Opinion

Scotland’s NHS: doomed without change

by | 26 Feb 2024

The real problem with the NHS is that the people who led us into crisis are still the people expected to lead us out of crisis. There needs to be a change of perspective on how the NHS is run.

First published by Common Weal

We are all due Audit Scotland a very big thanks. While some in the SNP think it is too critical and even floated ‘clipping its wings’, what Audit Scotland is doing is what our political system isn’t doing – analysing what is happening in Scotland not through a party-political lens but through a straight reading of what the evidence suggests.

That is why Audit Scotland’s report on the NHS this week is chilling – in lots of ways. What I want to argue here is that Audit Scotland has not really criticised the way the SNP has run the NHS, it’s a thorough critique of how Britain runs its NHS. Much of what is wrong now can be traced back to Thatcher’s internal market reforms.

But this does not let the Scottish Government off the hook in any way at all. It has very willingly chosen to be the most recent front for what is really a specific managerialist outlook on what the NHS is and how it should operate. What I want to argue here is that letting the arsonists put out the fire is the inevitable future unless someone wakes up.

Let me very quickly recap Common Weal’s health work (which, with shame, I’m many months behind in writing up). The NHS has been run by people who are not medics, managing the system based on a spreadsheet of performance indicators and financial management tools. It is woefully insufficiently medically-led.

The outcome of this has been a series of decisions which are tearing the NHS apart. The decision to reduce hospital capacity might appear reasonable if you’re looking at a yearly average occupancy rates. If you have any medical knowledge you will know that averages are dreadfully misleading because hospital admissions aren’t even nearly steady through the year.

Now we don’t have enough capacity at peak times. Meanwhile managers can only manage medical staff through performance indicators because that’s the whole ethos of New Public Management. But the people setting the performance indicators aren’t doing so with the workforce but to them. It has dumped massive bureaucracy on staff. This has increased their work pressures.

So people have left and others aren’t taking their place at the same rate, so then we have a staffing crisis. The only way to address that is agency workers who cost much more than the NHS staff they are replacing. And everyone in the system from top to bottom is structured into a system of blame-passing. Things go wrong in hospitals and if they do, managers want someone to blame, preferably as far down the chain as possible.

And so there is a chilling deterrence to medics who know that if they don’t do the thing that keeps them out of the blame structure their careers are at risk, whether or not the blame structure leads to good healthcare.

On top of all of this, the whole system is funded through a Thatcherite model of pricing every aspect of what the NHS does and pretending that that creates an internal dynamic system that saves money. It does not such thing, it drags the NHS around after whatever stupid ‘price signal’ they decide. I explained this last week on the basis of ‘if you price dentures too low, no-one will get dentures – and so on with absolutely everything’.

The managers are going to win here despite everything, despite the fact that they are pitifully wrong and everyone knows they are pitifully wrong

Right, this is the mess that got us here. Who gets us out of this? There isn’t a politician in Scotland with a coherent, comprehensive plan to do anything about this. Labour is about to get into power at the UK level and their health minister is an avid free-market privatiser. They’ll make it worse.

And in Scotland? It will be the same as absolutely everything else – since there is zero consequence for failure once you’re in the gilded circle of unelected ruler of Scotland (which, for our purpose here, I’ll call ‘health managers’), they are the ones who remain in place to oversee all the problems they created.

If you want to know how this is going to go, all you have to do is look at the genuinely contemptuous way the Scottish Government has handled the National Care Service (which got into crisis long before it even existed).

The NCS was created by the management class with virtually no reference to the people who actually know about and deliver care. It was another wet dream of bureaucratic centralisation in the hands of the unelected with increased marketisation (‘commissioning’) and iron-clad protection for the care profiteers (a substantial chunk of which is owned in offshore tax havens).

People tried to engage with it, no-one more than Common Weal. But it was futile; the manager class literally didn’t care. Eventually everyone – everyone – involved in care delivery had had enough. A tin-eared Scottish Government waved away every objection and left no option but major escalation. It is the first time in a while that every single key partner has called for a policy development process to be halted and rethought.

The Scottish Government had no option – but its contempt didn’t diminish. The ‘pause’ was a stage-managed farce which looked suspiciously similar to ‘cracking on as we please’. And the outcome illustrates why Scotland is a mess. Having been told by everyone who knew anything that these plans were a total mess, the Scottish Government went away for six weeks and…

…reintroduced them entirely as was. No change. Precisely the legislation everyone objected to so strongly. Scottish Labour have actually been good on this. The Scottish Government had promised that the Bill as reintroduced would be significantly amended at Stage Two of its process through Parliament. Labour offered continued support to the Scottish Government on condition that it published those amendments a Stage One.

The Scottish Government refused. Its manager class seem to have forgotten nothing but learned nothing. The position we are left in is that the Scottish Parliament must now approve in principle the Bill that faced such great opposition. Once that is done everyone is screwed because the Parliament has agreed it in principle. It must pass in some form.

So now we have to *cough* trust the Scottish Government to actually significantly amend the Bill. But on their terms only and only after this legislation is a fait acomplis. The managers are going to win here despite everything, despite the fact that they are pitifully wrong and everyone knows they are pitifully wrong. 

We need an NHS designed by nurses and doctors and radiologists and dentists and physiotherapists and everyone else who is at the frontline of delivering healthcare

In about five years Audit Scotland is going to reveal in all the gory detail just how much of a disaster all of this is. So now let’s jump back to today. The health management class has been called out for massive failures. Who is going to fix this?

Take a guess. The Scottish Government is in ‘do nothing’ mode generally so I’d estimate the chances that it is going to change course on the NHS as negligible. They’ll defer back to whom they always defer to – the insider management class. They are the one group of people in Scotland who are doing absolutely brilliantly out of the NHS crisis. The worse it gets, the more of them there are and the more power they are given.

If (and it’s a very big if) they are pushed into opening this process up, they’ll be in charge of the door handle. It will almost certainly turn into another stage-managed act of controlling patients and NHS workers. After all, that is more or less always what we get.

The means of fixing this is actually quite simple; to put out the fire, start by removing the arsonists. The NHS cannot heal itself if the thing that is causing its burns is allowed to keep singeing away and singeing away at the poor, broken body of our health service. Managers and financiers got us here, only medics will get us out.

We need an NHS designed by nurses and doctors and radiologists and dentists and physiotherapists and everyone else who is at the frontline of delivering healthcare. Unless I’m really weird and literally every medical professional I’ve ever met is from a tiny group of malcontents, they are furious, sick of it and know what’s wrong.

I run through the broad thrust of our health policy and, to date, not one of them hasn’t said ‘yes, that sounds about right’. And I’m talking many dozens of people here – I know a lot of people who work in the NHS on top of the network of experts we’ve developed to advise Common Weal.

It would be a simple move – conclude that, after a report as damning as Audit Scotland, the people who have been managing the NHS have failed, remove them and replace them. That is not what will happen. And of course you know what that group of insiders really want? Further privatisation. That was the health managers’ immediate response to the Audit Scotland report.

Remember, it is never the managers who failed, it is always you, the patient. You weren’t paying enough money. You must be punished for your failures. And so, with a snap and a hiss, another burning match is thrown onto the conflagration.

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