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

Four Parameters for the National Conversation – Kate Forbes

Our NHS workers are plumbing new depths of fatigue and pressure. Sitting in hospital, I watch the nurses rush around, scribbling notes on the backs of their hands for lack of paper, pen and time.

I know doctors and nurses who consistently work longer hours than they are paid to, every shift. Some only stay in the NHS because they know that, if they left, the burden on the remaining staff would become unmanageable.

NHS workers are pouring every ounce of effort, professionalism and kindness into their roles. That is what has really sustained the NHS in 2023. If we relied on the politics, the policies and the Budget alone, it might have keeled over by now. 

Even with the herculean effort of NHS workers, patients are waiting too long for almost every service (the only exception is midwifery – babies don’t wait). As MSPs, we receive copious quantities of casework from constituents detailing their agonising waits for treatment. Some end up going private, others stay in pain. Nearly all report excellent care – after waiting too long.

That is why senior NHS workers, including the new Chair of the BMA, are starting to query the sustainability of the NHS, without a massive injection of funding or a series of policy shifts that permanently relieves our workers of the immense pressures they carry. The BMA have called for a ‘national conversation’ (their title) on the future of the NHS, based on evidence, expertise and genuine engagement.

In principle, who could disagree with the need for a frank debate? But only if it leads to results. We’ve heard talk of reform in the NHS for years – but without urgent interventions there might not be an NHS to reform in a few decades. The greatest risk, however, is the wrong diagnosis of the root causes, which will be inevitably followed by incorrect treatment. In real life, GPs despair of patients googling their symptoms and comically self-diagnosing. There’s a similar trend in political debate about the NHS. Tune into Parliament TV most weeks and you’ll hear it yourself.

Everybody can list the symptoms – waiting times, a shortage of workers, bed blocking. The problem comes when politicians and commentators immediately jump to conclusions and suggest certain treatments which would almost certainly exacerbate the symptoms. You hear some insist that it’s the public sector to blame – if it were privatised it would become more efficient! Others condemn the shortage of money – if every penny of the devolved settlement was expended on the NHS, we’d wave away the problems. Both are ridiculous suggestions. 

So, yes we need a frank debate, but it’s got to have parameters. That’s to protect it from being a talking shop or, even more worryingly, a cover for politicians to promote their favoured policies without proper accountability. And Government should implement changes, even while the conversation is ongoing, by giving a cast-iron guarantee that they will back effective, sensible results, even if it comes at a cost – financially or politically.

I suggest four parameters to the conversation. First, there must be zero tolerance of any suggestion of moving away from the founding principles of the NHS, especially ‘free at the point of need’. Anything short of that is not the NHS, so don’t pretend that it is. Beware trojan horses, dressed up to look like the founding principles but which actually open the door to profit-driven, shareholder-appeasing healthcare. We’re trying to shift away from that approach in the care sector, so let’s not double down on it in the NHS.

Second, the NHS exists for the patients and not the government. It has become sacred (in name only), and the danger is that politicians give the appearance of caring without actually delivering what is required to sustain the NHS for the very patients who rely on its services. The NHS isn’t merely a debating point in Parliament or a line to defend in the Budget – it is those, of course, but also so much more. If preventative spend works, then we should see change to acute care – but somebody has to be willing to take the flack for the tough decisions first. 

Third, we don’t need more consultants to tell us what’s wrong. Nor do we need more managers to manage away the problem. We need to listen to the janitors, carers and nurses who work night and day and know exactly what’s going on. There was a day – or so I am told – when the ratio of doctors to managers meant that the administrative burden fell on clinicians. Now, there’s a risk that the ratio of managers to doctors mean we’ve quadrupled the administrative burden to keep pace with the ballooning bureaucracy, leaving less budget for the front line. 

Last, let’s not rearrange the deck chairs while the ship sinks. Major structural reform might be required, but it will inevitably distract from the simpler changes that could be made and will need to be made irrespective of structural reform. That’s self-evident in the proposals for the National Care Service. At the end of the day, carers deserve a higher wage and better terms and conditions with or without a major overhaul of the care sector. The same principle applies to the NHS. Free up resources in the deep recesses of management in order to employ more frontline staff, and you probably don’t need to put everything on pause whilst you redraw the NHS.

Our lasting gratitude to NHS workers should motivate us all to take a step back and actually listen. It can be an optimistic conversation, because there are solutions out there. Empowering NHS workers. Resourcing teams with better technology. Innovating processes and procedures. Putting the patient first. Full funding of the frontline. Ultimately the aim is simple: guaranteeing another 75 years of the NHS, free at the point of need, attractive as an employer and able to treat every citizen.

Kate Forbes is the MSP for Skye, Lochaber & Badenoch

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