Why NHS transformation is vital to improve the nation's health

Neil Gray’s timing could hardly have been worse. Appearing on a Holyrood panel at last month’s SNP conference the health secretary accused the media of “failing to recognise” the good work going on in the NHS and claimed journalists put forward a “persistent negative narrative” that leads the public to “only see that there is a crisis in the health service”.

“We need to make sure we rebalance the narrative for our patients and our staff and for those that are looking for a potential career,” he said. 

Days later, an avalanche of bad news hit. According to Public Health Scotland figures nearly 40,000 patients waited more than four hours to be seen in A&E in July, the worst-ever figure recorded for that point in the year and the first time fewer than 70 per cent of attendees were seen within the government’s four-hour target. In the same month the number of people awaiting discharge from hospital remained stubbornly high at 1,961, while the number of planned operations remained below pre-pandemic levels and the number of planned operations cancelled at the eleventh hour increased by more than 200 on July 2023.

At the same time, while NHS Education for Scotland figures showed that nursing and midwifery vacancies had fallen considerably in the year to the end of June, at 3,102 they still remained concerningly high. Indeed, though he welcomed the drop, Norman Provan, associate director of employment relations at RCN Scotland, said that “the number of nursing staff [NHS Scotland] says it needs to deliver safe care and the number of registered nurses employed in Scotland’s care homes continues to fall”.

As if the picture being painted wasn’t bad enough, Public Health Scotland, which is responsible for improving and protecting public health, went on to reveal that Child and Adolescent Mental Health Service treatment targets were starting to slip, with year-on-year waiting time improvements going into reverse over the second quarter of 2024. Finance secretary Shona Robison then included the health budget in the swingeing public sector cuts she announced as soon as summer recess had ended, with £18.8m being taken out of mental health services as part of a total health budget reduction of £116m.

To top it off, National Records of Scotland announced a year-on-year rise in the number of people dying an alcohol-related death in 2023, while the government confirmed there were 589 suspected drug deaths in the first half of this year.

Opposition politicians, predictably, had a field day with the barrage of bad news. Scottish Labour’s Jackie Baillie accused the SNP government of overseeing a period of “managed decline” in the health service, saying the NHS is “on life support” but that the government “seems to have given up on fixing this crisis”. Scottish Liberal Democrat leader Alex Cole-Hamilton accused Robison of “taking an axe” to the NHS to deal with “a fiscal firestorm of the SNP government’s own creation”, and Scottish Tory health spokesman Dr Sandesh Gulhane said that Gray needs to “get a grip” on the “NHS crisis” otherwise the service is at risk of “a total winter collapse”.

It is not just Gray’s political opponents who are lasering in on the negative news stories, though. Dr Iain Kennedy, chair of doctors’ trade body BMA Scotland and a GP with NHS Highland, says that while on an individual level there are countless stories of patients receiving excellent care across NHS Scotland, at a population level the picture is troubling.

“I do have some sympathy with his [Neil Gray’s] observation that there are often negative stories about the health service but there’s a reason for that and the reason is that we are in permanent crisis and, fundamentally, the capacity within the NHS in Scotland does not meet the demand,” he says. “My members and other healthcare workers beyond doctors are feeling that on a day-to-day basis, where we are constantly having to apologise to patients, primarily around the difficulty in accessing general practice and waits for hospital appointments.”

Part of the reason the service cannot meet demand is that it does not have enough staff to deal with the level of need in the population. As well as the 3,000-plus nursing and midwifery vacancies, there were nearly 460 unfilled consultancy roles across the medical and dental professions at the end of June in addition to over 650 allied health professional vacancies – the physiotherapists, podiatrists and other workers that GP receptionists are supposed to triage patients towards to take the pressure off general practice itself.

At the same time, a report issued by the BMA in June found that, while the overall number of GPs in Scotland has risen by almost 300 since 2017, the proportion of those practising on a full-time basis has decreased. Add in the fact that, as of last year, more than two-fifths (42 per cent) of practices said they had at least one vacancy while patient numbers have increased by seven per cent since 2013 and the overall picture is of a health service that is bursting at the seams.

Yet while the government has made repeated promises to recruit more staff, the BMA says it does not appear to be on track when it comes to general practitioners. And, despite the large number of unfilled nursing posts, Provan at RCN Scotland says a “failure of workforce planning” means newly qualified nurses are finding it impossible to secure their first job. The risk is, he says, that these people will be driven out of the profession entirely, meaning not only that the health service will continue to be unable to meet demand but that the £60,000 per person training cost will have been wasted.

“Nursing students [who] have been on placements within NHS and social care services […] have experienced overcrowding and pressures on services and witnessed significant gaps in the nursing workforce – to be told there are no posts available is directly at odds with their personal experience,” he says. “This is evidently a failure of workforce planning processes and we’re also concerned that these decisions are being driven by short-term financial considerations rather than service and patient need.”

