Chinese general Sun Tzu —
“Strategy without tactics
is the slowest route to victory.
Tactics without strategy
is the noise before the defeat”
The NHS was founded in 1948 – a year of bread rationing and rickets. Polio, diphtheria, whooping cough, tuberculosis and measles led to many deaths.
Fifty years on, when Labour became Scotland’s first devolved administration, Professor David Kerr was asked to lead a review into the NHS. His comprehensive report focused on telemedicine, unscheduled care, integration & innovation, partnerships & local needs and separation of services. The report was widely welcomed by all parties – but was sidelined when the SNP became the minority government.
In 2010, the SNP invited Campbell Christie to head a Commission into the future delivery of public services. His well-evidenced report, which was based on the principles of empowerment, integration, prevention and efficiency, recommended a framework of priorities and was once again widely welcomed by all parties.
It was a great opportunity for inspired political leadership to envelop Kerr’s practical recommendations within Christie’s robust framework – and effect meaningful reform. However, an independent budget review, which occurred around the same time, focused on managing major squeezes in public spending and overshadowed Christie’s broader vision.
The Commission had emphasised the need for a radical reform of public services, highlighting that health and social care should be integrated to better empower people and communities. It criticised existing systems for failing to sufficiently enable individuals and for funding models that disadvantaged smaller providers. Christie advocated for preventative, collaborative and asset-based approaches designed with, and for, individuals, to reduce inequality and improve outcomes.
Scotland legislated in 2016 to integrate health and social care into a single system managed by thirty-one integration authorities. This brought together NHS Scotland and local authority services designed to improve care by focusing on anticipatory and preventative support, enabling people to live independently and improving service responsiveness to community needs. Since then, the focus has not shifted sufficiently towards preventative strategies so that significant spending is still directed towards acute care and hospitals.
There is a consensus at Holyrood that the health service in Scotland is out of control and in need of reform. Recent highly critical reports by Audit Scotland have included:-
• “Regional NHS boards are expected to deliver services well beyond the capacity of their budgets.” and
• “Patient safety and experience are being compromised due to overcrowding, lack of privacy, poor building conditions and workforce issues.”
More positively, there would appear to be key areas of broad political agreement:-
• that whatever reforms are introduced, it is essential to continue to provide the highest possible levels of clinical care and patient safety.
• health provision and social care services should, as far as possible, be aligned.
• the principle of “free at the point of delivery” should continue to be observed; but with a reality check that because demand for access to health services cannot be capped, actions will inevitably be needed on the supply side.
• the need to embrace innovation and digital technology to improve efficiency and make better use of public funds.
Given this, why is no mature, constructive debate taking place about NHS reform and the need to secure a sustainable basis for social care services?
Is it
• apathy?
• because it is all too difficult?
• concern about how trade unions would react?
• because there can be no compulsory redundancy in the public sector?
• that it doesn’t fit with the five year Holyrood electoral cycle?
• worry that the electorate don’t want politicians interfering in a much loved institution?
• lack of political will/leadership?
• an unwillingness of political parties to work together?
• complicated by the need to address social care in parallel?
• most/all of these?
Donald Macaskill, chief executive of Scottish Care stresses that social care is in a “deep and unsustainable crisis” requiring “significant investment, systemic reform, and valuing of the workforce to meet rising demand and ensure quality care”. He criticises the Scottish budget for focusing obsessively on the NHS at the expense of social care, leading to funding shortfalls that threaten care service sustainability, closures and job losses.
NHS 2048 invites contributors to outline the changes they think can improve and preserve Scotland’s health and care services. My observations have included:-
- The need to map a national care service and its relationship to best align with the NHS.
- 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 NHS Scotland in the embedding of social health and care in the community?
- Integration of health and social care services – if approved by the Scottish Parliament – would add complexity to reform and create major structural challenges. Whether there is full integration or just greater co-ordination than at present, there is the need for strong, transparent, accountable and best-practice governance.
