Reform Scotland

NHS is not sustainable in its present form – Paul Gray

This article first appeared in The Herald on 15 November 2023

When the NHS was founded in 1948, we were told:

There are no charges, except for a few special items. There are no insurance qualifications. But it is not a charity. You are all paying for it, mainly as taxpayers, and it will relieve your money worries in time of illness.”

In 1948, the population of Scotland was around 5.1 million; now it is over 5.4 million – an increase of about 6%. And life expectancy for both women and men has increased by well over 10 years since 1948. But in 1948, 15 million prescriptions were issued in Scotland. By 2018, the 70th birthday of the NHS, that had risen to over 103 million – an increase of over 600%. And in 1948, there were just over 22,000 nurses and midwives in NHS Scotland; now there are around 60,000. So let us temper our aspirations of a return, by 2048, to the halcyon days of 1948. We probably want to hang on to minimally invasive surgery, MRI scanners and the Glasgow Coma Scale. They really were invented here, just like the Highlands and Islands Medical Service, which covered half of Scotland’s land mass from 1913 onwards and offered a template for the NHS.

However, we are now at the point where it is widely recognised that the current approach to providing health and care services is not sustainable in its present form. It is not sustainable for the people it is intended to serve; it is not sustainable for the people providing the service; and it is not sustainable in terms of continually increasing demand on the resources available to fund it. This is not the same as saying that it is beyond repair, or that it is fundamentally unfit for purpose. But the need for change and development is obvious and the moment is not near, but now.

Change is possible; governance of health and care services now is very different from what it was in 1948, but does it reflect the current and foreseeable needs of the population? Development and innovation are possible; there have been some profound, life changing advances pioneered in Scotland, but are there some developments that are now more urgent than others? Expansion is also possible as the numbers quoted show; but is it inevitable, and should it be planned and managed, and is it always the right answer?

If we are all paying for the NHS, should we care about it? I suggest that we should, and that most do. And if we care about it, should we be willing to talk about it? I suggest that we should, and that many might agree. But if we want to talk about it, ought we to think about the terms of the debate? I suggest that we should, and I would like to invite you to do so as well.

If we seriously want to have viable health and care services in 2048, we need to talk soon and act quickly. And we need to avoid using the discussion to prove that everyone else was wrong and I was right. If I proposed that we reinstate the NHS as it was in 1948, with the same staffing, governance, funding, diagnostics and procedures, I would be laughed out of court. But the reason for that is not that what was done in 1948 was wrong. It was absolutely right – for its time. It is just that a lot has changed since 1948, and we know things now that we did not know then.

So my first proposition is that we should remember that change is hard, and using it as a weapon to claim the moral high ground greatly reduces the likelihood of its success.

My second proposition is that development and innovation are needed, but they must be prioritised to the issues that are most fundamental and pressing.

And my third proposition is that expansion is not inevitable. If all we need is more of everything, we have three problems. The first is that more of everything is not available. The second is that more of everything is not affordable. And the third is that more of everything is not right.

Against that background, I want to make a final point. Change involves choice. Choice is difficult. Choice often means that some people get what they want, and others don’t; or some people get something quickly, and others have to wait. But there is one choice that everyone contributing to this debate can make: do I want to make it possible for everyone to contribute, or would I prefer to hear only the voices with which I agree? Our actions will convey that choice much more clearly than our opening statements of intent. Nobody will dissent from the idea that the debate will be open and inclusive – but if I think that health and care services should be free at the point of delivery, will I jeer at people who suggest that we consider other options? If I think that we should have more involvement of the private sector in the NHS, will I call people who believe it should be entirely in public ownership naïve? The more that we can discuss difficult issues openly and respectfully, and draw on evidence and analysis rather than opinion and oratorical skill, the more likely we are to do good. And who knows, we might surprise ourselves by hearing a different perspective, and seeing things in a light we had not recognised hitherto.

I welcome Reform Scotland’s willingness to host this debate. I believe that the manner in which we approach it will tell us a great deal about the likelihood of our reaching a successful outcome.

Professor Paul Gray was chief executive of NHS Scotland, 2013-19 and NHS Scotland Director of Primary and Community Care from 2005-2007.

If you would like to contribute to Reform Scotland’s NHS 2048 forum, please email [email protected]