Can Yousaf be a reformer?
Health Secretary Humza Yousaf has released an NHS ‘recovery plan’. It is timid, tepid and not up to the job.
Image: Scottish Government via CC BY-NC 2.0.
Saturday marked 100 days since Humza Yousaf’s appointment as health secretary.
The anniversary came as he gave the first major insight into his vision for Scotland’s health service, contained in the document ‘NHS Recovery Plan 2021-2026’. Given the timescale, it is possible that some of the proposals pre-date his appointment and for his sake we can only hope so, for the blueprint is a shallow glide across deep and tumultuous problems.
There is nothing inherently objectionable in the pamphlet. It promises a 25 per cent increase in primary care, 800 additional GPs and 1,000 mental health workers. There is a pledge of more investment in National Treatment Centres, including 1,500 more staff over the term of this parliament. These are all reasonable aims and there is encouragement to be taken in undertakings to expand the use of artificial intelligence, shift more healthcare to community level and dedicate 10 per cent of NHS spending to mental health.
The problem is that, upon reading the plan, I was reminded of a slogan former US vice president Walter Mondale adopted to needle his opponents: ‘Where’s the beef?’ There is more meat in a Linda McCartney's lasagne than there is in the 28 pages of the recovery plan.
The £29 million to ease backlogs in testing is a pittance and the £8 million allocated to address mental ill-health among NHS staff a risible sum. Bringing on board 320 child mental health workers will not even begin to address the scale of the mental illness crisis among young people, and while an extra 800 GPs sounds substantial, this is for a primary care system in which a quarter of doctors’ surgeries were understaffed before the pandemic. The same might be said for the £130 million assigned to deliver a National Cancer Plan. No one would knock increased investment to improve early detection, treatment and support but the sum involved, although sizeable, still amounts to less than one per cent of cash allocated to health for the coming year.
The recovery plan is a very SNP production: it is for all that is nice, against all that is nasty, but reluctant to do anything transformational about either. The reason is the same as always: doing things involves making choices and choices mean consequences. As long as policy remains at the level of warm words and grand ambitions — as long as it is about input and intentions rather than output and evaluation — it is a relatively low-risk affair. No government ever lost an election for promising to fight cancer but governments do lose elections for pursuing the sort of fundamental changes required to put their ideals into practice, such as raising taxes, cutting popular services or embarking on reforms that might fail to deliver. The SNP’s governing style is that sweet spot where self-service and cowardice meet.
Overhyped and underwhelming, the recovery plan belongs to the lamentable genre of virtuous gloss slicked over structural failings that is Sturgeonism. It is the public policy equivalent of those Oscar speeches in which a multi-millionaire tells a room full of multi-millionaires that something must be done about poverty and they all agree that something is a round of applause.
Spin has always been with us and all governments do it to some degree or another, whether to shore up their position, shut down opposition attack lines, deflect from failings or highlight overlooked achievements. In its current incarnation, dating back to the New Labour era, spin is almost as important as the business of government itself. The SNP operates one step beyond this: for them, spin is the business of government.
If not gloss, then what? To answer that, we have to go to first principles. What is the NHS for? Who does it serve? How well does it do so? What would make it better? The first two questions should bring us to the patient and it is only from there that we can answer the latter two questions. This is a novel concept in Scotland — indeed, across the UK — because instead of a patient-centred health service we have a health service around which patients are expected to work.
In most advanced countries, many of them with more impressive clinical outcomes, the health system exists to tend to the health of the population. Here, we do it the other way round. Since March 2020, people across the UK have daily had drummed into them the deathless mantra: ‘We must protect the NHS’. This was the incantation recited whenever anyone asked if the health service should have been shut down so comprehensively at the outset of the pandemic.
Whether it was wise to postpone quite so many treatments for chronic conditions and diagnostics and operations for the gravest illnesses. Whether severing the link between GPs and their patients was the correct approach to a health crisis in which public trust in clinical guidance was so pivotal. Whether it was best practice to bus elderly patients out of hospital wards and into care homes, many without prior testing and some even after they had tested positive for the virus.
The NHS came first and patients a distant second. This is not to denigrate the hard work of medical professionals and support staff, many of whom responded to a crisis with calm determination and a quiet sense of duty. They are not what is at fault; it is the system that is ailing and the petrified thinking that governs it. This system was not ushered in with Covid and the difficulty in getting the NHS up off its knees after the pandemic is that it was already down there when the pandemic struck. Much of what the health secretary brands ‘recovery’ (tackling waiting times, improving cancer care, meeting mental health needs) is actually a belated patch-up job on faults long neglected. The recovery plan the NHS needs is from 14 years of SNP government.
Recovering the NHS as it was pre-pandemic would not be any kind of advance. The impetus, instead, should be for reform that puts patients, not professional bodies, at the heart of health provision. After a year and a half in which many have been unable to see their GP in person, a spokesman for the Royal College of GPs in Scotland told BBC radio last week that ‘remote consulting’ (i.e. phone or video calls) had ‘served us very well throughout the pandemic’. GP consultations are not about serving GPs but about serving patients, and some patients feel unable to articulate their symptoms remotely while others struggle with the technology and avoid seeking treatment as a result.
A reorientation of the health service is needed to enhance the power of patients and place a much stronger emphasis on their choices and preferences. Delivery models should be designed around patient wellbeing and satisfaction rather than straitjacketed by outmoded ideology and bureaucratic conservatism. What should matter is what works and what works is what works for patients. The NHS is not charity the government gives us out of the goodness of its heart, it is a service we pay for. The notion that we should take what we are given and be grateful is born of fear and deference and the cynical lie that it’s either this or US-style private insurance. These impulses and the scare tactics that play on them still work but sooner or later a generation will come along for whom they no longer will. Reform now or face an existential crisis down the line.
Humza Yousaf will not choose reform. The health brief is a dangerous one for a man like him — a man with ambitions — and he likely understands that his task is to tinker here, jiggle there and make the right noises until he is moved elsewhere. Nicola Sturgeon held the post for five years with a decidedly mixed record but she was savvy enough to get out before the effluence hit the air conditioner. If he wants to be First Minister, and he plainly does, Yousaf will have to do the same. It will be cold comfort to patients but this health secretary is not the first and will not be the last to fail them.
Originally published in the Scottish Daily Mail on August 30, 2021.