How We Got Here
There is a current pattern around the NHS debate whereby opposition parties criticise the failure of successive recovery plans and the Government accuses them of undermining NHS staff. This is, to put it mildly, unhelpful.
The problems within the NHS go back long before Covid made them worse. In 2011, after a period since 1997 of improvement, the SNP government made a number of bad decisions. The worst were to reduce the medical student intake by 8% between 2011 and 2014, and to further delay the Calman Paulson Report of 2004 which proposed the establishment of a graduate entry scheme. This scheme was finally introduced in 2018.
The consequence has been to substantially increase medical workforce vacancies in senior roles, as GPs’ and consultants’ training is a process which takes 10 or more years. There was also a 20% cut to nursing student intakes, a 40% cut to midwifery student intakes and the closure of three midwifery schools. These decisions were to have a lasting effect. At the time, as shadow public health minister, I vehemently opposed the cuts. I cited a growing and ageing population, and increasing multi-morbidity.
The hubris of the government, which had an overall majority, was such that it passed a law which said no Scot should wait more than 12 weeks for in-patient or daycare treatment. This has never been met in any year since enactment and the law has been broken for over 1,000,000 patients in the ensuing 12 years.
But apart from these errors, the elephant in the room – then and now – has been social care. This despite the introduction of “free personal care” following the Sutherland Report in 2002, which was really only a sticking plaster for a fundamental problem. Labour proposed a Beveridge-style commission in 2012 to examine in a non-partisan way the fundamental problems facing health and social care. This proposal was rejected as taking too long. In 2015, the government promised to end delayed discharge, which has not happened. All these factors contributed to a situation in 2019 where only two out of eight NHS targets were met.
No-fault Compensation
In 2009, a commission on “no-fault” medical injury compensation was established, chaired by Professor Sheila McLean. It reported on the options for implementation, which were then consulted on extensively by the government. However there has been no progress since 2014. The result is higher levels of litigation. Some cases of birth injury have taken more than eight years to settle. Clinical negligence claims under the CNORIS scheme (“clinical negligence and other risks indemnity scheme”) exceeded £600 million in 2023 – more than double the £250 million reported in 2014 (the increase is in part due to adjustments under PIDR, (personal injury discount rate), which sets compensation at a level which takes into account future costs and returns on investment).
Attempts at Reform
The arrival of Covid became a classic example of Warren Buffet’s maxim on investment: “only when the tide goes out do you discover who’s been swimming naked.” Despite the heroic efforts of its staff, NHS waiting lists burgeoned. In September 2024, the total number waiting for inpatient and outpatient treatments reached over 725,000, the highest figure since records began.
One of the main drivers for reform was the Christie Commission Report. Its emphasis on integration, involving communities, and a focus on prevention is as relevant today as when it was published in 2011. If Campbell Christie were alive I think he would be disappointed by the lack of progress.
Audit Scotland has for many years been advocating for structural reform, including integration of health and social care and longer-term planning.
Health and Social Care Integration
Successive governments have attempted integration between health and social care. Between 1997 and 2007, Labour ran pilots of integrated care. These were slow to be implemented, in part due to the problems of separate workforces and management in the NHS and local authorities. A successful pilot in Perth and Kinross was terminated by Tayside Health Board. The SNP government resolved that further voluntary integration wouldn’t work and enacted a law which saw all councils except Highland opt for new Integrated Joint Boards (IJBs). These, funded jointly by NHS boards and local authorities, are responsible for care of the elderly, children and community care. These new bureaucracies have had variable success. In a 2024 report the Accounts Commission paints a bleak picture, reporting widening health inequalities, increasing demand, and a growing level of unmet and more complex needs. There is no significant evidence of any shift from hospitals to the community, which was one of the core purposes in the creation of IJBs. There was also a lack of “whole-system planning”, undermined by the complexity of governance arrangements. The quality of data was inadequate to reliably determine outcomes.
