Across the entirety of its 75 years, the NHS has been a public service under pressure. It has had to contend with issues around increasing costs, government under-investment, a complex and under-pressure workforce, and the constant innovation of new drugs and medical technologies – and yet through it all, it has maintained its position as our most-prized institution. When the public is asked for a view, the response is pretty consistent – the NHS is sacred, give it the funding it needs, and don’t footer with it.
That’s all well and good, but there are clouds on the horizon. According to the Scottish Fiscal Commission, Scottish Government spending on the NHS will need to increase markedly across the next fifty years (increasing from 35% of Scottish Government spending in 2027-28 to 50% in 2072-73) if it is to keep pace with demographic change, new treatments and the increasing prevalence of long-term health conditions. As you might imagine, this is an unaffordable proposition: spending is projected to exceed available funding by an average of 1.7 per cent in each of those fifty years, creating an enormous black hole in the public finances. So something has to give.
That outlook might be less troubling were the NHS not having to confront this difficult outlook from a position of instability. It has still to recover from the tumultuous impact of the Covid-19 pandemic, several Health Boards are in a state of financial distress, huge gaps have opened up in the workforce, and with various high-profile public inquiries ongoing, NHS Scotland is not exactly in rude-health.
There are a few obvious opportunities which will undoubtedly be part of the remedy. Invest in public health, the upstream measures which prevent people from developing damaging (and expensive) health conditions. It means thinking differently about healthcare, developing a health-promoting environment and programmes designed to promote early intervention. We also need to invest in primary care, to make sure that people get what they need at first point of contact. That won’t always be about healthcare or medicine – the public famously unpack a whole host of ailments and complaints on their GPs, many of which can’t be sorted by a scribble on a prescription pad or a referral to a specialist.
Of course, these observations are hardly original and indeed much good work has already been done in these areas. The army of link workers that has been developed over the last five years is a case in point, key workers based in GP surgeries who support patients with the difficult non-medical issues which may be impacting on health (especially mental health): managing personal finance and social security, managing housing issues and so on. Unfortunately, with the foretold financial pressures beginning to mount, it is the very services we need to be investing in which are feeling the sharp end of funding cuts.
Even then, however, redirecting public spending upstream won’t be enough. We need to think differently about how we provide healthcare, and about the culture of the organisations which provide it. Despite its best efforts, the NHS is a hulking, slow and (at times) unfeeling bureaucracy – and that’s despite the fact that it has brilliant, empathic and committed clinicians and managers working within it. The way it is run in Scotland in 2024 isn’t a million miles away from how it was established in 1947[1]: a centrally-managed public sector monopoly, delivered under an ethos of command and control, pulled by politics towards short-term targets. It’s a 20th Century institution struggling to come to terms with 21st Century needs.
Of course, many will defend the current system – the NHS should be directly accountable to Scottish Ministers to deliver national consistency. But that governance arrangement demonstrably fails to overcome postcode lotteries. For example, according to Public Health Scotland, there are nearly eight times as many people per capita getting knee operations in one Health Board area compared with another.[2] So a national system does not equal equality of output. Two Health Boards, with the same governance arrangements, the same national targets, the same ‘once for Scotland’ policies – yet huge variation in service outputs and patient experience.
That’s not to say we should follow the NHS in England, which has flirted with internal markets and competition and private sector interests that have been far too commercial for our sensibilities. Not many in Scotland would look south of the border for inspiration. But at the same time, we can’t allow our general nervousness about market-led healthcare to merely reinforce the status quo. The NHS in Scotland needs to be rethought and rewired. Might there be merit, for example, in extending the Self-Directed Support legislation to give patients more choice and control over their healthcare? If it’s delivered free at the point of use, then what’s the problem? Why is it that we think that’s a good approach to supporting people to access social care to meet their long-term needs but not their healthcare?
We need to challenge the NHS as a public sector monolith by thinking of healthcare as a complex ecosystem consisting of a range of public and third sector bodies working in partnership in support of the public good. We need to break-out of the ideological prison we have built in Scotland which equates public service with the public sector. Indeed, some of the best public services we have are delivered in the third (not-for-profit) sector, rather than through public institutions. The highly respected Feeley Review notes that when it comes to community based services, quality is generally higher among third sector providers, when compared with the public and private sectors.[3] The idea of ‘commissioning for the public good’ may sound anodyne, but it could have a radical application, were it applied to the healthcare sector. It could mean expanding on partnerships between the NHS and our leading charities, for example. We already have some great, if isolated, cases to draw on. CHAS, which provides specialist hospice care for children, is unremittingly brilliant in the medical care and family support it provides. It is part-funded by the state, part funded by the charity itself (through fundraising and other income generating activities). Or again, the William Quarrier Scottish Epilepsy Centre represents one-of-a-kind in Scotland: a specialist hospital for the assessment and treatment of complex epilepsy delivered by a charity and funded by NHS Scotland.[4]
These models of delivery are able to benefit from the best of the NHS but also add the value of the third sector. Able to operate without the dead hand of bureaucracy, they have been able to exhibit innovation and fleet of foot that often eludes mainstream NHS services. Now we’re not arguing that all healthcare provision should follow these models – far from it. I merely point out that when the NHS challenges its own out-dated operating model in favour of something a bit different, then little pools of possibility begin to grow. The NHS needs to be freed from its political straitjacket, to become more autonomous, with accountability pushed down to the local level. Then, and only then, will we begin to see a brighter future take shape.
Dr Ronald Culley has been CEO of Quarriers since April 2020. He previously worked as Chief Officer of the Western Isles Health and Social Care Partnership.
[1] Section 12 of the 1947 Act, Part II Section 12 stipulates: ‘Subject to the exercise of functions by Boards of Management, it shall be the duty of a Regional Board, subject to and in accordance with regulations and such directions as may be given by the Secretary of State, generally to administer on behalf of the Secretary of State the hospital and specialist services provided in their area’. This could easily describe the existing management and governance arrangements of the NHS in 2023.
[2] Public Health Scotland
[3] Page 42
[4] Placements are funded by the NHS and the clinical team is seconded from NHS Greater Glasgow and Clyde.
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