It tells you something about the state of the Scottish NHS that senior medics have been reduced not just to thinking the unthinkable, but to saying the unsayable.
Professor Andrew Elder, the president of the Royal College of Physicians in Edinburgh, has gone there. “It is legitimate to ask whether we can afford to provide every treatment available, free of charge and at the point of access,” he said. “If we cannot – which is plausible given the huge increases in medical treatments available – how should we decide what we can provide?”
The clear suggestion is of a health system in which patients are asked to pay for certain procedures beyond their contribution in taxes, or perhaps that those above a certain income be expected to do so.
This is controversial territory which few politicians risk inhabiting. Such is the sacred nature of the NHS that even hinting that aspects of it could no longer be free at the point of need tends to bring a dollop of ordure down on the hinter’s head. Professor Elder is a brave man.
He is also a practical one. The projections for funding Scotland’s health budget in the future are terrifying, and will have a major impact on the cash available for other areas. An ageing population more reliant on healthcare is only one of the issues to be faced.
The present is really no better. It’s not only the Royal Colleges that are worried – as far as I can tell, there isn’t a medic in the land who doesn’t think the NHS is close to falling over.
On Thursday, Audit Scotland published a report on the state of the Scottish health service that only added to the general alarm. Its findings were described as “staggeringly bleak” by Dr Iain Kennedy, the chairman of BMA Scotland.
Audit Scotland found that rising demand, operational challenges and increasing costs have added to the financial pressures the NHS is already facing. “Its longer-term affordability is at risk without reform,” it said, warning that “there are a range of strategies, plans and policies in place for the future delivery of healthcare, but no overall vision”. It called on ministers to work with NHS boards and staff “to develop a new long-term vision for the wider health system by 2025 that sets out national priorities [and] to enable the necessary reforms that will ensure the future sustainability of health services”.
Earlier this month, the Institute of Fiscal Studies (IFS) published a range of statistics that painted the scale of the crisis around productivity and performance in stark terms. Its findings included that the Scottish NHS handled 8 per cent fewer emergency admissions, elective day patients and outpatient appointments, as well as 21 per cent fewer elective inpatient admissions, in April-June 2023 than it did before the Covid pandemic struck. This is despite health spending per person being at least 10 per cent higher in real terms in 2022-23 than in 2019-20, and the NHS employing 9 per cent more consultants and 6 per cent more nurses than in 2019.
The IFS also revealed that the number of patients on the elective waiting list in Scotland has grown by 87 per cent. If the English NHS is in a similar state of disrepair, this is no comfort to Scottish patients forced to endure long waits for treatment. And in any case, England delivered 4 per cent more outpatient appointments than in 2019, while the Scottish NHS delivered 6 per cent fewer.
There is a growing sense of urgency around the need to address what amounts to a full-blown crisis, even if it is one the Scottish government doesn’t yet seem to have fully woken up to. Michael Matheson was forced to resign as health secretary last month due to charging £11,000 in expenses for an iPad bill, racked up by his family watching football while on holiday. His replacement, Neil Gray, will have to get up to speed quickly in one of the most complex and challenging departments in government.
Alex Neil, a respected previous SNP health minister, recently published a report on the government’s approach to NHS reform that was scathing in places about the plans – or lack of them – currently in place.
It needs to “waken up”, he wrote, and devise a comprehensive ten-year plan for the NHS that addresses its manifold problems, which include the need to cut record waiting lists, a huge increase in the recruitment and training of medics, a need for significantly more hospital beds, and improved pay and conditions. “The question is whether our rulers have the necessary wherewithal to implement these changes, or whether they will just continue tinkering at the edges… My message to the Scottish government is that if it is serious about addressing the crisis in the NHS in Scotland it needs to do much more than it is currently doing and it needs to do so now.”
The NHS, like Scotland’s other vital public services, needs a government that is fully focused on reform and not distracted by internal dramas or party politics. The SNP has spent this week obsessing about Gaza and Westminster parliamentary procedure, which is at least a change from panicking about police investigations and the party’s declining popularity.
If in every crisis there is an opportunity, perhaps the clear calamity facing the health service offers a chance to First Minister Humza Yousaf. His is an administration that seems adrift on the tide of daily news headlines rather than one with a clear programme. Yousaf is a former health secretary himself, even if he wasn’t particularly highly regarded in that role by his civil servants and colleagues – why not do what Scotland is crying out for, and what a growing series of experts say is now essential, and make NHS reform his major project ahead of the 2026 Holyrood election?
If he can’t get a grip, then someone else will have to.
[See also: Can Scottish Labour heal a fractured nation]
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