There is a consensus at Holyrood that the £19 billion NHS Scotland is out of control and in urgent need of reform. Quotes from senior politicians include:-
SNP – “Scotland’s NHS is in need of fundamental reform. The health service must be overhauled”.
Labour – “Across Scotland, our NHS is on life support”.
Conservative – “There is a crisis in our NHS”
Recent reports by Audit Scotland have further confirmed this:-
• “Regional NHS boards are expected to deliver services well beyond the capacity of their budgets”.
• “The Covid Recovery Plan was promised in 100 days. Achieving this meant that boards were not consulted. Yet they are the ones expected to deliver”.
• “Patient safety and experience are being compromised due to overcrowding, lack of privacy, poor building conditions, and workforce issues.”
What is needed?
• maintain high levels of clinical care and patient safety.
• align health provision with social care.
• preserve the principle of “free at the point of delivery”; but recognise that as demand cannot be capped, major decisions and actions will be needed on the supply side.
• ensure that NHS Scotland is a good employer with high levels of staff satisfaction.
• make better use of public funds and do more for less.
• imbed good governance and clear lines of accountability throughout the organisation.
How to get there?
A reform agenda should properly be led by politicians, ideally on a non-partisan basis. If this is not achievable, it should be led by the government of the day, supported by civil servants. However, since there seems to be little or no appetite from politicians to do other than speak in general terms about protecting and modernising the NHS, reducing waiting lists and improving overall healthcare delivery, proposals for reform may have to be initiated from outwith the body politic.
The organisation that would seem best placed to initiate this is Scotland’s national academy, the Royal Society of Edinburgh (“RSE”), with its 1,800 leading experts across the sciences, medicine, business, professions, and the public and third sectors.
If willing, the RSE could oversee the creation of limited-life Working Groups of, say 10-12 members each. The members could be a mix of RSE Fellows and others with specialist knowledge and expertise.
To embrace what would inevitably be a complex and broad reform agenda would require several Working Groups, each with a different remit. For example:-
Group A – undertake necessary research and data gathering, including mapping.
Group B – address long term policy issues.
Group C – address long term structural issues.
Group D – consider capital funding needs and make proposals.
Group E – identify short term practical fixes.
In addition to the Working Groups, there would need to be a small, highly respected panel co-ordinating their output. The panel’s remit would be to receive regular progress reports from each Group and ensure that the emerging proposals and recommendations were broadly accordant.
Group A (comprising members with an intimate knowledge and experience of the sector)
The Group’s remit would recognise that the stakeholders of the NHS in Scotland, (which help to influence clinical and professional standards), include health and social care partnerships, Integrated Joint Boards, local authorities, national clinical groups, Royal Colleges, local and national charities, Police Scotland, Universities, Unions and patient organisations.
To provide pertinent data that would assist in developing NHS reforms, the Group should:-
• map the constituent parts of the NHS in Scotland setting out who reports to who, and why.
• map the proposed National Care Service and its relationship to align with the NHS.
• map all significant NHS collaborators and other key stakeholders, ensuring that public services such as the Police (who are collaborators in the myriad partnerships that engage and surround the NHS, with their own governance, accountability, underlying values, and culture) are aligned
• take account of a possible shift of some health care services from hospitals to the community.
• interrogate the key financial metrics for health and social care as well as the financial projections being used by government to inform policy decisions.
Group B (comprising “thinkers”) to address major policy issues.
Given the growing divergence between demand and supply:-
• consider the root causes of poor health and related long-term healthcare costs. What prevention measures would best help people live healthier lives by tackling obesity and harmful addictions. Aim to increase life expectancy and reduce health inequalities.
• should dental and ophthalmic services continue to operate free to all at the point of contact?
• should free prescriptions be continued for all and free access to consultative services offered under General Pharmaceutical Services through the Minor Ailments Service?
• while the evidence of the efficacy of new and expensive drugs / treatments seems strong, is there a need to consider the extent to which some new drugs have limited impact on life expectancy and/or quality of life?
• are the days over of having sufficient capacity to offer ‘check-visits’, medication prompts, shopping support, housekeeping support, etc?
• given that a divide has been created because of the inequality of treatment between the NHS and social care, its workforce and its resourcing, should social care be a joint partner with the NHS in the embedding of social health and care in the community?
• could the use of home-based technology offer the prospect for shaping care to distinctive needs, and for radically reducing avoidable and unnecessary acute hospital admissions?
• should citizens be given a social care budget with the right to spend it in selecting the care support that best fits their needs and aspirations?
