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

From Christie to Covid: Why we need to reform the NHS – Gerry Marr

“The public services of the future must not only continue to provide a safety net for the vulnerable but make a coherent contribution to a stronger, healthier, economically viable and more equitable society”.
(The Christie Commission 2011)


This article is one of two papers which seeks to examine the evidence of key aspects which have impacted on the NHS in Scotland from the year of publication of The Christie Commission report in 2011 to the outbreak of the global pandemic circa 2020/21. This represents a contribution to the collective thinking on how we need to act differently to achieve fundamental reform, and secure the sustained change needed to build a future based on the founding principles of our health service.

The recent Audit Scotland report on NHS Scotland (Feb 24) has drawn unprecedented comment and reporting, having raised fundamental issues about the sustainability of the NHS in Scotland in the short to medium term.

The Scottish Budget (2024/25) approved by the Scottish Parliament in February 2024, has raised further concerns about the progress of the post pandemic recovery plan, and the infrastructure support needed to deliver it in the short term.

 The overwhelming sense of crisis in the health service pervades every discussion nationally, calling for an urgent, open, and honest national conversation about the future.

The majority view is the need to preserve the founding principles of our health service. Despite this, some take the view that raises the possibility that amongst many of the difficult decisions needed in any national dialogue, there may be the need to include the future possibility of charging for certain services, striking at the heart of universal cover, the very essence of the founding principles of the NHS.

Why has such a view emerged at this time? Careful analysis of the evidence on funding and performance over the last decade, as well as progress on strategy, policies and performance designed to take forward The Christie Commission’s recommendations, provides part of the answer.

The Institute of Fiscal Studies and The Scottish Fiscal Commission analysis shows that the NHS enjoyed a period of real growth in the first decade of devolution of circa 5%. By 2020, the real term growth was 0.4%. In 1999-20 Scotland spent 22% more per head of population than England but by 2019-20 that had fallen to 3%.

Real terms growth is the normal term used in financial analysis of available resources. It is more useful to use the actual budget allocations to the health service, documented in the annual reports of Audit Scotland. This is important because the cash allocation available to the NHS in Scotland, is the most reliable indicator that provides the evidence to understand year on year performance and the effectiveness of implementation of government policy and reform.

An analysis of budget allocations from 2011/12 to 2018/19 shows that they were significantly above the figure of available real term growth, providing clear evidence of government supporting the financial sustainability and performance of the NHS.

As early as 2011/12, despite growth in available resources, nine of the fourteen Health Boards had an underlying deficit. The Audit Scotland report of this period stated that the requirement for Health Boards to break even, encourages short term actions with little evidence of plans to secure financial sustainability over the short to medium term.

By 2018 Audit Scotland provides a helpful summary of a consistent pattern of financial pressures and the adverse impact on workforce and service delivery. The report states that no Health Boards were meeting all key national performance targets, with only one national target met across all the Health Boards. Despite an increase of 2.5% in cash, brokerage (loans) by Scottish Government was £50.7m, with Health Boards continuing to rely on non-recurring savings. Only three Health Boards met the 62-day cancer target, while waiting times continued to deteriorate. The report provides a summary of key workforce data over a 5-year period: key indicators show a 38% increase in agency/bank costs, affecting the medical and nursing workforce. Regarding clinical activity, there was an increase of 26.9% and 34.9% in waiting for outpatient and inpatient elective admissions respectively. The total number of elective admissions had fallen by 18.9% with emergency admissions increasing by 5.3%.

The report concluded that “The NHS is not in a financially viable position” and that “decisive action is needed to secure the future of the NHS in Scotland”.

While not seeking to diminish the impact of the pandemic, the reality is that the NHS in Scotland was experiencing sustained challenges in financial viability and performance prior to the outbreak of the pandemic. The need for recovery was already urgent.

Against this backdrop, what has been the progress in strategy, policy, and the implementation in the drive towards the reforms set out in The Christie Commission?

The Christie Commission’s four pillars of prevention, performance, participation, and partnership has been the driving force for reform since its publication in 2011. A commitment reinforced by the present government in the ten-year review in 2021.

The Christie Commission emphasised amongst other issues, the need for better integration as a means of shifting the balance of care and resources to community-based services.

Well in advance of 2011, there had been many efforts to achieve that objective. Governments consistently placed significant emphasis on structural change to achieve their objectives, in both policy and strategy.

Using international comparisons, the Scottish Government is not alone in pursuing structural change as the driver of reform, nor demonstrating that such approaches fail.

Since devolution, there have been a plethora of attempts to restructure as a route to integration. The creation of Integrated Joint Boards is the latest and most far reaching. A fundamental test of progress following the creation of Integrated Joint Boards is evidence of change in systems of care at a national level that is sustainable, with measurable outcomes. Regrettably, there is no evidence of this.