The knock-on impact of even small pockets of understaffing can be huge. And, while the £18.8m being cut from mental health services might look small in the overall context of a multi-billion-pound NHS budget, Kennedy says it is particularly worrying in the context of ongoing staffing pressures. In recent years he and his GP colleagues have been finding it harder and harder to refer patients on for mental health treatment and support, meaning they have been left to deal with health issues they are not equipped for while the health of their patients has suffered further.

“The majority of the referrals I make into mental health services are rejected, as are the majority of referrals from my equally experienced colleagues, and it would appear to be down to a lack of capacity,” he says. “Our colleagues in mental health are under so much pressure to triage patients out that the threshold for getting an appointment has risen and the bar is very high. We’re left in general practice to manage patients that we neither have the skills, experience or services to manage. That’s a phenomenon that’s new to me in the past five years and it’s getting worse.”

On top of the staffing issues, Katherine Smith, professor of public health policy at the University of Strathclyde and co-lead of the institution’s Scottish Health Equity Research Unit, says the health service is suffering from the fact that successive governments have been unable to effectively deal with the poverty and health inequalities that lead to deep-seated health issues. Eradicating poverty has long been a national mission for the SNP, and First Minister John Swinney put ending child poverty at the heart of his legislative programme for the year ahead, but official figures released earlier this year showed there had been practically no change in poverty levels for children and pensioners in the period between April 2021 and March 2023,  while the proportion of working-age adults living in poverty had risen. It is the NHS, Smith says, that is paying the price.

“Health inequalities are really wide and for the most deprived groups they have got worse,” she says. “Overall life expectancy, which was increasing before the pandemic, is decreasing and part of the reason for that is that life expectancy – and healthy life expectancy in particular – is so low for people in the most disadvantaged communities in Scotland.”

She adds: “Outside pandemics and wars you don’t expect life expectancy to decline, so that’s a massive red alarm bell and it’s right to draw attention to that. It’s a really bad sign about population health in Scotland. No matter how good a job the NHS does, if you have that high level of ill health in a population the service is going to struggle. Within that, the Scottish Government needs to have really good data to understand where things are working so it knows where to pull back and where to invest further.”

The Scottish Child Payment, which the government introduced in 2021 as a means of lifting Scottish children out of poverty and closing existing equality gaps, is a case in point. The SNP has repeatedly claimed that the intervention has taken 100,000 children out of poverty, something that should have a long-term positive impact on the nation’s health if true. However, Smith says the way the policy’s impact is being evaluated is not robust enough to give a true picture of its effect, meaning there could be a case to say the money would be better spent in other ways.    

“The child payment is a really good idea, and it should be making a difference – the government is putting money in and that should be bringing people above the poverty line, but that’s not coming through in the data in the way we’d expect,” she says. “That might be to do with the way the data is being collected, which is a DWP responsibility. It looks like it’s not capturing who has had the child support benefit, but it’s really important when we’re doing these things and spending a lot of money to fix a problem as tricky as health inequalities that we have a plan for monitoring policies. From what we’re seeing at the moment, there leaves a lot to be desired.

There are big ambitions on child poverty and big ambitions on housing and that’s great, but actually tracking how that impacts is not being done properly. If you invest a lot into a policy, then you should be tracking its impact.”

Against this backdrop there has been much talk about the need to reform the NHS in Scotland. Gray has said he is committed to implementing changes that would focus on four key areas: improving population health; prevention and early intervention; providing quality services; and maximising access. In June he said that “significant transformation to how our health services operate has never been more urgent and our vision for reform focuses on changes within current NHS structures to deliver for Scotland”. He has, however, also said the government remains committed to maintaining a service that stays in public hands and is free at the point of delivery – a service that looks largely the same as the one that currently exists, in other words.

For Kennedy, though, it is vital that potentially radical change is looked at because “the NHS in its current form in Scotland is unsustainable”.

“We will need some change in the NHS,” he says. “One of the questions I’m asking is do we need incremental change, or do we need disruption with radical change […] I’ve had good relationships with all the cabinet secretaries I’ve dealt with so far – Humza Yousaf, Michael Matheson and Neil Gray – but we need more than good relationships and warm words. We need action and I think what I’d like to have seen from all of them, and what I’d like to see from Neil Gray is some bravery to be honest with the public about the current viability of the NHS, what it can truly offer and what the plan is for the years ahead. We need a long-term plan to 2050. 

“It’s difficult for politicians because they work on five-year cycles, but the public is wise – they know we need a long-term plan and they are fed up with the NHS being used as a political football. We need a cross-party consensus approach to designing the NHS. It’s right that it’s sacrosanct but it’s not going to survive so we need to look at the principles. We believe that it should still be free at the point of delivery, but we already have private healthcare being used. The reality is that we have a two-tier service, and we need to be honest about the current contribution of private healthcare and decide what’s going to be free at the point of delivery in the years ahead."