This article appears as part of the Unspun: Scottish Politics newsletter.
If only one or two parts of health and social care were in a bad way, perhaps fixing it would not be such a fraught task.
But unfortunately, together with colleagues providing a commentary for the Wealthy Nation, Healthy Nation publication, we have identified at least nine areas or aspects of the NHS in Scotland where the people of Scotland are being served poorly, from overall health outcomes through staffing to the provision of primary, secondary and public healthcare.
In the last two decades, healthcare outcomes and productivity in Scotland and the rest of the UK have deteriorated relative to many similarly wealthy countries.
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This should persuade us that the current model of healthcare in NHS Scotland, and arguably the UK as a whole, is outdated and unable to quickly adopt changes in practice that benefit the population it serves.
The Scottish Government’s recently published NHS Scotland Operational Improvement Plan recognises some pressures, but we believe there is an urgent need for politicians to publicly accept that without significant reform, NHS Scotland will remain unable to meet the challenges it faces.
Unless we address financial, structural and cultural issues, the experience needed to restore a high-quality health service will be lost as senior clinicians retire and younger doctors look abroad for their future.
Estimates of the proportion of GDP spent on health and social care in the UK vary between 9-12%, with some other countries spending more, and in many cases less, whilst achieving better outcomes.
Additional spending cannot and does not serve as a cure-all.
The Barnett Formula results in higher per capita funding in Scotland than in England, but Scottish waiting lists for routine surgery are longer than in England.
In short, there can be no doubt that our current structures are relatively inefficient and leading to poorer outcomes when compared to our European peers, irrespective of spending.
Structure and culture matter too. It seems reasonable to state that NHS Scotland is a politicised bureaucracy, with politicians serving it both as the funders and as the protectors of what has until recently been viewed as a national treasure.
Managers who are directly responsible for performance are incentivised to respond to demands from above that may conflict with focusing on delivery of high-quality care by motivated and happy staff.
This contributes to frustration, burn out in clinical staff and what might be described as a ‘toxic’ culture within these organisations.
It is hardly surprising, then, that recruitment and retention is in crisis in almost all areas other than management and administrative roles.
We are short of nurses, laboratory technicians, and all grades of doctors in most specialties.
Competition for medical school places in Scotland is at its lowest ebb, our young doctors are leaving to work in countries like Australia, and more and more nurses, consultants, and other healthcare staff are leaving or retiring early.
Many of the issues outlined above stem from the fact that Scotland (and the UK as a whole) has a remarkably centralised, bureaucratic and top-down healthcare system compared to many of our European neighbours – one which does not place enough trust or responsibility in the hands of either clinicians (as opposed to non-clinical managers) or patients.
Starting to fix these problems means learning from other European countries such as Germany and Sweden. Both countries have different models of how healthcare is funded with Sweden relying on local taxation and Germany statutory and/or private health insurance.
But in both countries, compared to Scotland, outcomes are superior across most areas of healthcare, responsibility for funding and delivery of healthcare is decentralised (with patients exercising choice about where they receive healthcare), there is an allowance for a mix of public and private provision, and there is better retention of staff beyond the age of 60.
These lessons from Germany and Sweden have informed three specific proposals in our essay.
The first is that extending patient choice is essential to ensuring high standards and better patient outcomes.
Second is decentralising power and responsibility within the NHS, with funds more directly following patients which is essential to this devolution of power and underpins many of the other suggestions we have made.
Third is the recruitment and retention of able and motivated people from medical school through to changing job patterns and roles to aid retention towards the end of people’s careers.
The next Scottish Government needs to publicly accept that the NHS is currently unable to deal with many of the challenges it faces and that an honest debate with the public about urgent reorganisation and reform of finances, structure and culture is necessary.
To address these issues, it should convene a commission of senior, independent experts and business leaders, without political affiliation, that can consider the modernisation of healthcare provision in Scotland.
Professor Alan McNeill FRCS(Urol), FRCP(Ed), FFSTEd was a Consultant at NHS Lothian University Hospitals. This article draws on his contribution to the Wealthy Nation, Healthy Nation collection of essays published by the Centre for Policy Studies