and seven speciality health boards. Yet the pressure on the system is acute and at 70, the NHS cannot now expect a peaceful retirement. 

But is it in crisis? In terms of Bevan’s four founding principles, Scotland’s NHS is mostly free at the point of use, although people still pay for dental treatment or for private treatments if they face a lengthy wait.

It is available to everyone who needs it, but perhaps not to the level they expect. Technology is increasingly used to reach more remote patients, but many say it does not replace the quality of a face-to-face interaction.

The NHS remains paid for out of general taxation, but with more and more health boards relying on bridging loans from the Scottish Government to meet rising demand, some political voices are suggesting a new tax, charges or insurance scheme.

And lastly, is the NHS used responsibly? There are some who might ask if the NHS has ever been used responsibly, with many people expecting to be fixed or put back together as a result of their own unhealthy behaviours.

The fears are that the generations who cannot remember the NHS being born see it as a consumer service. While older people, who are living longer and presenting with multiple complex problems, represent the vast majority of patients, those between 16-30 tend not to show up for GP appointments, recent figures published in the Lancet Public Health have shown.

People often claim they love the NHS, it is a well-used slogan, but perhaps that love is not an equal relationship.

The service is often not treated with love, and lifestyles largely remain unhealthy in Scotland, which suggests that many people do not take as much responsibility for their own health as the NHS would like. 

Scottish governments since devolution have talked up the NHS as a national treasure, loyal to Bevan’s original founding principles, and public support for this has created a realpolitik where even the Conservative opposition remains more committed to them than perhaps could be said for their counterparts in the UK Government.

Successive Scottish governments have also made efforts to restructure the system to meet modern demands, including regional restructuring and the integration of health and social care.

A new GP contract will see primary care hubs established with a GP at the head of a multidisciplinary team. These could be closer to Cathcart’s vision than ever before.

But despite these reforms, capacity remains a concern, with health boards struggling financially and high vacancy rates despite the recruitment of record levels of staff. Like the NHS itself, its workforce is getting older.

As people get older and live with more complex needs, it seems the NHS demands a bottomless pit of resources.

More people are waiting longer to be seen, national performance targets are routinely missed and recruitment and retention, particularly of GPs, remains a serious concern. 

In 1948, 15 million prescriptions were issued in Scotland. In 2018, the figure has risen to over 103 million, with many of the specialist drugs offered eye-wateringly expensive for taxpayers.

The country’s spending watchdog, Audit Scotland, has raised the issue of health board finances several times, warning that financial shortfalls have had a direct impact on services, particularly at boards such as NHS Tayside, Highland and NHS 24. 

NHS Tayside was placed under special measures this year after it emerged it had used charitable trust funds to plug gaps in its core services.

The future viability of the NHS, then, depends on the success of reforms in redesigning the whole way care is delivered. The National Clinical Strategy, published in 2016, called for more local community health centres and hospitals to help people manage their own conditions closer to home and to ease pressure on increasingly centralised specialist hubs.

The question is, can health boards afford it? In reality, local, smaller hospitals and services have faced the axe as boards struggle to make an unprecedented £445m savings. In practice, service planning has followed the same centralising ethos adopted 15 years ago, before current demographical pressures were predicted.

Despite ambitions for redesigning the NHS to meet modern and future challenges, in the prevailing financial climate, it seems boards can only plug short-term holes in its current model.
As Caroline Gardner, Auditor General for Scotland, warned in October, it still wasn’t clear how moving care into the community would be funded.

“There is widespread agreement that healthcare must be delivered differently if it is to withstand growing pressure on services,” she said. 

“There is no simple solution, but these fundamental areas must be addressed if reform is to deliver the scale of transformation that’s needed across the NHS. Involving staff, the public and bodies across the public sector will also be crucial for success.”