We need change to avoid perpetual crises and maintain an equitable, universal NHS

I want to start with a traditional happy new year wish to you, but right now it looks like it is not going to be a good one for Scotland, especially for those of us working in health and social care where we continue to drift from one crisis to another as we seek to provide the care our patients seek.

As a country we have got ourselves into a bit of a rut with healthcare, and it is not clear to me how our politicians plan to get us out of it. The source of the problem goes back 20 years or more of poor strategic decisions. I don’t think it is fair to single out the present Cabinet Secretary for Health and Social Care for how we got here, but clearly he and the First Minister do currently hold the responsibility for finding a way out of this situation and right now I’m not convinced a clear plan exists. There are just so many other pressing problems and distractions preventing them from focussing on the long-term solutions required, it may just be in the ‘too difficult’ box, one they hope will come all right if they just sit tight and deal with today’s acute problems. I don’t think so. For sure, the pandemic and cost of living crisis have had a major impact, but these are things that we will over-come in the medium term. The fundamental healthcare problems are the underlying issues that need addressed, and our current health and social care strategy simply do not add up and will not find a way out. Without a policy change we will continue to drift from crisis to crisis. And while the pandemic did not help, it was not the cause of the situation, rather it merely brought the situation to a head and exposed the inherent weaknesses in the current policy direction.

The BMA are calling for a national conversation with the public on the future of our health and social care system, something I fully support. Some might say it is an easy thing to call for, harder to deliver on. Undoubtably it is an uncomfortable conversation for politicians, particularly those in power to oversee with the inherent need for us all to face facts and be realistic about what we need and balance that with what we can afford, or perhaps more accurately what we are willing to pay for through general taxation. The reality is not everything will be affordable, so what do we prioritise? We are clear care needs to stay free at the point of need – but given how many people are now going private to avoid long waits, how do we protect that founding principle, while delivering what we need from our modern day the NHS?

Our population’s expectations have changed out of all recognition since the early NHS days, they have been led to believe that if a treatment is seen to be effective and is available somewhere in the world, it should be available here too. We have significantly underinvested in community care and fallen to the pressure to adopt new high-tech treatments for a few at the expense of getting the absolute basics of care right for the majority. What we need is to bring resources ‘upstream’, closer to where patients live. There is good evidence with more district nurses, health visitors and GPs we can prevent more activity ending up in hospital and with better support packages for paid carers we can address the delayed discharge problem that is holding up admission from A/E. What I believe most patients want more than anything are clinicians that have the time to care, to listen and explain, who show compassion and provide continuity. We are so often failing on many of these through no fault of the doctors themselves – who are simply faced with having to apologise for the many and various failings of the system as a whole.

The current policy direction results in ends that do not meet, patients get frustrated at their inability to get basic care and the system often resorts to squeezing the workforce for efficiencies, reducing time to care and other unintended consequences that can further exacerbate the crisis. The workforce is the largest single cost, but also the single most important resource. This pressure is adversely impacting on staff retention (and combined with some disastrous pension policies from the UK Treasury) and is compounding the service provision difficulties.  I’m not suggesting that workforce planning is easy with so many confounding variables, but we have not done well with a very short-term planning approach that has been particularly laid bare by Covid.

If we carry on without policy change then the health inequalities in Scotland will further widen as those with the means to do so will increasingly go private for parts of their care. For general practice without change I anticipate the rise of large doctor-light salaried practices in urban deprived areas, while more affluent areas continue with the traditional model further widening inequalities.

So, my message to the Scottish Government for 2023 is they must act now to review the strategic direction of our NHS. Whatever we do, it will take some years to turn this NHS ship around, but it must change if we wish to avoid perpetual crises and aspire to maintain an equitable universal NHS that meets the needs of the majority. 

Dr Andrew Buist is Chair of BMA Scotland’s GP Committee

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