The price of energy and the associated cost of living crisis are issues expected to both continue and dominate the 2023 political discourse, but could it be the health service that drives the political agenda?
Ambulance staff will strike across England for two days this month in an escalation of the widespread industrial action there. Paramedics will be joined by call centre staff and drivers. Staff critical to the functioning of an emergency service.
They will be joined, too, by nurses in England, with Scottish nurses likely to follow suit, having rejected a 7.5 per cent pay offer late last month.
Speaking to friends in the nursing profession, they are exhausted, physically and politically. They don’t want to strike and they certainly can’t afford to lose more pay but they feel they have little choice. It is a cry for help as much as a demand for a better pay settlement.
The arguments are well rehearsed. A shortage of staff compounded by Brexit. The trauma of Covid-19 and the demand it placed on services. The lag effect of the virus on all our services and screening programmes leading to a higher demand from sicker patients. A lack of beds caused by an acute shortage of support packages and places in the community for people who are clinically well enough to leave hospital but too infirm to return home without additional support.
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That last issue, of “delayed discharge”, has dominated debate about the health of the NHS for the past decade or more. Before the pandemic, we were told the issue was not fundamentally with the NHS but the local authority services that supported it.
Money, or lack of it, was clearly a factor. Social and community-based services within councils had been subject to real-terms budget freezes at best for most of the past ten years while they watched the NHS budget rise above inflation each year. Increasing the budget of the sacred NHS is considered a vote winner. Increasing the budgets of councils that are responsible for the delivery of far more public services than most of the public acknowledge lacks the same political payoff.
It is the great irony of the devolution era that while the SNP demands power from London, the party hoards it in Edinburgh and draws it to the centre from all 32 of the country’s local authorities. Falling budgets combined with increased statutory duties leaves local authorities with less to spend on tailored local need and priorities. It also means less ability to reform.
The textbook theory says move to a preventative public spending agenda. Prioritise people living healthier lives for longer in their own homes. In practice it would mean multiplying by a factor of ten the amount of money we spend on home adaptations. It might also mean prescribing heating and better-quality food to those most in need. It requires money that doesn’t exist. Existing budgets, therefore, have to be “realigned”. Code for cuts.
All these factors are at the root of the substantial distrust held by health and social care services towards the proposed National Care Service. A sound idea on paper that is in deep political trouble.
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Delayed discharge is the preferred euphemistic term to bed blocking. This past week, though, we’ve seen several first-hand reports of how serious the situation is facing emergency services across Scotland but acutely in Glasgow’s Queen Elizabeth University Hospital. One doctor was quoted as saying “We are waiting for others to die” before they can provide beds. It’s no time for euphemistic language when even the doctors have abandoned their bedside manner.
We have all become acclimatised to lengthening delays in the health service. Until now we tholed it because we understood the pressures facing services post-Covid. We also accepted that while things were undoubtedly very challenging, first-class emergency care would still be there if we really needed it. That informal deal hangs in the balance.
There is a comfort for Scotland’s health secretary, Humza Yousaf, in knowing that these problems are UK-wide and that much of the blame for the country’s financial mismanagement lays squarely at the feet of the Conservative government. Where blame lands at his feet, it arrives partly sanitised. A number of factors could change this in 2023, concentrating the potency of the NHS in Scotland as a political issue.
The first is just the sheer number of people who either have themselves or within their families had a negative experience of the NHS being there when they needed it most.
Secondly, there appears to be a growing willingness to think the unthinkable for the English NHS by the Conservatives. The landscape south of the border is awash with proposals designed to reduce demand and drive efficiency in the NHS. Ideas have included charging for missed appointments and introducing insurance models.
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The vast majority of these ideas would be instinctively unpopular in Scotland, unless of course they work.
Were everything to change in England while things stayed the same in Scotland, might there be even greater political pressure on the Scottish health service yet to come?
In its present form the NHS could absorb every penny available to it and still face staffing shortages and soaring demand. The truth is that without reform, this precious institution built from the rubble of the Second World War will crumble due to 21st-century life expectancy.
This year will be the year where the dial moves on the politics of health. For years, politicians chose not to waste political energy on NHS reform, now they can’t afford not to.