The government, recognising that there were serious problems, proposed a National Care Service. This plan has now collapsed in the face of serious opposition to even more centralisation and the emasculation of local authorities.
Delayed Discharge
The delay in hospitals discharging patients deemed fit has been a perennial problem in managing efficient throughput. There are currently 1,964 out of 13,700 NHS beds occupied by delayed discharge patients {see Care Home Census for Adults, Public Health Scotland 2014-2024]. The resulting pressure on admissions is evident in the sub-optimal and sometimes undignified corridor care of patients. The situation has been made worse by cuts to hospital beds of around 1,200 since 2010. It has also been affected by the decision in 2016 to terminate any funding in future of patients in care homes by the NHS. They must now remain in hospital long-term (there are 50,000 in care homes funded by NHS England, and there were 1,900 funded in Scotland in 2016). The latest statistics show that only 34,113 out of 40,079 registered care home beds are occupied. In 2022, the NHS funded 300 care home beds as an “emergency” measure. But given the situation in hospitals, failure to fund many more and reverse the perverse decision to end such funding in order to minimise delayed discharges is incomprehensible.
Alcohol and Drugs
The government has relied on Minimum Unit Pricing [MUP] and brief interventions in primary care to tackle Scotland’s alcohol problem. Tertiary alcohol services were cut.
Advertising bans proposed in my Members Bill were rejected by the then government. I note that Ireland has now banned alcohol advertising.
Despite criticism of MUP, it has been associated with a significant narrowing of the gap in Scotland’s consumption of alcohol over that of England, along with a reduction in hospital admissions.
On drug treatment we have had the restoration of funding [cut by 23% 2015-17], a national emergency with a taskforce producing new medication-assisted treatment [MAT] standards, and a National Mission. Yet drug deaths remain stubbornly the highest in Europe. In 2002, while I was the Minister in charge of drugs, we opened two drug courts, one of which is now closed. Drug treatment and testing orders [DTTOs] had reached 1,100 per annum but then plummeted to below 500. We piloted the diversion-from-custody treatment centre for women in Glasgow’s Bath Street, as recommended by the McLean review of 2001 in its report “A Safer Way”. This centre was commended as a model for women in the 2012 Angiolini report, “A Better Way”. The centre treated 4,000 women over 20 years before being closed by Glasgow Council with government approval.
There was a failure to fully fund the welcome transfer of Scottish Prison Health Services back to the NHS. Prisons are overwhelmed with drug-using prisoners, with nearly 40% reporting using them. A report in September 2022 noted that opiate substitution treatment was not recorded on the Vision software, only on paper-based records. The number of deaths from drug overdose following release from prison have improved, but remains a concern.
Primary Care, 1999-2024
A further problem has been the substantial reduction in the proportion of funds applied to primary care. This reduced from 9.79% in 2005/6 to 7.78% in 2012/3. Direct spending as a proportion of overall NHS funding reduced from 7.5% to 6.5% between 2017/18 and 2023/24. Audit Scotland also report there are fewer whole time equivalent GPs and the Scottish Government commitment to increase the number of GPs by 800 by 2027 is unlikely to be met. This is against a backdrop of an increase population, significant demographic change with a consequent increase in complex multi-morbidity.
Since 90% of health care, primary prevention and most of secondary prevention takes place in primary care, a more realistic proportion would be around 12%. Even the recent increase was subject to a cut of £65 million in the emergency budget [FOI: December 2022].
One result following the 2003 GP contract has been an inexorable contraction in GP out-of-hours services, with many centres closing. A second was the closure of Saturday surgeries, resulting in up to four days of closure when there were public holidays.
By 2011, the numbers applying to join partnership GP practices had declined substantially. In 2015, I conducted a survey of Scottish GPs and reported an impending crisis in recruitment, with increasing closure of branch surgeries and of partnership practices. These reverted to Health Board-run “2c contracted practices”. By 2024, 2c practices had doubled to 90, while the total number of practices had shrunk from 990 in 2012 to 889.