I have also suggested that political parties should take a bipartisan approach to NHS Scotland reform and social care provision in the national interest. There would have to be compromises on some strategic issues including NHS and social care alignment, as well as on structural issues such as regional boards and workforce planning. However, with goodwill, none of these should be impediments to change. Cross-party action for the common good is an imperative for a restored and strengthened NHS, improved social care services and, thereby, a healthier Scotland.
While waiting for this to happen, there are specific steps that could be taken to shift the balance of funding from the NHS to social care. The following is one of these.
Health service costs
NHS Scotland’s 2023/4 operating costs were £17.2 billion and comprised:-
1. Hospital Services
£9.7 billion – 56.5% of total operating costs
- Inpatient and Day Case Services: Care provided to patients admitted to hospitals, including surgeries and treatments requiring overnight stays or same-day discharge.
- Outpatient Services: Consultations, diagnostic tests, and minor procedures that don’t require hospital admission.
- Accident & Emergency: Immediate treatment for urgent and emergency health conditions.
2. Community Health Services
£3.7 billion – 21.5% of total operating costs
- District Nursing: Provided in patients’ homes or community settings.
- Health Visiting: Support and advice for families with young children.
- Allied Health Professionals: Physiotherapy, occupational therapy, and speech and language therapy.
- [The combined cost of staff working in the hospital and community sectors accounted for £9 billion of expenditure – constituting 52.2% of total operating costs]
3. Family Health Services
£3.3 billion – 19.2% of total operating costs
- General Medical Services: Primary care services provided by GPs.
- Pharmaceutical, Dental and Ophthalmic Services.
4. Public Health Initiatives
- Health Promotion: improving public health and preventing illness.
- Screening Programs: Early detection.
- Vaccination campaigns to prevent infectious diseases.
5. Mental Health Services
- Support and treatment for mental health conditions within the community.
- Inpatient Mental Health Services for individuals with severe mental health needs.
6. Capital Expenditure
- Construction and maintenance of healthcare facilities.
- Investment in new technologies and equipment.
7. Administrative and Support Services
- Development and maintenance of health information systems.
- Continuous professional development for healthcare staff.
4. to 7. above account for the balance of £0.5billion.
Health service savings and their re-allocation
My proposal for shifting the balance between the NHS and social care is in two parts:-
- that the NHS is required to make financial savings, principally by reducing headcount; but also in other ways.
- that the funds released are ring-fenced and channelled directly into improving social care provision.
Instructing public sector organisations, such as NHS Scotland, to make savings periodically is a good discipline. It promotes efficiency; it drives innovation and productivity improvements; it strengthens accountability; and it supports sustainable public service delivery.
I have uplifted the 2023/4 operating costs from £17.2m to £20m – which is broadly where I would expect them to be in two or three years when reforms could begin to be implemented. If the increase was spread evenly across the seven headings above, the numbers would be:-
£bn
Hospital services 11.3
Community services. 4.5
Family services. 3.8
Other. 0.4
Total. 20.0
The mandated savings need to be meaningful; but at the same time realistically achievable within a short period of time. For the purposes of this paper, I am suggesting that all parts of the NHS in Scotland be required to make a minimum of 5% savings. In total, this would release at least £1 billion.
The savings would be* :-
£m
Hospital services 565
Community services. 225
Family services. 190
Other. 20
Total. 1,000
* It would be for those with a detailed understanding of health budgets to determine whether this across the board allocation is appropriate
The second part of the proposal is to channel all of the health service savings into social care and use them to address unmet need, staff shortages and low pay, with the priorities being determined by those who have expert knowledge and experience of the care sector.
Ideally, staff losing their jobs in the NHS would be redeployed in providing social care services – although without trade union agreement, this would offend a long-standing public sector policy of no compulsory redundancy. An alternative approach would be to combine voluntary redundancy with a freeze on new recruitment.
Plea
Asking the parties at Holyrood to include wording along the following lines in their manifestos for the 2026 parliamentary election:-
“We acknowledge that reform of health services in Scotland and their alignment with social care services would best be taken forward, in the national interest, on a cross party basis; and we support the principle that savings from health services reforms should be used to improve social care services.”
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.