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8 March 2024

How “moral distress” is spreading in the Scottish NHS

In Scotland, medics find they are simply prevented from helping patients in ways they deserve.

By Chris Deerin

I hadn’t come across the term “moral distress” until this week, when it was used by Dr Iain Kennedy, the chair of the Scottish BMA, during a discussion we were having about the state of the NHS

It’s a fascinating if disturbing concept, and stems from the financial and institutional constraints that health workers operate within. Their inability to provide a level of care that they believe is reasonable can lead to them experiencing psychological unease, depression and even post-traumatic stress disorder.

The notion of moral distress first came to prominence during the Covid crisis, when 78.4 per cent of doctors felt they were experiencing it. Dr Kennedy said it remains a live issue today: as the NHS stumbles from crisis to crisis, medics find they are simply prevented from helping patients in ways they wish to or think are deserved.

Such might be an inevitable outcome of Britain’s insistence on maintaining a rationed system of healthcare amid an ageing and sickening population, an explosion of expensive new technology, the rising cost of medicine, and the large gaps that are opening up in the NHS workforce. The tensions inherent in this can be seen in the increasing suggestions from within that a system free at the point of need may no longer be sustainable. The head of the Royal College of Physicians in Edinburgh, Andrew Elder, recently said it was “legitimate to ask whether we can afford to provide every treatment available, free of charge and at the point of access”.

It’s clear that most NHS staff, politicians and voters want to maintain a “free” service. But the problems are mounting and not easily solvable. Wherever you look on the NHS dashboard, red lights are flashing. 

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Statistics released this week show consultant vacancies in Scotland stand at 436 posts, up by 5.8 per cent on last year. The number of posts that have been vacant for six months or more now stands at 238, a 12.2 per cent rise.

It’s not just consultants. In December 2017, the Scottish government pledged to increase the number of GPs in Scotland by at least 800 between 2018 and 2028. Six years on, just 11 per cent of that target has been reached. In real terms, after adjusting for part-time work, the size of the GP workforce has shrunk by 5.4 per cent in a decade as the number of patients registered has increased by 7 per cent. There are gaps in the essential areas of nursing and midwifery, too. According to Dr Kennedy, medical schools are for the first time struggling to fill their student rosters, something that in past decades would have seemed scarcely believable. 

He gave various reasons for this recruitment horror story. These include uncompetitive financial terms – Dr Kennedy’s twin brother earns far more as an engineer than he does as a GP. There is a global market for medics, with better pay and conditions available in other countries, Scotland’s comparatively high tax rates mean some are choosing to work in England instead. The Covid pandemic only highlighted and exacerbated the challenges within a sector that demands long hours and brings with it high levels of stress and emotional engagement. 

“Doctors are voting with their feet and what they are doing is well beyond strike action,” Dr Kennedy said. “They are retiring early, they are reducing their hours, they are emigrating. It’s considerably more attractive now to be a consultant in England than it is in Scotland. Young doctors are making a choice and they just look at the hard facts, the pound signs, they’re going to choose a country that is outwith Scotland.”

The nature of the conversation with patients has changed, too – when referring someone to secondary care, GPs will struggle to say which week, month or even year they will likely be seen. A phone call to the hospital will often provide no enlightenment. 

This comes as little surprise – the stats around waiting times and lists make for grim reading. The number of patients on the elective waiting list in Scotland has grown by 87 per cent since the start of the pandemic. The percentages of patients waiting less than 18 weeks for elective treatment and less than four hours in A&E departments have also fallen substantially since the start of the pandemic. The ambulance service cannot meet its target for reaching urgent patients within eight minutes because of the delays in admission to A&E. Between 10 per cent and 16 per cent of hospital beds are occupied by people who are medically fit to be discharged but are stuck in hospital because of the lack of available social care services and care home beds. There’s been a rise in people seeking help for mental health conditions, but the system isn’t remotely set up to cater for this level of demand.

Perhaps the most damning thing said by Dr Kennedy concerned the approach being taken by the Scottish government to the crisis. “It seems unbelievable that there is no vision, no strategy, no plan for NHS Scotland,” he told me. “Even the small building I’m in here, a medical practice for 10,000 patients, has a written-down strategic plan. To think that NHS Scotland has no vision, no plan, seems quite incredible.” Politicians were frightened to admit how precarious the situation has become, and therefore the scale of the issue was being “hidden from the public”, replaced by a “culture of cover-up and secrecy”. Often, it took the media and think-tanks to reveal the truth.

In 2024-25, the NHS will account for between 35 per cent and 39 per cent of Scottish government spending, a share that has increased sharply over time. All the projections say this share will only continue to grow, eating into the cash available for other important public services. The Scottish Fiscal Commission has warned that health spending will need to grow by around 3 per cent in real terms per year in the late 2020s and 2030 merely for the quality of service to stand still. This compares with around 2 per cent for all Scottish government spending.

It all amounts to a policy disaster, and one that the SNP seems unwilling to confront in any meaningful way. The government instead seems intent on covering itself by cherry picking official stats that paint the national picture as far rosier than it is. This treats healthcare workers, and the population as a whole, with something close to contempt. It’s not just medics who should be feeling moral distress.

[See also: Will the SNP now finally wake up to the NHS crisis?]

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