This report examines whether the current structure of the NHS is the most effective way of providing health services in 21st century Scotland; looks at the lessons we could learn from other European countries such as The Netherlands, Denmark and Sweden and how they might be applied here.
Like Scotland, all the countries we studied guarantee universal access to health care. The difference is many of these countries have adapted to the challenges of providing modern public health care better than Scotland.
There have been huge changes since the NHS was set up in 1948. People are more affluent, more demanding as consumers and they can expect to live longer, making them more vulnerable to chronic illnesses. At the same time, there have been great advances in surgery, biotechnology and pharmaceuticals.
This has increased pressure on the NHS as evidenced by long waiting lists and times. Previously such problems were put down to lack of money. However, with a massive injection of resources– up by 55% in real terms over the past decade – such arguments no longer hold true. Health spending in Scotland is now higher as a percentage of GDP than in the other countries we studied.
The extra money, combined with central control through a system of targets, has reduced waiting lists and times. But we still lag behind other countries in key measures of performance, particularly in cancer care where our survival rates and cure rates are among the worst in Europe.
The reason is that we are not using the extra resources to best effect. Central control through targets has limits. If waiting time targets are met within existing budgets, there is no pressure to increase productivity or to improve the service for patients.
This approach also denies patients in Scotland control over the health care they receive. Patients have limited choice over where, when and how they are treated, whether it be GP practice or where they receive specialist care. In the absence of choice, there is no means of accurately measuring and responding to demand which leads to resources being misallocated
Crucially, monopoly healthcare providers such as the NHS are also poor at introducing new technologies which helps explain our performance in cancer care.
Reform Scotland’s alternative follows other European countries in empowering patients by making the service more accountable to them and giving them greater control over the health care they receive.
There are three main elements to our proposals. The first is that there should be a new relationship between the health service and patients, with the NHS acting more like an insurer by defining patient entitlement. This would clarify the role of government in health care as regulator and funder, but not a direct provider. If something, such as a new drug for cancer, was not available on the NHS then the government should be honest about that and allow people to take out supplementary insurance without turning themselves into private patients.
The second is that the role of the 14 Health Boards should be changed so they become mutual organisations – Health Commissioning Co-operatives – run in the interests of patients and commissioning care on their behalf. They would be specifically tasked with providing information to patients and their GPs to enable them to make informed choices about their care.
The third is that existing health care providers would become independent, not-for-profit trusts providing health care based on the approved NHS price for a range of treatments. New approved providers from the public, voluntary or commercial sectors would be free to offer their services at these rates, extending patient choice and competition.
Such reforms will ensure that the health care system in Scotland puts patients first.
They are also the key to providing real value for money in our health service and to raising standards for all.