This should not detract from the considerable local efforts of progress in innovation, commitment and leadership, achieving meaningful changes in services to local people.

The Accounts Commission Report (2018) on progress of Integrated Joint Boards provides details of financial and service pressures. More significantly, the report states that a key part of the reforms would be that Integrated Joint Boards would achieve a shift of care closer to home.  By 2018 key national measures showed no progress on this key objective. The report makes a series of far-reaching recommendations on actions needed to drive implementation. The recommendations were accepted by the Joint Ministerial Group on Health and Social care (2019).

By 2018 the total resource to Integrated Joint Boards was £9bn made up of a 70/30% allocation from health and social care respectively.

 The legislation included the transfer of the management of several acute hospital services to Integrated Joint Boards. This had not happened.  In addition, the report shows that resource allocations between hospital and community care remained static.

The government insisted that the creation of Integrated Joint Boards would produce major improvement in delayed discharges, with a projected saving of £160m annually. This has not happened.

In 2019/20 there were 542,204 delayed discharges, 67% were patients over 75 years. This represented a total of 8.9% of available beds (Public Health Scotland).

The combination of fiscal pressures, deteriorating performance and little evidence of success on integration and transfer of resources and activity was a sustained pattern in the health service before the global epidemic.

During this period there was no lack of policies and implementation plans supported by one off supplementary funding. What evidence points to the success or otherwise of such approaches?

The Finance and Public Administration Committee of the parliament budget scrutiny report (2023/24) provides a helpful analysis based on evidence from submissions from several key stakeholders.

In summary, it presents a picture confusing and constantly changing government strategy in health and social care. Their report highlights a pattern of dislocated, subject based policy developed in isolation, alongside disparate implementation plans with a lack of clarity over transparent measures of progress.

Failure of implementation is a recurring theme. The Health Foundation report (Leave no one Behind: The State of Health and Health Inequalities, Jan 23) is a comprehensive report on inequalities in Scotland. The report is clear on the lack of progress due to complex, multiple, disconnected policy initiatives with little evidence of effective interventions intended to improve key aspects of health and wellbeing. The report echoes the failures of intended transformation in health and social care.

In his recent NHS 2048 blog Sir Ewan Brown raises fundamental issues of stewardship and governance. Having reviewed the membership of non-executives on boards he concludes that they lack the appropriate skill set. He is also clear that the relationship between Government, the Civil Service and Health Boards is not fit for purpose. His blog echoes much concern on the effective stewardship of health services in Scotland.

 Jackie Ballie, in her recent article, expresses disappointment at the view of NHS Scotland Chief Executives on proposals that include the need for charging for services in the future. Her disappointment reflects her concern that this information became public through a leak from a private meeting.

The culmination of the lack of reform and failure of policy development and implementation, compounded by the extreme service pressures post pandemic, has provoked a compelling plea for an honest, transparent conversation on the future of our NHS in Scotland. Given the evidence presented in this paper, are the views of chief executives justified in the current circumstances? Or does it reflect further on the failure of the stewardship of our NHS in Scotland?

There is real danger that such ideas at a time of “crisis” particularly by a group of senior executives who must share their part in the failures of the last decade, gain credence. If nothing else there is no way of predicting the unintended consequences of such decisions, leaving a legacy that would compound inequalities in health and social care that currently exist.

The point is, a rush to a debate about affordability in the current crisis fails to reflect on the failures of reform over the last decade, compounding the errors of the past. A reactive response that denies the people of Scotland the opportunity to be involved in at transparent, honest conversation.

Many sources have called for brave decisions. The brave decision is the unequivocal commitment to the founding principles of our NHS as part of any conversation about the future. Anything less would be a betrayal of our future generation who would never forgive us.

My next article will explore how recovery from the current crisis can be the first step in the reform of our health services and that there is evidence of how that can be achieved and sustained.

Gerry Marr, is the former Chief Executive of South Eastern Sydney Local Health District, Sydney, Australia taking up the position in February 2014 until he retired in August 2018. Prior to this position, Gerry held Senior Executive roles with the NHS Tayside, firstly as Chief Executive Tayside University Hospitals Trust, then Chief Operating Officer/Deputy Chief Executive Officer, and then Chief Executive from 2010 until 2013. Prior to his work with NHS Tayside, Gerry held senior roles in the areas of system performance and human resources management with the NHS Scotland Department of Health. In his early career, Gerry held senior management roles at major tertiary hospitals, including Yorkhill Hospitals NHS Trust in Glasgow and the Women and Children Services, Greater Glasgow Health Board.

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