Measuring failure alone won't fix the NHS

Political opponents have seized on a report from health think tank the Nuffield Trust on the performance of Scotland's NHS to describe it as “a damning reflection of the SNP’s neglect of our health service” - but it isn't. In some ways its more dispiriting than that.

The report does little more than to compare various input and output measures in the NHS in Scotland and elsewhere in the UK. The picture is decidedly mixed – better on Accident and Emergency waiting times but worse on general waiting lists. More GPs but much lower spend on hospital buildings.

There are fewer delayed discharges but on average people spend more time in hospital. We spend more on social care but are the only UK nation to fail to reduce A&E admissions post-Covid. One finding which does catch the eye is that Scotland is no longer the UK nation that spends the most on health (which is now Wales).

But is this a 'damning reflection' of SNP neglect? It's a hard case to make; not only are the above differences in performance between Scotland and the UK mixed rather than conclusive, the actual variances are pretty small. If Scotland is facing neglect of medical services, so is everywhere else in Britain to much the same degree.

On the other hand the SNP response to this report is no less unpersuasive – that “the SNP has a plan for Scotland’s health service and it is working”. Once again, if it has a different plan than elsewhere in the UK and it is 'working' then it is very difficult to discern it from the data. In some instances things are getting marginally better – but in others they're getting worse.

The attempt to turn this into an election campaign issue is serving no-one very well because everyone is pointing at very small differences, blowing them out of proportion and claiming this is a stark political alternative – and that is not what is happening at all.

In reality all the administrations are overseeing what looks very much like slow, managed decline using what are effectively minor variations on the same broad managerial approach and the same broad financing strategy.

For now, the politicians would like to turn this into a short-term acute crisis, either to show they are solving it or to show opponents are not. But this is not an acute crisis, it is a chronic one. And they aren't solving the problems in the system or failing to solve them, they are simply running the system, tweaking it slightly in one direction or the other and then trying to make political capital out of whatever they can.

That is why this report is dispiriting; it does not find evidence of a solution being implemented anywhere which appears to be working much more than at the margins. But it contributes to the problem as well in that it does not identify solutions or even clear causes for the problems it identifies.

It states that Scots are finding it harder to access care and implies that this is mainly because productivity fell sharply during Covid and has not returned to pre-Covid levels. But why are we carrying out less care per member of staff for each pound we spend? Why are we markedly less productive than in 2019?

And we're spending more time in hospital than we were pre-Covid, but why? Is it NHS practice? Is it the nature of illness? Is it social or cultural expectations? If we know data isn't going in the right direction, surely the question isn't where it's going but why it’s going there?

Nuffield is an important think tank that does excellent research and it is certainly unfair to imply blame because it does not 'solve' the NHS crisis in a comparatively short election briefing. But the conclusion that 'politicians must be more open' is unpersuasive. Owning up to underperforming doesn't improve performance if you can't identify why you are underperforming.

There is a large industry of experts warning us we're in denial about the NHS but other than those coming from the right which push their usual solution of privatisation and de-universalisation, there is an awful lot less to be heard in terms of credible analysis or plans.

Common Weal believes that this is because almost all of them take the system as is and assume it is somewhere near optimal and do not seem to question whether we deliver healthcare in the right way. We at least have an analysis which suggests that centralisation, marketisation, managerialism, disempowerment of frontline staff and poor democratic feedback prevents the health service from healing itself.

We also think there is far too much political cowardice in taking action on reducing failure demand, particularly through interventions on and regulation of Ultra Processed Foods and by providing much more effective mental health services. We continue to believe that a properly-functioning National Care Service would have been the single biggest boost to NHS productivity.

We have set out this analysis and our solutions, but that is an exception in the debate. If we frame this issue as 'managed decline', that is where we will end up. Health services are not falling off the cliff no matter how politically expedient it is to say so during an election. But nor are the issues being fixed, no matter how politically expedient it is to say so during an election