Scotland’s independent think tank
Scotland’s independent think tank

We can’t go back to the way we were – Professor Paul Gray

Whatever we do, please don’t commit to putting health and care services back to “the way they were” when all this is over.

The NHS has made some radical changes in recent days. Lots of stuff that couldn’t be done has been done. The roll-out of digital technology to reduce face to face consultation and limit travel has leapt over hurdles that were apparently insurmountable a few weeks ago.

Pharmacists – highly trained professionals as they are – are making a fuller contribution through an extended minor ailments service and have been given access to the emergency care summary for patients. A few weeks ago, all that was languishing in the “ooh, that’s difficult” box.

Out of hospital care services, whether voluntary, state provided, privately provided, or provided by individuals out of the goodness of their hearts, have been recognised as essential – not the poor relation, not an afterthought, but critical equal partners to the NHS. The way we were was the wrong way. This is the right way.

These changes have taken place because people care. They have cared enough to sacrifice some of their own status and power, in order to free up others to move further and faster than we might have imagined possible. They have cared enough to cancel breaks and take on extra shifts to make themselves available. They have cared more for others than they have for themselves and we are in their debt already. And that debt will grow. They must not be forgotten when the new day dawns.

Some of the changes cannot remain in place, of course. Elective surgery that has been cancelled will have to resume at some point. Face to face consultation has its place, and will doubtless be reinstated in some cases, although we will never return wholesale to the old modes. 

But what must remain is our capacity to move at speed, to innovate, and to break down barriers to change. Our risk appetite has been altered radically by events, and while that will be recalibrated, let’s not over-correct when this is past.

We’ve also rediscovered our enthusiasm for experts. It’s been an odd awakening. You don’t become a virologist by distance learning (also known as reading stuff on Twitter, and listening to your mate who knows someone who delivers stuff to a hospital and heard two people chatting about how this thing spreads; he wasn’t sure if they were staff or not but they sounded as though they knew what they were talking about).

We’ve also decided that being kind is ok. We’re learning not to mistake decency for weakness. We’ve learned that it is sometimes important to do what we are asked, lest we end up having to do what we are told.

We want to “take the politics out of the NHS” but we have discovered that the NHS is an intensely political construct. The decision to provide a national health service largely free at the point of delivery is a political decision: it is not therefore unreasonable that politicians have their say. Other decisions are available and other countries have taken different courses. But where we are, whatever the disagreements about the precise way in which the NHS should deliver its services, it has become clear that politicians of every stripe do care about it; they too have set an example in giving due regard to expert advice in this hour of need.

We will have got some things wrong, or less than right. There will be a combination of factors at play here. In any institutional system, the three key factors of time, cost and quality interact. The cost constraint has for the moment been largely removed, and the time constraint is significant. However, even without much cost constraint the lack of time will have an impact on quality in some situations. So we will need to review the quality of what has been done, and do it constructively. It will be unconscionable to review decisions through the lens of our approach to scrutiny heretofore. Our scrutiny will have to be context-sensitive or we will spend more time explaining what was done than we spent doing it; and we will be required to defend people who gave their all, instead of praising them, just because they missed out a step in the governance process while having the misfortune to save a few lives.

The way we were had much about it that was excellent, and it had much to commend it. It was in need of reform and that was not a contested point. But the most excellent part of the way we were was of course the people. And they are the people who transformed the way we were into the way we are, because they had to. Let them be recognised for what they did, and are doing, and will yet do. They are doing it for us, and not for themselves.

Professor Paul Gray was chief executive of NHS Scotland, 2013-19