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

Predictions for Holyrood health policy over the next 5 years – Gordon Hector

Now that the dust has settled on the election, we can start making some intelligent guesses about the debates which will shape the 2021-26 parliament. Political predictions are famously easy to make, after all. Here are mine, on how health and care will evolve at over the next 5 years – and which the new Cabinet Secretary for health will have in their in-tray this week when they turn up for day one:

  1. There’s going to be a big argument over social care

There is a majority, but not a consensus, for creating a national care service: SNP, Green and Labour manifestos were in favour, and Lib Dem and Conservative against. So please get used to the horrendous acronym ‘NCS’.

It’s great politics, and totally misleading.

It’s great politics because social care is patchy, confusing, and expensive – so slapping ‘national’ on it gives voters the impression it will become a single institution free at the point of use, like the NHS.

It’s misleading because this is not what it means. It does not mean nationalising care homes. Instead it’s about implementing the Feeley review: setting up stronger forms of accountability, led by the centre, with councils’ role reduced. It’s not really a national service – more of a nationally regulated system.

It is still a big change, though. Devolution’s history is littered with thoughtful reviews which are only half-implemented, and big structural changes which don’t work. So we could end up with the care equivalent of the patient safety programme in the NHS – a world-leading culture change policy, using a smart combination of hard and soft power to inspire change from within.

Or, equally likely, it could mean a care version of the Scottish Police Authority or perhaps the education quangos – centralised, unpopular, ineffective.

That in turn makes it a big test for the Scottish Parliament. The politics of creating a ‘national care service’ could become a one-dimensional arms race to show affection for care. But what will really change lives is the detail: how exactly will new structures work? What kind of relationship will providers have to government?  What mechanisms will improve quality? These questions are far less political, but they are also the difference between changing stuff, or just inventing a shiny new organogram.  

The test for Holyrood is whether after a constitutional election it is capable of exploring those questions, or not.

  1. More cash – but too much is never enough

Every party promised more cash for the NHS. A big Boris Barnett cheque is in the post. So NHS spending is going to go up, presumably in line with the SNP manifesto of £2.5 billion or so by 2026.

That sounds big. But on current structures, with current demand and health inflation projections, the NHS will happily eat that amount and still require more.

In previous budget negotiations, parties tussled over specific bits of the health budget. We might see that again, as all opposition manifestos identified particular priorities. Labour wanted 11% of spending for mental health, the Greens 10%. Staff welfare was a focus for Lib Dems and the Conservatives.

These ideas are both sensible. But again, it probably won’t be enough because we are living through a sea-change in understanding of mental health, and post-pandemic will likely return to an ever-more-global market for healthcare staffing. The cost pressures are all relentlessly upwards.

Get used to this central dynamic in health funding: we can spend ever-increasing sums. We probably will. But without anything else changing, it probably won’t feel like it for staff or patients.

  1. Ramping up NHS services after the pandemic

The manifestos all talked about clearing backlogs of care. The Lib Dems and Greens kept it vague, Labour made it their centrepiece pledge, and the Tories put £600m on it. The SNP promised a ‘10 % increase on pre-pandemic levels of activity”, which is quite weirdly focussed on a particular input.

This is important. But again it’s all thinking on pre-pandemic lines. None of the parties really adressed how we both catch up the backlog and avoid going back to the way things worked before the pandemic. In the past year, we saw rapid change in remote healthcare, online consultations and breaking down barriers between teams. NHS Near Me has become a familiar – and trusted – system for anyone with wifi and a doctor’s appointment.

The great opportunity is to bottle some of that: as Paul Gray wrote, this is the moment to grasp all the issues with culture, structures, technology and staffing that stifle innovation and underpin long-term clinical and financial problems.

In this context, saying ‘we’ll just do the same as before, but 10% more’ is deeply underwhelming. Without something a bit smarter, once the backlog is cleared (or if it is cleared) then 2023-26 are going to spent as a repeat of the years before the pandemic – ever-increasing strain, with no real plan to make the whole system sustainable.

  1. Local healthcare

The SNP manifesto proposed a few more elective care centres. ‘Centres’ is a clever word as it implies a physical place. It isn’t: it’s more like a team. Few voters will have picked up that ‘new elective care centres’ is really code for ‘a model of care which sees services concentrated into bigger centralised units while shifting the balance of care to preventative and community services’. Less snappy, I guess. But that is roughly what it means.

There are very good reasons for this model. Concentrating care is financially and clinically more effective. Many countries are going through the same process.

It comes at the price of gradually downsizing smaller units and represents a new bargain for patients: better care, on average, but often on the other side of the country. No-one has ever really explained that to them, but there might yet be votes over the next 5 years in pointing it out. Which is why the Conservatives proposed a local healthcare guarantee. The Lib Dems said something similar. Labour suggest every major hospital has an elective care site.

All of this means we could have another 5 years of political debate framed around local vs centralised medicine. But in policy terms, that’s not quite the right strategic choice facing the country.

Across Scotland, rationalising elective and specialist care is either happening, or happened. That’s it. Done. There’s no going back.

But just as remote working has changed many companies’ assumptions over how concentrated you need your workforce to be, the challenges of small-hospital, rural and remote medicine in Scotland could, with a bit of imagination, have a fresh approach too. You might still have to put most specialist services in the central belt, but you could, for example, balance that out by building Inverness into a bigger research and teaching site. Telecare like Near Me has immense potential to rethink where staff need to be located. There might be a future model for GPs which blends traditional primary care, specialist triage for some clinical specialities, and virtual care.

This is less about local vs central, and more about how things can be re-thought, in the context of a broadly already-centralised system with under-pressure primary care, and in light of big advances in technology. What we really need is a post-pandemic Kerr report for the 2020s – or something on that kind of wide canvas to explore these questions. A big, meaty speech from whoever is health secretary would do. Or indeed an opposition party setting out its stall, now we’re out of the heat of an election.

If we don’t get that then I think that by 2026, this could feel like a wasted moment.

Conclusion: nothing has changed

In short, care could be really changed, but health is staying familiar. Even expecting manifestos to be safety-first, and even reflecting the political importance of paying homage to the NHS after the past year, it just doesn’t get anywhere near to recognising just how challenging the next decade is going to be. Nor does it live up to the opportunity of post-pandemic recovery.

It’s more of the same. But the world is utterly changed.

Perhaps reassuring, depending on your perspective – or perhaps a bit depressing.

Either way, it will be as the slogan goes: five more years.

Gordon Hector is a policy consultant and former Director of Policy and Strategy for the Scottish Conservatives.