By Alasdair Galloway

As regular readers of Talking Up Scotland will be well aware John and Stewartb have long and honourable records of showing how much better the NHS in Scotland perform (ambulance waiting times, A&E waiting) compared to the NHS in other parts of this sceptred isle. As well as this valuable service they regularly call out claims to the contrary – misreports – often from the BBC and the Herald.

Let me be quite clear that I have absolutely no problem with this, and in fact agree fully with both. And yet …..and yet …. Can we honestly say the NHS in Scotland is what we look for or need? It might be said “well its better than elsewhere”, but the evidence of unfilled posts is there. My, at the time, General Practice was sending out texts on an increasing, though still exceptional basis, telling us that the practice was closed to all except emergencies, so if the appointment you had waited four weeks for was due that day, then tough!

How strong are rebuttals which major either on “historically” high expenditure or on providing funding for more to be employed in the NHS? For sure they cannot be ignored, but they don’t tell the whole story, do they?

For one thing, simple example, if all employees have had a 10% rise then there is a need for the employment cost budget to increase by 10%. Nothing really has changed.

Likewise the argument that funding is available for however many additional staff, if there is not a sufficient number of trained staff in that specialty. Its like going to the shops with your pocket full of money to buy something you know they won’t have. There is a need to plan the NHS workforce. We need to examine the age profile of our population of GPs, and to put in place training places from undergraduate, all the way through to GP training for sufficient numbers so that there are enough GPs to provide the kind of service that we want. And, just to be clear, that will take something like 10 years to have maximum effect. Until then do we continue to raid less developed countries who need all the doctors they can get?

But, to get to the nub of the problem, what kind of NHS do we want? Our worst nightmare should be its privatisation for financially it makes no sense. Private sector involvement depends on there being enough inefficiency that can be removed from the current system so that not only is the cost to the public sector reduced, but they can make the kind of profit level that they seek. Instead they tend to focus on creaming off the wealthier clients, or those so desperate to have their condition treated that they are prepared to pay (ie not very wealthy, but not poor either).

England, of course has pursued this direction, and it can hardly be an accident that David Cameron, while still PM refused point blank to say what proportion of the NHS budget was taken up by the costs of administering the market that has been set up there. Then we pay more for less, but are part of the more efficient private sector. Ha ha!

So, what is my heresy?  That heresy is that attention needs to be paid, not just how much we spend or how many we employ, there is a need to attend to how we organize the NHS. Over the last 12 months I have had to make more use of the NHS than I would have thought possible, and most certainly desirable. One thing that has struck me during the manifold appointments I have had is that the system seems to be stuck on “slow”. Appointments are seldom offered quickly; tests aren’t always carried out soon after the consultation and the results are often just as slow to come through.

Why this is happening I am unsure. However, I suspect the strain of Covid continues to have its effect in that doctors and other staff are determined not to go back to the pressure of that time, but rather to exercise more control over their working environment. If the system on any one day is dealing with a smaller number of patients (obviously not including emergencies) than before, then clearly, all other things equal, it is setting itself up for patients waiting for treatment, queues and the other things the BBC/ Herald major on.

This clearly shows that if we want our NHS to be what we want it to be, then we need to increase expenditure. For instance, if the above conjecture is correct and has led to a decline in patient treatments in any one day of, as an example, 10% then resources need to be increased by that sort of sum as well.

So, more doctors, nurses and every other kind of medical staff. But also more equipment, more buildings. The issue, in short is not as simple as budget size as politicians confront each other with the charge “mine is bigger than yours”. The retort to this is, as often before, it depends what you do with it. In short, the debate about the NHS has to go further, critical as they are, than budget or even number employed.

There is need to consider whether the system is set up to be as effective as it might be, which is not the same as “efficient”. Efficiency is a simple input:output measure, so that if with 100 units of input I produce 80 units of output compared to your 70, I am more efficient. To a considerable degree, I would contend that efficiency has loomed too large in the minds of decision-makers. However, as we seek to extract the last few drops of juice from the system, perhaps this is inevitable. But, it is clear to me that the primary influence should be effectiveness – is the NHS providing the service that patients want? Is it organized, is it timeous from the point of view of the service user? None of that is measured directly by budget or even numbers employed.

In conclusion, the difficulties of creating an effective NHS, yoked to the UK, are all too obvious. In particular, the difficulty is of doing these things in a debate, in a context where tax is a dirty word, where Douglas Ross’s Conservatives can complain about recent tax increases in Scotland at a time when taxation overall in the UK – determined, remember by his party at Westminster – is at a historic high with ne’er a shred of embarrassment.   

As I have argued here before if we want high quality public services – not just health, but education, the police and all the other public services particularly where there is a direct interface with the public – then we need to be clear that we will be required to pay high quality taxes. If that means paying tax in Scotland at a higher rate than in England then that is the price to be paid for fee free HE, no prescription charges, Scottish Child Payment and so on. But, if such services are provided in a way that is not as effective (in the above sense) as they might be, then much of the positive effect is lost.