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The Scottish NHS isn’t in crisis – but it soon will be. We’ll have to pay more.

EVERY so often, through the fog of Brexit, you catch glimpses of what Scottish politics would have been like had it not been dominated by the confusion and uncertainty caused by Britain’s imminent departure from the EU. Clearly, health would have been one of the issues dominating the air waves; school reforms and the “privatisation” of child care would have been up there too. But last week’s Audit Scotland report, suggesting that the health service in Scotland is cracking under the strain of underfunding, would have been a huge story. We love our free national health service, but we’re still reluctant to pay for it – and that may have to change.

The panic headlines need to be placed in perspective, however. Yes, targets are being missed, though often not by much. For example, the number of cancer patients getting treatment within two months of referral is at 94.9 per cent against a target of 95 per cent. But there’s no doubt hospital buildings are in a poor state, staffing costs are rising, there aren’t enough GPs – as my son discovered when he was turned away from our local GP practice, which has stopped taking new patients. However, satisfaction levels with the Scottish NHS are still remarkably high at 66 per cent – much higher than Wales or England.

It’s not entirely clear why this is, but it probably has a lot to do with the state of the NHS in the early 2000s before the SNP entered government. Back then, winter news bulletins were dominated by stories of people lying on trolleys in A&E, dying on waiting lists and being forced to go private to get early hip replacements. Things are a lot better now. But I’m not saying this was all down to the magic of SNP governance, even though Nicola Sturgeon provided text-book political leadership in the six long years she was in charge of the NHS.

No – the NHS got better because there was a lot more money going into it, thanks to our flexible friend, the Barnett Formula. Spending rose by more than a third in real terms between 2002 and 2010. So much money was piling into the NHS, indeed, that eventually the Scottish Government couldn’t resist putting its fingers in the till to divert a little of the cash to other worthy causes – like education, child care, the elderly.

The key figure in the Audit Scotland report last week was that – in crude terms – health spending has only risen by 1 per cent in Scotland in real terms since 2010. In England, spending increased by 6 per cent in that period. Health experts say that the NHS – because of new techniques and rising costs – needs 3-4 per cent a year just to stand still.

The Scottish Government has always been very careful in disguising this jiggery-pokery. Every year John Swinney would commend the Government for increasing health spending while delivering all the other national objectives. And yes, health spending increased in real terms every year, and there are more staff working in the NHS than ever before and more is spent here per head than in England. But what they didn’t say was that spending was not rising in line with increases in the UK as a whole.

Now, given the battle-strewn wasteland that is the English health service, you may wonder where all that cash went south of the Border. The succession of market reforms, begun by Labour and extended by the 2012 Tory Health and Social Care Act, has been chaotic – increasing administration and forcing English hospitals into quasi bankruptcy. A bizarre series of scandals, such as Mid Staffordshire patient care scandal, has darkened the image of the English NHS. Scotland has avoided the staffing conflicts that led to rolling strikes by junior doctors.

But the Scottish service isn’t cheap – the NHS costs more than £1,000 per head more here than in England. And the Scottish Government can’t rely on Barnett consequentials in future to deliver big cash injections, as the English health service is increasingly privatised and Holyrood raises more of its funds through taxation. There needs to be a new strategy. There is one: it’s called integrated health and social care.

The idea is to merge the NHS and local council care services to save money and reduce bed blocking. But when big bureaucracies try to merge to save costs, they usually start by increasing them. Joint committees proliferate and duplication ensues. The Scottish Government has put £500m into integration over three years, but it’s not clear when any real savings will happen.

In the meantime, Scotland’s population is ageing much more rapidly than England’s; NHS pension costs have gone up by nearly a fifth in five years; and the living wage is going to increase costs further. So the financial situation is not going to get much healthier – which means hard choices. Either cut back on other government programmes, introduce privatisation; or increase taxes. There really isn’t any other way.

Privatisation would be politically unacceptable in Scotland, and the Government is hardly going to restore prescription charges seven years after abolishing them. And anyway that would just be small change in a £14bn budget. Efficiency savings are always important but it’s disingenuous for governments to claim that they can pay for drug costs by making nurses work harder. Health care is labour-intensive.

Eventually, the Government is going to have to face the prospect of increasing taxes, and here, Brexit could help. The gulf in political culture north and south of the Border has never been greater, and one of the dimensions of that cultural divide is attitudes to taxation. Opinion polls invariably show that Scots are prepared to pay more taxes to fund better public services. The only problem is that the SNP Government doesn’t believe them.

For all its social democratic rhetoric, the SNP has pursued a fiscally orthodox approach to public finance. The idea of increasing taxes is anathema to most SNP ministers. The former Finance Secretary, John Swinney, always seemed to find money for roads and prestige projects like the new Forth crossing, but fell back on traditional make-do-and-mend for social services. The Scottish Government fears that if it increased taxes, businesses would all leave Scotland and ordinary voters would turn Conservative over night. They regard with alarm the rising popularity of the Scottish Tory leader Ruth Davidson, Herald Scottish Politician of the Year.
But Nicola Sturgeon should have more courage in her own social democratic convictions. The way to combat the Tory threat is not to starve public services of funds, which will only undermine public faith in them, but to use the Scottish dimension to start a debate about increasing taxes, marginally, to pay for the NHS. This will have to happen anyway in a few years, as Barnett is phased out and the money supply from Westminster dwindles.

Instead of doing so in response to crisis, it would be better to mobilise public support for higher taxation today by appealing to the communitarian instincts of Scottish voters. They aren’t stupid and realise that quality costs money. We still spend a lot less per head in the UK on health than comparable countries like France, Germany or the Netherlands. The NHS has never been more popular in Scotland than it is today, and it should be possible to reach a national consensus on tax. In the shadow of Brexit, with so many uncertainties, the Scottish Government should start a debate on how to protect our public services from the coming turmoil. Including asking people to pay a bit more for them.

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About iain2macwhirter

Writer and journalist.

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