Not only had funding failed to keep up with hospitals, but the “Inverse Care Law”, first propounded by Julian Tudor Hart in 1971, has continued, resulting in practices in the most deprived communities, which have the greatest demand, receiving less funding than the least deprived.
My 2015 paper, “Fit for the Future – a Challenge to Revitalise General Practice”, proposed implementation of the Greenaway Report on medical education and a review of IT and data collection, with improved linkage to other primary services and hospitals. Many of the issues and solutions which I proposed for primary care were replicated in a Royal College of GPs’ 2019 document also entitled “Fit for the Future”.
The addition of many more health workers to primary care has been a welcome development. But at the same time, some Integrated Joint Boards are disrupting health-centre-based teams, removing district nurses and health visitors from local primary care to distant teams. The result is a significant loss of continuity and cohesion in long-term care. The integrated network, including GPs, district nurses, health visitors, practice nurses, and also social workers, physiotherapists, pharmacists, mental health nurses, psychologists (clinical and health), phlebotomists, and – for some networks – paramedics, is vital. (In the 1980s, the Forth Valley GP Research Group ran a pilot attachment of a social worker to three Stirling practices, urban, suburban and rural, all with differing levels of deprivation. It demonstrated clearly the benefit of early intervention and support from social work alongside health visiting. Unfortunately, despite its evident success the pilot was never followed through.)
Proposals for Structural Changes – Territorial Health Boards, National Health Boards and the Abolition of Integrated Joint Boards
In Scotland, with the recent collapse of the Government’s proposed National Care Service, there needs to be a new vision for the future. Whilst structural change is important if it simplifies governance and increases efficiencies, the disruption of networks caused by major changes can be problematic in the short term.
In 1997, Scottish Labour rejected the English model of separate and competing trusts covering hospitals and health in the community, reverting to a cooperative and collaborative model. The number of boards was reduced from over 40 trusts to 14 territorial boards, but retained the seven special (national) boards. This process, begun under Labour to reduce the cluttered NHS landscape, should be continued. The territorial hospital boards should be further reduced to three mainland boards, matching the successful cancer regions of West, East and North. The island boards should be merged with their local authorities.
On new medicines, the Scottish Medicines Consortium does a great job, and is highly cost-effective compared to NICE in England. It has improved its operation steadily since inauguration. It is faster than NICE and involves patients more. However, having determined that patients should be able to access a new medicine, this decision then goes out to all 14 health boards for a decision as to whether and when such access should happen locally. This creates a postcode lottery.
The concept of Managed Care Networks[MCNs] should be mandatory, expanded and fully supported. For example the MCN for oesophageal cancer in the West cancer region has data which shows clearly that integrated specialist care provided by that MCN had better outcomes than those across the UK. But some boards chose not to join their regional MCN, resulting in poorer outcomes.
The roles of the non-territorial boards, as listed below, should be reviewed.
• Public Health Scotland
• Healthcare Improvement Scotland
• NHS Education for Scotland [NES]
• NHS National Waiting Times Centre
• NHS 24
• Scottish Ambulance Service
• The State Hospital’s Board for Scotland
• NHS National Services Scotland
• Golden Jubilee Hospital
Public Health Scotland should be retained nationally, but the local functions and staff should be based in local authorities, with ring-fenced government funding. Local public health should be driven by implementation of primary prevention, including where appropriate tackling the social determinants of poor health:
• from hospital to community – providing better care close to or in people’s own homes, helping them to maintain their independence for as long as possible, only using hospitals when it is clinically necessary
• from treatment to prevention – promoting health literacy, supporting early intervention and reducing health deterioration or avoidable exacerbations of ill-health
• from analogue to digital – greater use of digital infrastructure and solutions to improve care.
The Golden Jubilee Hospital should become part of the new West Territorial Board.
The 30 IJBs should be abolished and their functions allocated to local authorities with direct government funding. Audit Scotland, in its latest Account Commission Report , refers to big deficits, large turnover in senior staff and little evidence of any shift from hospital to community.
