Shona Robison: change in the NHS takes longer than I would like, but it’s happening

To mark the 70th anniversary of the NHS, Shona Robison has been asking people to share their stories of care throughout the decades. 

Photographs and memories are expected to be displayed in various celebratory events across Scotland, reflecting the deeply personal experiences of a service which people access at significant emotional milestones in their lives.

In this respect, Robison is no different.

Holyrood sits down with the Health Secretary shortly after she has met two people who, she says, embody the “whole journey” of the NHS in Scotland – a man born on the day the NHS was formed on the 5 July 1948 and a baby born that very morning. 

While maternity services are often a source of joy, Robison’s own recent experiences of NHS services have been less happy, with the loss of both her parents in the space of 18 months. She describes the end-of-life care they both received as “compassionate and caring” but it is clearly still raw for her.

“My mum was old enough to remember the days before the NHS,” she says.

“She grew up in the Manchester area and remembered people not being able to afford going to see the family doctor. It was not uncommon for kids to not turn up at school because they’d passed away from diseases that are now immunised against. 

“So my mum, whenever she heard an attack on the NHS, she would always make the point that if people had known what it was like before the NHS was formed, they might appreciate the fact we have a fantastic institution. 

“It’s an institution with challenges, of course, but when you look around the world and see we have a service free at the point of delivery that has saved countless lives, prolonged life expectancy and made huge strides in public health, it is still the envy of the world. We should be very proud of it.”

Robison remembers her own first memory of hospital involved visiting her mother after an incident she feels directly responsible for.

“I probably shouldn’t admit this. I was about four or five at the time and the house opposite where we lived was a derelict cottage, and for whatever reason I became terrified of this cottage,” she remembers.

“I had convinced myself that I had seen somebody standing in the window of this place, to the extent that every time I walked past one of the windows in our house I would duck down. One day my mum had had enough of this and decided she was going to take me across the road to show me this derelict cottage. 

“All well and good, except on the way across the road, she got her heels stuck in the grating of the road. A car was coming and she was worried she was going to fall in front of the car, so she fell over and broke both her ankles.”

Robison’s fears about the abandoned cottage were replaced by fears for her mother, and it was an incident she apologised for “regularly”.

“I do remember visiting hospital and it was the first time. I remember the smells, a strange environment. Obviously, now I spend half my life visiting hospitals…”

Robison’s visits have not been restricted to professional ones, however. She reveals she was recently recalled as part of the breast screening programme.

She says she got a “fantastic service” from Ninewells in Dundee. 

“It was, you know, a very personal reminder of the fact we now have these screening services that were not around 70 years ago. In fact, they weren’t around even more recently than that, and it is such an important thing for everyone to take that opportunity when you get that letter,” she says.

Robison describes going through “all the fears” when she was recalled.

“You know, when I arrived home and opened the letter, I expected it to say, ‘we’ll see you in another few years’, and when it said, ‘we need to see you again’, it catches your breath. You think, ‘oh my God’ and the leaflets come and you read through them and your mind takes over, as it would for any woman in that situation,” she remembers.

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“I went along for the appointment and there must have been 20 women in that room, all having been recalled, all in the same boat. It didn’t matter what my job was or anyone else’s, we are all women in the same boat in that moment in time. We all went through the same process, the same fears and for me, the relief. 

“But I know for some of the women in that room, it wouldn’t have been that outcome. That’s what has stayed with me. But that’s what the screening service is for. When there is bad news, it’s early detection that gives you the best chance.”

The image of the Health Secretary sitting in a waiting room with women from all walks of life conjures up the universalist vision of Nye Bevan, something Robison clearly recognises as an important part of why people feel so strongly about the NHS.

“It is our number-one treasured institution and public service, without a doubt,” she says. 

“It has a special place in people’s lives because in their moment of need, they’ve had that experience. Even with the challenges, we do have record levels of patient satisfaction. People recognise that the NHS has challenges and difficulties but it’s something people feel proud of.”

But the fourth of Bevan’s original founding principles of the NHS – one that is less talked about – is that the service should be used responsibly. With poor attendance rates at appointments and Scotland’s unhealthy lifestyle behaviours adding to pressures on services, it could be said many who say they ‘love the NHS’ have a funny way of showing it.

Robison says the 70th anniversary could provide a reminder to use the NHS responsibly. She says stories of aggressive behaviour towards staff “angers me incredibly”, while there is an “individual and collective responsibility” to challenge behaviour at A&E which is often fuelled by alcohol.

“It’s time to remind ourselves that although there are record levels of resources, there are also record levels of demand, whether that is turning up for your appointments or only going to A&E when you need it. 

“It is a service with huge demands on it which needs careful and responsible use.”

