Anyone who doubts the depth and breadth of the crisis in the NHS should read the diary written by Dr David Caesar, consultant in emergency medicine at Edinburgh Royal Infirmary, in The Times. At the end of another gruelling shift, he writes: “There are no words, just looks of despair and dejection. The fatigue is bone deep.”
A few days later: “Our starting position today at 7.30am is close to 300 per cent over capacity” and “the wait to be seen is nigh on ten hours”. In such circumstances, the surprise is not that the system is broken but that any part is functioning at all. A&E grabs headlines because patients languishing in corridors or stuck in an ambulance outside are graphic illustrations of a service in crisis but, in truth, the problems leach into every part of the NHS.
No wonder opposition parties demand that Humza Yousaf, the health secretary, be sacked.
• Diary of an A&E doctor: ‘There are no words, just looks of despair’
But does anyone really believe replacing Yousaf with some other poor unfortunate would make any meaningful difference? He is no more the problem than any potential successor could be the solution.
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It is easy to demand a sacrifice but any reasonable appraisal must conclude that these have little to do with party politics. NHS England is overseen by a Tory government, NHS Wales by Labour and NHS Scotland by an SNP ministry yet each faces broadly the same crisis for broadly the same reasons.
SNP parliamentarians and SNP supporters boast that the Scottish NHS performs better than its counterparts elsewhere in the UK. Even if this were true, what of it? Scotland’s Barnett-financed public spending advantage gives the Scottish government greater resources, per capita, than is the case in England or Wales.
In any case, “marginally better than England, not quite as bad as Wales” is hardly an impressive boast if, like the SNP, you think the rest of Britain something close to a failed state. It tells us nothing about the absolute, rather than relative, quality of the Scottish NHS. Since the NHS is the unofficial state religion, few people wish to acknowledge that it isn’t really working but the problem is the system, not the politicians notionally responsible for it.
Heroic doctors and saintly nurses usually do their best but often that is not enough. By global standards, the NHS is pretty mediocre. It is not especially underfunded — we spend more than Spain or Italy, though less than France or Germany — but it is notably bad at keeping people alive. Cancer survival rates, for instance, are poor when compared with peer countries. Britons are the only people to think the NHS is the envy of the world. No one else agrees.
Certain stubborn realities cannot be ignored. The demand for health care is increasing faster than its supply. That means more, not less, rationing. Sometimes this means doctors and hospitals declining to treat certain non-emergency conditions such as varicose veins; more generally, it means an ever-stricter triage process.
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Those who can already turn to private treatment. This trend will continue for the foreseeable future. Those who cannot must make do with healthcare rationing. Waiting lists are the price paid for a service free at the point of use. They are a feature of the system, not a bug in it.
All of this is going to get worse, not better. This is an actuarial certainty. Older people need more care than younger people and there are going to be many more older people in the future. This reality is exacerbated by medical advances. Put simply, more and more treatments will be available but many of these will be expensive. This is excellent news for individual patients but unavoidably increases pressure on an already-buckling healthcare system.
Something has to give. Nicola Sturgeon makes grand claims about record investment and higher-than-ever levels of staffing in the NHS but so does the Westminster government and, in any case, if this is really such a time of plenty for the health service why is it so obviously failing?
Yes, the pandemic has made matters worse and, yes, Brexit has made it harder to recruit staff from the European Union but some staff shortages are the consequences of choices made closer to home. It was Sturgeon who, when health secretary, cut university nursing places by more than a fifth. That was a pennywise, pound-foolish decision at the time and has helped make today’s staffing problems worse than they might otherwise have been.
Still, there is no avoiding the fact that morale in the health service has never been lower. Every nurse, midwife or doctor you speak to has tales of woe to report. Many are cutting back their hours or considering quitting entirely. Pay is only a part of the problem; the sense of dread that comes from thinking you are always just half a step from disaster is much more debilitating.
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In the short term there are few grounds for thinking any improvement is likely. Spring will ease some problems but only temporarily. The countdown to next year’s winter crisis has already begun.
Health professionals are at least prepared to look at reality. If we wish the NHS to remain broadly the same, much will have to change. “The public and politicians need to decide what they want to prioritise and they will need to make choices” says Iain Kennedy, chairman of the British Medical Association in Scotland. The NHS “all-you-can-eat-buffet” is no longer sustainable. This is obviously correct. The political failure, then, is not of policy but dishonesty. Leadership begins with telling the truth.