A “National Health and Social Care” oversight body should be established, promoting standards, training and incorporating current inspection of both health and social care. This should incorporate NES.
NHS 24 and the Scottish Ambulance Service should be amalgamated. The State Hospital Board should have responsibility for all forensic services, including medium secure units and prison medical services. I welcome the restoration of female high security beds at the state hospital.
NHS Administration
Another major issue is NHS administration. There are many aspects to this and few are currently good. A Kings Fund “long read” included a survey which showed that one in five people who used the NHS in the past 12 months received an appointment invitation after the date of the appointment. Nearly one in three people said they have had to chase up results of tests, scans or x rays. The same proportion said they had not been kept updated about how long they would have to wait for care or treatment. Close to a quarter of people had not been told who to contact about their care while waiting.
More than three in five people said it made them think NHS money was being wasted, while 56% felt that their time was being wasted, and 55% felt that staff time was being wasted. Although the statistics are for England, there is little reason to believe that the NHS in Scotland is any different. It is no wonder that satisfaction with the health service is at its lowest since records began.
Digitisation may help, while the staff managing appointments need to be more valued.
Prevention
Politicians have extolled prevention over the years. Vaccination programmes and screening programmes have increased. Uptake of the former is good but too many do not participate in screening. However there is little other primary prevention. The concept of tackling the social determinants of health, contained in the Marmot proposals, are critical to improving health and reducing pressure on the NHS. Creating Marmot “cities” is just one part of a need to get serious about applying new funding to community and neighbourhood services – see the Kings Fund blog and NHS England’s Neighbourhood Health Guidelines. This is vital if secondary and tertiary services are not to be overwhelmed. There also needs to be a focused approach to tackling obesity and physical inactivity, such as through the Daily Mile, which is now in 973 Scottish schools.
Primary Care
Primary care is central to primary, secondary and tertiary prevention. Its central role was iterated in the Alma Alta declaration of 1978 and has been updated in the ASTANA Kazahkstan declaration of 2018.
In the UK, the shift to primary and community care, which has long been sought, needs new impetus and proper funding. Neither the 2003 nor the 2018 GP contract has proved satisfactory. In particular, rural and remote areas have been poorly served by the changes. The current situation of unemployed qualified GPs is unacceptable. Meantime, the trend of employing physician associates in any situation diagnosing undifferentiated presentations is causing concern, even when supposedly supervised by a GP. Whilst workforce planning is never easy, it is imperative that this is undertaken as a matter of urgency.
Another example of wasting GP time in Scotland but not in England is the requirement for paper-based prescriptions to be signed manually. GPs spend hours each week on this.
Other Primary Health Professionals
Community pharmacies in Scotland have developed their roles significantly, with a minor illness system, a chronic prescribing system, and pharmacist prescribing, mitigating pressure on GPs. However some scripts cannot be filled because of lack of medicines, causing inconvenience to patients, community pharmacists and GPs. These medicine supply problems have been ongoing since 2013.
Community opticians have also increased their role in screening, monitoring, prescribing and linkage to specialist ophthalmology. Free eye tests, introduced in 2006, have been shown to increase early diagnosis and prevention of sight loss with increased uptake, though more so in better-off communities. [ H.Dickey et al]
Specialist nurses should be attached to either large practices or clusters. Community link workers must be permanently funded and become an integral part of primary care. Social workers should be attached or linked to primary care teams or clusters.
IT and Digitisation
In 2005, as an addiction psychiatrist I was concerned by poor outcomes and a lack of data in the addiction services. I proposed replacing the 25a, 25b and waiting list data with a Single Shared Assessment IT system, which would include audit data of process and outcomes. It was developed on an iterative basis working with stakeholders, and was at beta testing in 2007 when it was terminated. A new system was ordered in 2014 and rolled out to all health board areas in April 2021. This delay has contributed to the poor Scottish record on drug misuse.