But according to Audit Scotland, those record levels of resource are not keeping pace with the record levels of demand. Can Bevan’s other principles – that the NHS remains free at the point of use, available to all and paid for through regular taxation – endure?

“Yes, it can, but it will evolve. It will look different and feel different,” says Robison, pointing to the new GP contract which will place the family doctor in the centre of a team of practitioners including pharmacists, physios, community nurses and mental health workers.

But the vision to keep people safe in their own home, treated in the community and only using tertiary services like hospitals when they absolutely need to is “going to take a bit of time,” she admits.

This has been evident in the length of time it has taken to thrash out an agreement with the BMA on the new GP contract and the reported lack of progress made by the health and social care integration boards. 

Meanwhile, Audit Scotland has said it still isn’t clear how the shift of care into the community will be funded.

“Change is difficult and can sometimes be resisted. Sometimes it takes longer than I would like, but it’s happening,” says Robison. 

The new GP contract is in place, she adds, pointing to 250 new pharmacists, 400 additional paramedics and 330 new health visitors as examples of how the new multidisciplinary teams are being built, as well as a new medical school with a focus on primary care training.

Integration, meanwhile, is delivering a seven per cent reduction in acute unscheduled bed days, argues Robison, although she concedes the progress has been “patchy”.

“That’s why we have a review of the health and social care partnerships, because we want to take stock of where we’re at and learn from the best,” she says.

The closure of local hospitals has caught the headlines over the last year, with many health boards consolidating services using longstanding clinical arguments about how centralised care is of higher quality. 

But with modern capacity issues and a national clinical strategy which calls for the need for community hospitals and more local beds, aren’t these moves more about cost-cutting?

“It depends what those community hospitals do, doesn’t it? 

“There’s been a massive expansion in integrated beds, intermediate care beds, beds that might be provided in a community hospital or care home that are step-up or step-down beds, so avoiding admission to hospital when they need a bit of TLC, rehab and some rehydration and actually getting someone out of hospital when they’re not quite ready to go home. There are 700 more of these beds now than there was. 

“I think there is a role for community hospitals, but some of the community hospital estate is quite old and needs to be modernised. I’ve opened a huge number of health centres recently that are fit for purpose, modern, all under one roof, where you have not just health services but also social work, welfare rights, third sector organisations. It’s very much the model.”

Robison admits some frustration with variation between boards but insists she remains “a realist”.

A new ‘once for Scotland approach’ is attempting to consolidate good practice, she says.

“It basically says ‘if it’s happening there and working well, you’ll have to have a damn good reason for not making it happen in your patch.’”

Like with integration, Robison points to the importance of relationships within organisations. Hospitals in Inverness and Lanarkshire are asking frontline staff for ideas about where efficiency savings could be found, for example.

“I don’t have all the answers; chief execs don’t have all the answers, but quite often the frontline staff do have the answers. They’ve been talking for years about ways of doing it. Empower them to do it.”

The most high-profile intervention at health board level was in Robison’s own local health board, NHS Tayside, which was placed under special measures and its leadership team replaced after a number of stories about its spending. Robison says the health board had been “an outlier”, failing to live within its means.

After years of receiving practical and financial support from government, it emerged eHealth funding had been mis-recorded and charitable funds inappropriately used for core services. 

“It felt like every step Tayside was taking forward, it would take two steps back,” says Robison, leaving her “with no other choice than to change the leadership”.

After only a few weeks, the new team has already made “a very palpable difference”, she says.

All boards have since been asked to provide details of their endowment funds which have been passed to the charity regulator OSCR, and Robison does not expect a similar story at other boards, but there are lessons for the NHS as a whole, she adds, including making the audit processes more agile and accountable and separating endowment fund trustees and board members.

The new NHS Tayside leadership, meanwhile, will be tasked with rebuilding public confidence in local services Robison knows all too well from her own experiences.

“The issues that have been highlighted are no reflection on the frontline services Tayside provides,” she says.

“I have nothing but praise for the service the staff provide, be that hospitals or community services. People get a first class service from staff who work very, very hard, as they do anywhere in the NHS, to provide services. We shouldn’t forget that.”

The episode has coincided with a ramping up of political pressure on Robison, with Scottish Labour in particular calling for the Health Secretary’s job. 

It is a job Robison describes as “all-consuming” and a “huge responsibility” but also a “huge honour”. 

“All of us are just playing a small part in time. It is a journey the NHS is on and it will continue to evolve and change over the next 70 years and we just need to play our part and ensure that when we pass it on to the next set of leaders, that it is on a clear direction, in a good place and that the staff feel supported. And that patients continue to get a quality safe service.”

The political pressure, meanwhile, “comes with the territory”.

“My late mother used to say ‘what doesn’t kill you makes you stronger’. It’s part of the body politic. What gets me up the morning is the good stuff.”