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6 July 2017

Scotland’s NHS has a lot to teach the rest of the UK, but it’s still heading for a crisis

A new report praises the country's health service, but politicans still need to ask the tough questions. 

By Chris Deerin

The rising cost of drugs, increasing demand from pushy patients, an ageing population, and the over-medicalisation of some conditions have combined to exert extreme financial pressure on the NHS. There is, usually, a pill for whatever ails you, you’re determined to have it, and it costs. None of this is going to change any time soon.

Scotland, the sick man (and woman) of the UK, has additional challenges. Life expectancy for its males is 77, up from 73 since the turn of century, but trailing England’s 79. Scotland’s women have seen their lifespan increase over the same period from 79 to 81 – however, south of the border the figure is 83. You will also live longer in Northern Ireland and Wales than in Scotland.

Dig deeper and the stats don’t get much more cheering. “Healthy life expectancy” in Scotland is just 60 for men and 62.5 for women. While there was a reduction of 36 per cent in premature mortality caused by illnesses such as cancer, heart disease and strokes between 1994 and 2015, 65 per cent of today’s adults are overweight, with 29 per cent classed as obese. There has been almost no change to these figures since the start of the millennium, and there continues to be a clear link to deprivation. Eighteen per cent of pupils in the first year of primary school in Scotland’s most deprived communities are overweight, obese or severely obese compared with around 11 per cent in the least deprived.

Then, famously, there’s the booze. We Scots still knock it back like there’s no tomorrow (or if there is, it will announce itself with a raging hangover). Alcohol sales are a fifth higher in Scotland than in England and Wales. They have also increased over the past two years, after a fall between 2009 and 2013. Alcohol-related harm is a serious problem: there are around 22 deaths each week due to alcohol misuse, and an average of 674 hospital admissions. The stats show, miserably, that both remain much higher than they were in the 1980s.

This gives some idea of the scale of the challenge faced by those seeking to improve the nation’s public health. Whether you’re a politician, a medical professional or a civil servant, making a real difference is a daunting prospect.

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I felt some sympathy for Nicola Sturgeon as she hailed the findings of a report issued on Wednesday – the 69th birthday of the NHS – that suggested methods used by the health service in Scotland should be studied and adopted by other parts of the UK.

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The Nuffield Trust research – it will produce similar documents for the other constituent parts of the country – praised the “altruistic professional motivations” of frontline staff. And it said that the nation’s smaller size allowed for a more personalised service than in England: “better ways of working are tested on a small scale, quickly changed, and then rolled out. This is overseen by a single organisation that both monitors the quality of care and also helps staff to improve it.” This was contrasted with an English system “with a tendency towards too many short-term, top-down initiatives that often fail to reach the front line.”

But it wasn’t all good news. The Scottish NHS is in major financial trouble, found the researchers. “The need for savings is at least as great as for other UK countries, and health boards are struggling to find ways to deliver them. Limited national planning for the next few years and a polarised, hostile political context make an honest national debate difficult.”

There are, it goes without saying, many clever and committed people working in the health service, and it works wonders on a daily basis. But the quality of the political discussion is considerably less impressive. Among senior Scottish NHS figures, the overwhelming view is that a big, open debate is needed about the future of the nation’s healthcare before the system reaches full-blown crisis point. It must confront the hard questions, the growing pressures and the serious financial constraints that will only intensify in coming years. New priorities must be set, and should be decided based on as broad a consensus as it’s possible to reach. Some of the most challenging and uncomfortable ideas are coming from within the NHS itself.

Because the SNP runs a minority government in Edinburgh, it has found it difficult to pursue policies that would prove controversial (which is pretty much everything when it comes to healthcare). The opposition parties will often oppose for the sake of opposition. This makes it impossible to, say, close hospitals or wards, even if there is a strong clinical reason for doing so.

Then there is the Nationalist obsession with providing as many services for “free” as they possibly can. Everyone living in Scotland gets free prescriptions, regardless of wealth or income. “Should this really be the case when you can buy paracetamol in the supermarket for 16p?” says one doctor. Eye tests are taxpayer-funded, too. In England, the government has smartly asked providers such as Boots to pay for the tests as a loss leader, on the basis the patient/customer will then be likely to buy spectacles or contact lenses in the store.

With talk of lifting the public-sector pay cap, should the NHS maintain its “no compulsory redundancies” policy? With the state pension age scheduled to rise to 67 by 2028, should funding of free personal care for the elderly still begin at 65?

Would interventions such as a sugar tax save money in the longer term by bringing down obesity? And what about wider public policy. “Should the A9 road be dualled when the health record in our major cities is dreadful and the money could be spent there instead? It’s about priorities,” says one health service policymaker. ‘Equally, we know that adverse childhood experiences have a massive impact on life prospects so why not spend more money in areas such as early intervention rather than on free prescriptions?”

The SNP has shown a thirst for setting national targets, some of which are more useful than others. An analysis by the former chief medical officer Harry Burns of the plethora of “targets and indicators” is due soon. “A number of them are not necessarily helping us, and are of questionable value,” says a source. “The 12-week treatment guarantee, which has been turned into a law, is a case in point – if a clinician thinks 16 weeks is safe why spend the money on making it 12 weeks? Scotland is the only country in the world with such a guarantee.” Given the financial constraints, can Scotland afford a drug misuse target that 90 per cent of people should be seen within three weeks?

Some warn that a discussion about charging for additional services will have to be returned to sooner rather than later. The precedent is dental treatment, where most people already pay a contribution. Co-payment by the better off, to free funding for those on lower incomes, is also mentioned. And then there’s the thorny issue of rare drugs and end-of-life care: whether someone with no quality of life should be kept alive for an extra two weeks at huge cost.

If patients and taxpayers are to be asked to show an increased level of understanding and maturity, the same is surely true of politicians. Given the awfulness of Scotland’s health record, there is no more important issue facing the nation. So let’s talk about it.