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

The NHS in Scotland: Public Expectations & Political Delivery – David Belfall

On 27 March 2024, the King’s Fund and the Nuffield Trust published the results of the latest British Social Attitudes Survey, conducted in 2023, showing public attitudes towards the NHS and social care across Great Britain – England, Scotland, and Wales. Some of the most striking findings were as follows: –

  • Overall satisfaction with the NHS was 24% – down from 70% in 2010.
  • 52% were dissatisfied with the NHS – the highest proportion since these surveys began in 1983.
  • 84% of respondents agreed that the NHS has a major or severe funding problem and 48% would support the government increasing taxes and spending more on the NHS.
  • The 2 top priorities cited by survey respondents were making it easier to get a GP appointment (52%) and increasing the number of staff in the NHS (51%). Other priorities were improving waiting times for planned operations (47%) and in A&E (45%).
  • Public satisfaction with GP services – historically the service with the highest level of public satisfaction – fell to 34 %, the lowest level recorded since these surveys began.
  • Only 13% were satisfied with social care – the lowest level since these surveys began. 57% were dissatisfied.

Some limited comparative information is available for Scotland alone, which suggests that attitudes here do not vary widely from the rest of Britain. Thus, the level of dissatisfaction with both the NHS in Scotland and with social care is slightly higher in Scotland than in England but slightly lower than in Wales.

Unless I have missed something, the results of this important survey have not raised a ripple in Scotland. Is this because the results are as expected and not surprising? Nor do the political parties seem to have commented. Is this because they do not know how to react?

Certainly, none of the Scottish political parties are currently offering much to the public on improved NHS performance, nor are they conveying a true recognition of the scale of the problem and the time it will take to secure lasting improvements.

The Political Dimension
Ultimately, the person responsible for the NHS in Scotland is the Cabinet Secretary for Health. The NHS is both a massive, complex business and – not least because of the public resources it consumes – a political football. Few MSPs have any business experience, and fewer still have any significant experience of business management at senior level. They will however be acutely aware of the political dimension.

As Harold Wilson once said, a week is a long time in politics and few politicians have horizons which extend beyond the next election. Our political system does not readily accommodate long term issues – as the problem of developing and delivering the green agenda amply demonstrates. Other long-term issues – including the NHS but also housing and drug misuse – fall into the same category.

Against this background, the post of Cabinet Secretary for Health, while undoubtedly regarded as important, poses challenges rather than opportunities for the aspiring Minister. He or she is much more likely to spend time trying to downplay or excuse failures and avoid brickbats rather than basking in the warm glow of public approval. Nor will he or she be able to shuffle off responsibility for operational matters to, for example an NHS Chief Executive, as Sir Ewan Brown suggests in his NHS 2048 blog. It would be a brave Cabinet Secretary indeed who responded to a Parliamentary Question or an approach from another MSP concerning a constituency case by saying that this was a matter for the NHS Chief Executive and he or she had no power to intervene.

The nature of the Cabinet Secretary’s role – as currently viewed – also explains why (in response to one of Sir Ewan’s other questions) his or her most senior official in recent years has been a civil servant. For such a position the Cabinet Secretary is looking for someone who will watch his or her back, and not create any waves – functions for which traditional civil servants are ideally placed and skilled. By comparison, introducing someone such as a businessman from the private sector would carry risks, since he or she will not be so closely attuned to the politics and the public mood, and might say or do something which departs from the approved script.

Major improvement is clearly needed in the performance of NHS Scotland. If this is to be delivered, an altogether different type of Cabinet Secretary is required. What is needed is a visionary figure who regards NHS improvement as his or her life’s work and is able to convey to the Scottish public that he or she knows what needs to be done and is determined to deliver. He or she would need the unflinching support of the First Minister and a reasonable period in office (say 5 years). Further, that Cabinet Secretary would need to give at least as much attention to the business dimension as to the political dimension. In that respect he or she would need not only the support of an NHS Chief Executive with significant senior management experience (preferably in both the public and private sectors) but also the active involvement and support of a panel of senior business leaders. Judging from his NHS 48 blog, Alex Neil knows what is needed and might have been able to fulfil this role as redefined, but he has left the Holyrood scene. Who else, currently behind one of the Holyrood desks, might be able to do so?

Public concern about the NHS centres heavily on the delays in obtaining a GP appointment, the delays in receiving specialist treatment, the delays at A&E (including the sight of queues of ambulances waiting to discharge their patients), and the delays in freeing hospital beds because of the shortage of appropriate care packages. As regards ambulances waiting outside A&E Departments – each with 2 paramedics per patient – it ought not to be beyond the wit of man to find some solution which is not so wasteful of manpower and resources. In all other respects, however, there is a clear need for more manpower, if performance is to improve. I shall focus on the need for more doctors, though I recognise that similar concerns arise in relation to other health professions.