Another example of poor procurement is GP IT. In 1984, Dr David Ferguson created a GP software system called G-Pass. In the 1990s, he gifted the system to the Scottish NHS and by 2003 it was being used by 80% of GPs. But it was never developed and eventually needed substantial upgrading. In 2006, a Deloitte Report stated that it was not fit for purpose, but noted that the existing commercial alternatives were also poor.
ATOS, which was the NHS’s preferred provider, offered to take it over and TUPE the existing staff. ATOS would then modernise the platform. Instead, the Scottish NHS opted to make the staff redundant and switch to EMIS and Vision at considerable cost. Now EMIS has withdrawn from Scotland and Vision’s parent company is in administration. GPs are almost universally unhappy with the IT systems or their connectivity to hospital-based portals. These hospital portals were reported by a parliamentary committee in 2012 as failing to communicate with each other.
Another example is when NHS 24 decided to develop its own IT in 2008. Some years later, and with substantial cost overruns, it was piloted but withdrawn rapidly for not meeting patient safety standards.
Cyber security is also a concern due to recent ransomware attacks on some hospital systems, while some hospitals report still using faxes, pagers and paper records.
IT problems are not exclusive to the NHS, and reflect a larger problem in the Scottish Government where there has been a lack of expertise on technology, in part due to a reluctance to pay the necessary level of remuneration.
At government level, unless there have been substantial changes since I was an MSP, there is movement of civil servants from department to department every few years. This
is simply no longer effective. Committees and task forces too often find that the supporting civil servant is changed in the middle of their work.
In the NHS, managers are tasked with meeting multiple targets. This has led at times to “gaming”. The worst example was exposed by a whistleblower in Lothian. A subsequent report by Audit Scotland was carried out because “public trust in the waiting list system had been undermined”, according to Lothian NHS. Audit Scotland found a management culture across the NHS of “managing” waiting lists to minimise missing targets but was unable because of poor data to say whether this practice was widespread.
This was not the first time this had happened. There was a similar abuse in 2005 which led to the current overly complex waiting lists system. Since many NHS targets have not been met across the UK there needs to be careful reconsideration of the target-led approach.
Mental Health Services: Adult, Child and Adolescent [CAMHS]
Mental health services have been under pressure for years. Continuing the funding of the learning disability hospital beds until they were replaced by fully funded new community facilities was a great success but has not been replicated. There is a lack of beds in adult psychiatry. This is evidenced by, for example, the difficulty in ensuring the transfer of mentally ill offenders from prisons (without a visit by the Mental Welfare Commission being completed and the report/findings being gathered and produced, it would not have been possible to highlight the lack of progress in mental health issues in prison that has taken place over a 10-year period since the 2011 report).
The child and adolescent services have been particularly poor. In 2015 it was noted that, from 2008, although there had been an increase in nurses and psychologists, there had only been one additional consultant appointed. At the same time it was reported that 15% of referrals were “rejected” and the non-attendance rate was also 15%. A Freedom of Information request found that out of the 6,250 rejected referrals, almost two-thirds were from GPs who had often already tried other agencies suggested by CAMHS. The frustration of parents was palpable.
The target of having 90% seen within 18 weeks is improving. However, tackling assessment of children who are neurodiverse remains a problem.
Conclusion
In summary, we cannot go on spending more and more on the NHS without radical change. Structures are only a small part of such change. It requires a major shift to primary and preventive care whilst addressing the social determinants of ill-health. It requires a whole-system approach to health and social care.
The NHS is a cherished institution, but Covid exposed what we already knew – that it has the worst outcomes of many countries except the US.
See also Alex Neil’s essay for Reform Scotland on the NHS in Scotland
Dr Richard Simpson OBE FRCPsych FRCGP is a former GP and psychiatrist, and was a Labour MSP from 1999-2003 and 2007-2016. He was shadow Public Health Minister from 2007 to 2016.