Brian Taylor: So you want to see big changes in the health service? Join the queue

The NHS is struggling like never before
The NHS is struggling like never before

POLITICIANS in search of a cheap round of applause – a not uncommon occurrence – can generally rely upon three little letters.

Not SAS. That was Michael Portillo in a rather curious Conservative Party conference speech.

No, those lauded letters are NHS. Frequently delivered as “our marvellous NHS” or “our wonderful NHS.”

Properly cajoled, the customary audience response is to whoop and, indeed, cheer.

All the while, our enthusiastic onlookers are quietly asking themselves: “Is our NHS really marvellous or wonderful?”

The answer, of course, is no. It is in critical condition. Covid, of course, made matters much worse – but there are also longer-term, structural problems.

I have nothing but the highest praise for those who care for patients and their anxious families.

However, we need to lose the atmosphere of awe. The NHS is simply not working, north or south of the Border. We need to face that frankly, without in any way belittling those who strive to make it work.

Such, presumably, was the motivation of those NHS managers who indicated, in minutes leaked to the BBC, that they had a “green light” to examine ideas which were previously regarded as off limits – such as charges for wealthier patients.

The universal political response? How very dare they?! Up with this we will not put. Our NHS is marvellous. Wonderful, indeed.

My own response? Not sure that works – but thank goodness someone is prepared to look at reform.

Or do we just accept a system where ambulances are delayed, where A&E units are full to bursting, where patients are lodged in corridors for hours, and where one in every seven Scots is on a waiting list of some kind?

As The Herald disclosed, a group of Scottish GPs suggested to a medical conference that there might have to be a fixed consultation fee for wealthier patients “in a bid to reduce demand.”

Not certain such ideas would save much unless the charges for the wealthy were prohibitively punitive.

Which could be viewed as somewhat unfair, jeopardising the very social and fiscal solidarity upon which the health service depends.

In essence, we have two choices. We can change the method by which health care is funded or we can seek to lessen or divert demand.

Broadly, there are four methods of funding. Britain’s NHS, where cash comes from general taxation; mandatory deductions from payslips to cover health care; universal insurance where care may be provided by the private sector; and pay as you go.

I discussed this with Mark Hellowell, the Director of the Global Health Policy Unit at the University of Edinburgh.

He said that co-funding – or charging some patients – could have an impact but was likely to be limited, partly because such systems were frequently accompanied by multiple exemptions.

In addition, he noted that systems which, in effect, involved deterring patients from seeking primary care might end up causing problems – and costing more cash – if these patients later presented to hospital with more serious problems.

Dr Hellowell said that, on balance, he might favour a system which ear-marked or hypothecated funds raised for health care.

That is because international evidence suggested that folk were more inclined to tolerate such levies if they knew that the cash was going directly to health care. However, he conceded that he was probably in a minority within the academic community on that one.

In essence, there are problems with every system of funding. For example, workplace deductions will require an additional system of cover for those who are not employed.

I also think there is a structural, political problem with changing our funding method. From habit and utility, we are, understandably, thirled to the system of universal provision.

However, it has its own problems. Chief among which is that we may tend to undervalue – and over-use – something which does not come attached to an evident price tag.

We may resort to NHS care too readily. Hence the current Scottish Government appeal to people to consider whether they really need to go to A&E.

If we do not charge for access, might we charge for ancillary services? There are still prescription charges in England, although they have been scrapped in Scotland.

Two points. Reintroducing prescription charges in Scotland would be politically damaging for whichever party made the attempt. Further, the exemptions and the attendant bureaucracy might mean relatively little would be saved.

Might we then curb costs in other ways? Perhaps by restricting the availability of new medicines? There are clear limits to the equity – or efficacy – of such a move. Although, in practice, drugs are already assessed, with a balance between cost and likely clinical value.

What about another idea from the leaked paper? Sending patients home more quickly?

In reality, that brings us right up against another huge issue which was to the fore at Holyrood this week. The subject of social care.

It is universally recognised that one way to ease blockages in the hospital system would be to free more beds by discharging patients. That would also ease strain on A&E – and would be beneficial throughout the system.

However, to do that, we need a much better system of social care. This week, Holyrood’s finance committee warned sharply that plans for a National Care Service lacked cost precision.

As I have noted here previously, some also fear that the new service might aggrandise management without necessarily improving the service where it is needed, on the ground.

Another point. Say we divert more money to the NHS. What would we spend it on? More staff and more skills would be welcome.

But recruitment already faces problems, partly because of poor workforce planning in the past. And Brexit scarcely helped. Only this week, Labour’s Anas Sarwar spotlighted staff shortages in Tayside’s oncology service.

Splashing out cash now will not work immediately. That will take enhanced training, effective recruitment – and a period of years.

Ideally, we need greater investment in return for efficiency savings and reform. We need better social care. We need constraints on demand, where possible. And we need improved recruitment.

For all of these, we will have to wait. But then, in the health service, we should be good at that by now.