It is clear – surely – that we have been training too few doctors for a very long time. The shortage of supply has been reduced for many years by importing doctors, especially from the Sub- Continent – which in itself raises ethical issues. More recently it has been much exacerbated by many doctors moving to part time working, others moving abroad after qualification and others retiring early, not least because of a foolish decision about their pensions (now apparently reversed).

We need now to try to overcome this shortage, firstly by increasing the number of medical training places, and then by taking radical steps such as:

  • offering those who gain places at medical schools a contract to pay all their university fees and living expenses during training in return for 10 years work in the Scottish NHS:
  • offering double pay to those GPs who are prepared to work for more than 30 hours a week:
  • providing an incentive for those doctors who are prepared to work on beyond retirement age.

I entirely appreciate that such steps would require substantial additional public funding – a topic to which I will return – and that the powerful medical unions will have views – but steps such as these are what we should now be considering.

As regards earlier discharge from hospital beds to appropriate care packages, this would also require substantial additional funding, plus funding for care packages to delay and prevent hospital admissions. As Alex Neil suggested in his contribution, this will cost hundreds of millions of pounds and will take time to set up, but we should be making a start now. To date the politicians have gone so far as to recognise the problem but have signally failed to come up with a deliverable solution.

In my view the scale of the challenge facing the NHS requires radical change to its structure at least for a 10-year period. The Cabinet Secretary needs to be at the centre of this. I would create a Scottish NHS Reform Task Force, consisting of no more than 15 members, chaired by the Cabinet Secretary, with cross-party representation if at all possible, and including the most senior figures from the health professions and also from the business world. The NHS is the National Health Service, and the Task Force should be unashamedly directive in its approach. Decentralisation, however desirable in principle, should be set aside for the duration of the Task Force’s life.

The Task Force – in effect a supreme NHS authority – would need to be supported by local bodies, drawing in local expertise, but these would be explicitly delivery mechanisms. They would replace the regional health boards, have no more than 15 members each, and might number 4, as Sir Ewan Brown has suggested. The Task Force should also be supported by a Manpower Board given the importance of expanding the workforce.

After 10 years, and assuming that all goes well, the Task Force might then be replaced by a structure more on the lines Sir Ewan suggests. At that stage some decentralisation might then be possible.

Advances in medical sciences mean that, as a result of new and in some cases expensive forms of treatment, people are living longer, are taking up more of the time of health professionals and are living long enough to need expensive care packages. All this means an increase in costs, which can only be borne by the state or by the individual.

Scots who have the means to pay – either directly or via an insurance scheme – already have access to a thriving private health care sector (though smaller than in England). It provides a means of bypassing NHS queues for access to specialist care or surgery. A private GP service is also beginning to emerge. The private health sector can be expected to grow further. Who could blame older people if, in their declining years, they decide to spend their resources on, for example, joint replacements or cataract removal, rather than enduring unconscionable waits for NHS treatment? To the extent to which the private health care sector expands health capacity in Scotland, it is to be welcomed – and indeed is being increasingly used by the NHS to reduce delays for some specific treatments. But its success is an index of the NHS’s failures, and it provides, undeniably, a 2-tier service which benefits the well-off and disadvantages those less well placed.

There are those who would like to see the private health care sector grow further as a means of relieving the NHS and reducing the need for public funding. This may indeed be the outcome, incidental or deliberate, if we do not spend significantly more on the NHS. If the NHS’s performance is not to decline still further, the inescapable fact is that substantial additional public funding is required. This can only be found by reducing other public spending programmes, or by raising the tax take. Given the state of the economy, it would be foolish to imagine that sufficient resources can be found – at least in the short term – to eliminate NHS delays at primary and secondary care levels, but it should surely be possible to find sufficient resources to reverse the current trend.

One option would be to establish a separate NHS levy, within the tax take, which would be spent only on the NHS, so that the public could be satisfied that it would not be used for other purposes. Of course, the Treasury and the Scottish Government Finance department would be outraged by any hypothecation of taxes in this way, but perhaps the time has come to challenge such orthodoxies?

Whether or not hypothecation is pursued, there is a hard choice to put to the Scottish electorate – to accept continuing and probably increasing delays in the NHS or pay more in taxes. Oh, and by the way, spending more on the NHS means spending less on X, Y and Z, and do not expect any quick changes in NHS performance until the necessary changes have been worked through.

Politicians are not noted for putting hard choices before the electorate, preferring to fudge issues and sugar pills wherever possible, but I believe that it is possible that a brave politician with the necessary force of personality, strength of commitment, political standing and widespread credibility could make the case for such an increase in public spending (and therefore taxes) with a reasonable chance of success, given the support which the Scottish public has always expressed for the NHS, and the widespread public recognition that more needs to be spent.

Wanted for Scotland – Aneurin Bevan, Mark 2. Are you there?

David Belfall was Director of Health Policy and Public Health at the Scottish Office (as it then was) for 3 years in the 1990s. He has since served for 5 years as a Non-Executive Director on a regional health board.

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