NHS in Scotland: Time for us all to grow up and take responsibility for our health?


Analysis by Dr Stephen McCabe

The NHS is often described as “the envy of the world”. But it depends how you look at the world.

In Scotland the NHS is independent but, in common with the rest of the UK, it is a healthcare system based on a so-called “single payer” (i.e. government funded) model, free at the point of use. Similar arrangements exist in Scandinavia, Italy and Spain.

Dr Stephen McCabe, working GP
Dr Stephen McCabe, working GP

In contrast, other countries in Europe such as France, Germany and Holland use systems of compulsory health insurance which often involve upfront payments for care.

There are also examples across the EU where the differentiation between public and private healthcare is much less marked than it is in Scotland and the rest of the UK. So, for example, in France over 30 per cent of hospital beds are “private” and in Germany the figure is more than 60 per cent.

In addition, the UK has fewer doctors and fewer hospital beds per head of population than most other wealthy nations.

In 2010 the OECD stated that “the quantity and quality of the NHS remains lower than OECD average” and in 2011 the European Health Consumer Index ranked the NHS as “better than average” but still well below the best, which were Holland, Switzerland and Iceland.

In contrast, using different methodology and criteria, the Commonwealth Fund in 2014 ranked the NHS as the best system in the world.

The one consistent conclusion that emerges from these various studies is that the NHS in Scotland continues to perform better than the NHS in England, Wales and Northern Ireland.

Historically speaking the NHS is performing well. Waiting times have fallen dramatically. Infant mortality has declined whilst life expectancy has increased. We have seen a decline in deaths related to smoking, cancer and heart disease and – contrary to the general perception – our mental health services are felt to be among the best in Europe. Satisfaction rates with the NHS have never been higher.

Yet problems do exist. Whilst cancer survival has improved it still lags behind in a number of areas. Our child mortality remains higher than many other EU countries. We are seeing a growing burden of hospital admissions related to alcohol and obesity. The gap in life expectancy between rich and poor has widened despite the overall improvement. And there continues to be too much variation in terms a clinical practice, treatment and service delivery across the country.


For over a year now we have been told by the media and by opposition politicians that the NHS in Scotland is “in crisis”. The naysayers have jumped on the recent Audit Scotland report into the NHS in Scotland. In reality Audit Scotland’s criticism of Scottish Government was muted. Its first key summary point highlighted the difficulty Scottish Government is facing:

  “Significant pressures on the NHS are affecting its ability to make progress with long-term plans to change how services are delivered. Tightening budgets combined with rising costs, higher demand for services, increasingly demanding targets and standards, and growing staff vacancies mean the NHS will not be able to continue to provide services in the way it currently does. Together, these pressures signal that fundamental changes and new ways to deliver healthcare in Scotland are required now.”

What they are calling for is radical change to the NHS in Scotland. And in essence Audit Scotland is correct. The NHS in its current form with its current model of delivery and its current level and model of funding is not sustainable no matter what Scottish Government tries to do to patch it up (and no matter which party was actually in power at Holyrood).

We still have too many hospitals trying to do everything when what we need are fewer hospitals and a more focused service provision.

We have longer life expectancy and an ageing population but the price of keeping people alive longer is that this leads to an increased level of multiple co-morbidity and an exponential rise in demand for NHS resources.


At the same time we have people demanding the NHS pays for everything in the face of a “tightening budget” and we end up with the situation of spending millions of pounds on new cancer drugs to keep people alive for an extra 6 or 8 weeks yet insufficient funds to pay for long term care.

We have an NHS being stretched by the demands of largely preventable disease: alcohol problems, obesity, type 2 diabetes, smoking-related lung disease, for example.

We have a society that seems to a large extent to have abdicated self-responsibility for health and well-being and expects the NHS to clear up the mess and pick up the tab.

And yet at the same time we have an NHS that won’t spend sufficient money on cheap, easy to deliver and highly effective therapeutic interventions such as cognitive behavioural therapy.

Finally we have a society which demands free health and social care but refuses to contemplate the substantial rise in taxes that may be needed to pay for it.

Is Scottish Government to blame for all this? Of course no,t but it has been in a degree of denial about the problems that exist. In part this is down to personalities. One can argue about the effectiveness or otherwise of the previous Cabinet Secretary for Health but at least he was out there and approachable and prepared, superficially at least, to listen. In contrast the current Secretary is seen as somewhat distant and aloof. When I raised an issue with my MSP the previous Cabinet Secretary called me at home to discuss the matter. I cannot imagine the current secretary ever doing that.

In contrast we have opposition politicians who have decided to “weaponise” the NHS to score cheap and lazy political points against the Scottish Government without stopping to think about the demoralising effect such “weaponisation” has on the hard-pressed NHS staff trying to deliver care under difficult circumstances.

We are now at the stage where Scottish Government needs to talk about the rationing and rationalisation of services and needs to place the burden of difficult decisions fairly and squarely on to the shoulders of the public – which services do they want to keep and which are they prepared to let go?  Reading between the lines of their report, this is what I suspect Audit Scotland is suggesting.

And we need our opposition politicians to be constructive and participate positively in this reconstruction process.

Stephen McCabe is a practising GP based in Skye