Is Scotland waking up to the dire state of its NHS?

If the NHS is the closest thing we have to a religion, as Nigel Lawson reckoned, then Paul Gray is not just a blasphemer but an apostate. Professor Gray has called the NHS in Scotland ‘unsustainable’ and urged a public conversation about reform, including the use of the private sector. His intervention is significant because professor Gray was between 2013 and 2019 the chief executive of NHS Scotland. He is, to be clear, not proposing privatisation, merely urging a debate about delivery and funding. But even that is scandalous to a political establishment that prides itself on having less private sector involvement than there is south of the border.

Professor Gray told the BBC:

‘If we decide that actually the way we do it is the best way, of all the choices we could make, that’s OK, we’ve had the conversation. If on the other hand we decide there’s more space for the private sector, perhaps they could do more, then good, that’s fine too.’

He added: ‘What we can’t afford is just to carry on as we are and hope for the best.’

He is not the only prominent figure speaking out of turn. Professor Andrew Elder, president of the Royal College of Physicians of Edinburgh, points to the increased demand on the NHS brought by rising life expectancy. Encouraging a ‘national conversation’ on the future of the health service in Scotland, Professor Elder said:

‘The biggest challenge for our NHS can be summed up by the following questions: can we afford to provide every treatment available for the general public, free of charge and at the point of access? If we cannot – which seems probable in the coming years – how should we decide what we can provide?’

It is difficult to clap either man in the stocks for anti-NHS thoughtcrime, given their expertise on the institution. Nor are they the first to talk like this. There was a political stooshie this time last year when leaked minutes showed NHS Scotland directors discussing the need for a ‘two tier’ health service that included charging wealthier patients for treatment. If the response to that disclosure is anything to go by, SNP ministers in Edinburgh will run a mile from the professors’ suggestions.

Yet it is clear that the NHS in Scotland — and we could say the same across the UK — is not working in its current form. The Scottish Daily Mail reports that waiting lists have hit 830,000, an all-time high that represents just shy of one-fifth of the adult population. NHS Scotland last met its A&E waiting times target in July 2020, and only then because attendance numbers plummeted during Covid. Setting the pandemic aside, the target hasn’t been met since August 2017. The story is even worse on cancer targets. The 62-day standard — 95 per cent of patients should wait no longer than 62 days between an urgent referral and beginning cancer treatment — was introduced in the final quarter of 2012. It has not been met in any quarter of any year since.

NHS reform is an especially difficult conversation in Scotland because it trespasses against national myths about egalitarianism and a supposedly superior commitment to fairness and dignity than is seen in England. Suggest to Scottish voters that rich people pay for their healthcare at the point of use and you wouldn’t get too much pushback. Present those same voters with a definition of rich and with the details of a system in which people with more money would inevitably end up getting better, or at least faster, treatment and the pushback could skite Ben Nevis into Ben Macdui. It would be seen as simply unScottish.

Now, that doesn’t mean reform is off the table now and forever. Principles are always most strongly held when they don’t appear to cost anything. Provided it was done properly, a candid public discussion of the parlous state of the NHS and the danger that it might collapse altogether could persuade Scots that avoiding reform is no longer an option. Even then, the shape any reform took would have to adhere to certain principles — affordability, comprehensive coverage, protections for the poor and chronically ill — to get a hearing from the public or the Scottish parliament. Merely discussing change would be agonising so we could expect implementing it to be considerably more exacting, not least given Scotland’s poor track record on public sector reform since devolution.

Then there are the externalities. Bearing in mind that high earners in Scotland already pay the highest income tax rate anywhere in the UK, might NHS charges on top of that prompt some to relocate? Would faster appointments and consultations for a modest fee attract health tourists hoping to escape NHS waiting lists in England or Wales? If certain procedures or medicines become no longer available on the NHS, what kind of systems would be needed to regulate an influx of private sector providers?

Trying to talk about NHS reform, especially if it includes charging, would be invidious at the best of times. Trying to talk about it during a cost-of-living crisis, with families seeing a marked reduction in their disposable income, lifestyle and choices, could prove politically cataclysmic for whichever party goes first. Equally cataclysmic, however, would be presiding over the implosion of a beloved institution because you were too weak, cowardly or ideological to try to save it. Like it or not — and really no one likes it — the NHS conversation will have to be had soon.