• consider re-casting the notion that the NHS is an arm of political delivery and promote it as a national service with strong values. How could lines of communication be strengthened across the whole of the NHS in Scotland?
Group C (comprising members with knowledge of the sector)
The Group’s structural issues remit:-
• whether it would be beneficial to create a real entity that is NHS Scotland, accountable to Scottish Ministers and at arms’ length, confining Government to policy, monitoring, agreeing strategy and the business of creating, protecting health and preventing disease – and holding NHS Scotland to account?
• whether the roles of NHS chief executive and Director-General Health & Social Care should be split, leaving the civil service to focus on policy and strategic direction. If so, what qualities and experience would be needed in the chief executive?
• whether there is a need for a more contractual system where the responsibilities of NHS Scotland and the government / politicians are spelled out in detail?
• consider how leadership across the NHS could be strengthened by pushing decision-taking down to the lowest possible level.
• whether there is a need for a clear accountability framework defining the roles and responsibilities of each principal stakeholder, including mechanisms for performance evaluation and oversight? How could performance management be better aligned with long-term outcomes rather than short term metrics?
• how could patient and public involvement best be engaged – eg patient councils, advisory groups and participatory decision-making processes?
• how should hospitals and health centres be situated and used to deliver safe and sustainable healthcare whilst supporting reform? What activities should be done in what settings, and could some activities be distributed differently within or between tertiary, acute and primary care to deliver more efficiently and effectively?
• Are there sufficient hospital beds to prevent ambulance queues and meet the needs of an ageing population?
• how best to value the NHS workforce to retain and attract talent?
• could some health care services be transferred from hospitals to the community.?
• can reform of the NHS be achieved without compulsory redundancies?
• how best to implement a culture of continuous improvement, encouraging innovation, learning, and adaptation to changing healthcare needs and priorities.
• If a key role of hospital management is to facilitate the work of consultants and other clinicians, is this working, or does it need a fundamental rethink?
Group D (comprising financial experts and working closely with Scottish Futures Trust).
The Group’s remit:-
• working with Group A, map the level of capital spend that NHS Scotland proposes to commit in order to upgrade infrastructure (which is often outdated and inadequate to meet the needs of modern healthcare) and over what timescale.
• consider the particular needs and circumstances of rural communities.
• given that the high cost of finance terms (particularly PFIs) from previous capital projects inevitably sucks essential revenues from delivering front line services, what is the most cost effective approach to funding that spend?
Group E (comprising “doers”)
The group’s short-term fix remit:-
• identify opportunities for greater collaboration and integration among boards, health and social care partnerships and other stakeholders to improve coordination and decision-making.
• replace the flawed Blueprint 2 governance guidance with a prescriptive governance code applicable across the whole organisation (ie not restricted to boards).
• given Audit Scotland’s withering criticism that “regional health boards are expected to deliver services well beyond the capacity of their budgets”, what are the pros and cons of regional boards?
• if regional boards are retained should their number be reduced from 14 to (say) 4 – Glasgow & Clydeside, Lothian, North of Scotland and South of Scotland?
• could the structure of NHS Scotland be further simplified by combining the 8 speciality boards into a single unit.
• review overall governance including whether the number of regional board members should be reduced from up to 28 to a maximum of (say) 15; propose more effective recruitment and development for chairs and non-executives; ensure that there is diversity of thought, experience and background on all boards; whether each regional health board should include a member of staff who is not part of the senior management team; whether the remuneration of board members should be increased to reflect their responsibilities, replacing the daily rates element with fixed fees; strengthen whistleblowing to give concerned staff direct access to the non-executive members of boards.
• working with experienced consultants, review digitisation opportunities to investigate the application of artificial intelligence to do more for less; and consider how data analytics and performance indicators could best be used to monitor healthcare quality, identify areas for improvement, and inform decision-making at all levels
Where appropriate, Working Groups should consult with, and take advice from, the Royal Colleges, including GPs.
To reflect the urgent need for reform, a timetable of no more than 24 months would be set for publication of a set of proposals and recommendations. Hopefully, they would form a constructive platform for the government of the day to mould as it sees fit.
Sir Ewan Brown CBE FRSE has served on the boards of listed and private companies, universities and charities. He is the author of Corporate Ego, which describes the spectacular fall from grace of seven prestigious Scottish companies – Burmah Oil, Ivory & Sime, Lilley, HBOS, RBS, Johnston Press and Standard Life; and he identifies major failings in governance as the common cause. Ewan contends that governance in the public sector, and NHS Scotland in particular, is not fit for purpose.