The reform our NHS really needs

 With NHS reform getting a lot of attention, the Socialist Health Association Scotland has published a discussion paper I drafted that outlines the issues and seeks views on the way ahead. It is vital that those who support the founding principles of the NHS engage in this debate and don't leave it to those who use 'reform' as a code for the privatisation of healthcare.

Nicola Sturgeon’s resignation has reminded everyone that she was the first SNP Health Secretary in 2007, holding the post until 2012. It has to be said she started well, building up constructive relationships with the trade unions. The previous Labour Health Minister, Andy Kerr, did many positive things but could be abrasive. In the main, she continued with the previous government’s policies. Labour had ended the marketisation of the NHS, abolished NHS Trusts, and introduced cooperation rather than competition. She went a little further by outlawing private companies running GP practices, a growing trend in England, and further developed the NHS partnership model of industrial relations. But, overall, it was continuity with emollience.

However, while continuity has its strengths, it also meant tough political decisions were ducked. Nicola Sturgeon binned a report by Professor David Kerr that proposed a shift from hospital to community care, with better social care integration. Consequently, when budgets tightened with austerity, bed numbers fell, but social care capacity did not respond to growing demand from an ageing population. After promising to scrap PFI, they rebranded it. Instead, we got worthwhile reforms around minimum alcohol pricing and free prescriptions, but the significant structural challenges were ignored. The focus on inequality and prevention, recommended by the Christie Commission, is still gathering dust on the shelf.

Now, in the wake of a pandemic, these long-standing issues are biting the NHS with a vengeance. Waiting times have spiralled along with staff vacancy rates, ambulances queue outside A&E, cancer treatment has slowed, drug deaths have doubled, and health inequalities are worsening. Even when they eventually got around to reforming social care, they took a sensible National Care Service plan around national frameworks and turned it into a centralised monster - devouring local government and community services in its wake.  

This table highlights how much NHS capacity has been reduced.

So, it is now left to others to pursue genuine reform. Not Tory privatisation or insurance systems which, as Gordon Brown highlights, would add more costs to an NHS whose spending levels have not matched similar countries. A point seemingly lost on a particular Green Scottish Government minister as well.

As for Scottish Labour's new plan to merge health boards, that is fine as far as it goes. I recall coming across the same plan presented to a pre-devolution health minister when I worked in the health department. The problem is that merging acute boards makes sense only if you manage community services in another way. We have tried many different ways of doing this since Joint Finance in the 1970s, and none have been a complete success.

An actual reform programme would start by tackling the underlying causes of ill health. It is a national disgrace that men in the most deprived areas of Scotland not only live 14 years less but can expect to spend 35% of their lives in poor health. NHS capacity has to be grown, not cut. That means better primary care, dentistry and more beds in our hospitals. A fully integrated NHS that ends the costly small business model and the growth of corporate dentistry, financed from tax havens. 

A National Care Service based on local accountability, which improves pay and conditions for carers in Scotland, improving the quality of social care and relieving the pressure on hospital capacity. We now have more patients that don’t need to be in a hospital than the number of beds in our largest hospital. We also need proper workforce planning and fair pay and conditions to tackle recruitment and retention in health and social care, ending reliance on exorbitant agency costs, locums, staff banks, and the private sector.

And last but not least, recognising that one size does not fit all in a diverse Scotland. A strategy for rural health care services.

The NHS is on life support. However, real reform must address the underlying pressures, which means tackling health inequalities and social care.

Nicola Sturgeon departs - opportunity, or more of the same?

Nicola Sturgeon's resignation and subsequent leadership contest are likely to dominate the airwaves for a while at least. Personally, I wish her well - eight years as First Minister is a tough shift for anyone. I have had my disagreements with her over the years, but as the STUC said this morning, she was always willing to engage with trade unions, and there was genuine and mutual respect. I will not be joining any celebration, and those who compare this to Thatcher's resignation have seriously lost the plot.

It will be a real challenge for the SNP to replace her and take forward their independence agenda. But, in an uncertain world, economically and militarily, that will be a big challenge anyway. My main criticism of the Scottish Government is the obsession with process over delivery. If you want to build confidence that Scotland could do better as an independent country, then the various delivery problems, including the ferries, recycling and the National Care Service (NCS), need to be managed better. 

The SNP, since entering government, hasn't been known for developing a debating culture. However, even before Nicola's resignation, there were signs that the culture may be changing. As Stephen Flynn, the SNP's Westminster leader, put it, 'there has to be space for people to disagree and to disagree without being disagreeable'. The SNP Trade Union Group has called on the Scottish Government to be more creative with its powers, and they have joined criticisms of the NCS and Freeports.

The Red Paper Collective published the latest edition of their magazine this week in time for the Scottish Labour and STUC conferences. The editorial picks up on these themes, including Stephen Noon's call for a more consensual path for Scotland's constitutional debate. Gordon Brown's Commission at least got the constitutional debate on the UK agenda, even if it offered a limited vision for Scotland. Professor James Mitchell offers a sceptical analysis of the de-facto referendum strategy, which is now up for grabs anyway. As a strategy, it again focuses on the process rather than the case for independence. Beth Winter MP gives us an insight into the different approaches Wales is taking to their constitutional debate.

Alex Rowley MSP, offers some thoughts on how to end Scotland’s constitutional groundhog day. His article is worth reading in full rather than the lurid newspaper headlines. Scottish Labour also needs new thinking on the constitution if it wants to achieve more than simply replacing the Tories as the opposition. He also looks to the Welsh approach for inspiration. He argues that Scottish Labour should make a case for new powers when it is in Scotland's interest.

My contribution to the magazine focuses on one such new power – immigration. This is a crucial issue for Scotland as our population is not projected to increase at the same rate as the rest of the UK. The number of working-age Scots to support our ageing population won’t be available without immigration. Devolved immigration initiatives are not new in Scotland, going back to Labour's Fresh Talent Initiative. However, other countries have gone much further, most notably Canada. Sadly, UK ministers and shadow ministers have not seriously looked at the international evidence and how this can be achieved without the leakage of migrants to other parts of the UK. The Scottish Visa system proposed by the Scottish Government is a good starting point, although it would need more UK cooperation than they may like. On this point, Gordon Brown's duty of cooperation would help.

As Neil Findlay asks in his Red Paper article, 'Where is the mature discussion?' He is critical of Nicola Sturgeon starting a debate that fell far short of what she promised, and the same applies to her unionist opponents. A 51%-49% strategy is never going to deliver a settled position. Nevertheless, he ends on a positive note, hoping that someone in the SNP will recognise that creating a new state based on a polarised, divided community is not a particularly good idea. And that Scottish Labour will equally wake up from its delusions. 

Just maybe, a change in SNP leader is an opportunity to build sustainable change in the same way the case for devolution was made. But again, like Neil, I won't be 12 stone again or achieve a single-figure golf handicap!

P.s. A bit of personal news. I have taken on the role of Interim Director at the Jimmy Reid Foundation this week. I would be pleased to hear from friends of the Foundation who have projects they wish us to take forward.