Covid-19: What our Scottish NHS needs post-pandemic

In the first of a series examining how life has changed following the pandemic, Ben Wray turns to our NHS...

THE National Health Service is rightly a treasured institution in Scotland. Free at the point of use for everyone who needs it, it is the living embodiment of an idea that has long been held but very infrequently practised: that if we club our resources together to look after one another, we will all be better off.

Now into its 74th year, the NHS has had its fair share of scrapes and bruises, but the pandemic has been a challenge like no other in its history. Never before have Scotland’s doctors and nurses had to cope with repeated waves of infection at this scale. Covid-19 has been a giant stress-test of that precious idea that everyone – poor and rich, young and old – can receive the same high-quality healthcare when they need it on the NHS.

How has our national health crisis affected the ­National Health Service? Will the NHS look the same post-pandemic as it did before March 2020? And what needs to change to make sure it continues to be a public service for everyone?

The 1 in 67 problem

IN early January, Scottish Accident & Emergency waiting times hit a new peak as Omicron swept through the country. Just 67.4% were seen within the four-hour waiting time target. More than 2000 people waited over eight hours, and 690 people waited more than 12 hours.

These numbers tend to have a numbing effect, but behind the data are real lives – and waiting too long can mean a life lost. Dr John Thomson, vice-president of the Royal College of Emergency Medicine, told a Scottish Parliament committee in November that “for every 67 patients who wait for between eight and 12 hours for admission to hospital, there will be one avoidable death that is related purely to that excess wait in an emergency department”.

The problem is there are no easy fixes, even when the pandemic eases. In fact, it is well-established that beyond the waiting lists, there is also a back-log of people who have health problems accumulating but are suffering in silence, either not wanting to go into hospitals due to the fear of catching Covid or ­(wrongly) believing that their issue isn’t serious enough during a national health emergency.

The data bears this out. The number of planned ­operations was over 25,000 in January 2020, ­before the pandemic erupted. Since then, it has only reached over 20,000 in two months, June and ­November 2021. Patients being seen for elective ­(non-emergency) care is still 17% lower than the pre-pandemic ­figure, with over half a million on the waiting list, the highest number ever recorded. The fear is that the ­near-future could be even more difficult for the NHS than the present.

Louisa Harding-Edgar, academic fellow in General Practice at the University of Glasgow, who also works two days a week as a GP, has been ­researching the significant drop-off in referrals for lung cancer during the ­pandemic, and tells The Sunday National that the potential size of the back-log is “really scary”.

“We are going to be under a huge amount of strain,” she adds.

Long waiting lists can lead formerly dedicated users of the NHS to turn to the private sector instead. Some 3400 patients paid for private procedures from April to June 2021 in Scotland, ­compared to just 2300 over the same months of 2019. One private healthcare ­consortium, the Circle Healthcare Group, has just completed a £20 million expansion of its Ross Hall Hospital in Braehead, introducing 17 new consulting rooms, in response to “an exponential increase in demand within Scotland’s private healthcare market”.

Wilma Brown, Chair of UNISON ­Scotland’s Health Committee and ­employee director for NHS Fife, says that it’s the strain on the NHS which opens up opportunities for the private ­healthcare market.

“Someone might say ‘I am going to use that five-grand that I was saving up for my retirement on surgery, because I can’t bear to wait anymore’,” she says.

It’s not just patients going private; the NHS drafts in agency nurses at four or five times the salary to fill in for staff off-sick, and NHS managers outsource operations when the waiting list pressure gets too big.

“Already we send patients to private companies for operations that we can’t give them within the timescale,” Brown says. “You will see that step up as we ­battle to bring down the waiting lists.”

The “enormous strain” on nurses and doctors

WELL aware of mounting problems, Health Secretary Humza Yousaf ­published his NHS Recovery Plan in August, which aims for a 10% increase in capacity in five years, backed by £1 billion in new investment. Key to delivering on this target is the recruitment of 1500 additional staff.

This will not be easy. There were 4812 reported vacancies in the NHS last year, and the Royal College of Nursing (RCN) say nursing vacancies have never been higher. The Scottish Government has to find a way to fill the present vacancies on top of the 1500 new jobs it plans to ­create.

Brown, whose background is ­nursing and has been on the front-line during the pandemic, describes the Scottish ­Government’s recruitment challenge as “huge”.

“If we need 3000 nurses in five years time they’ll need to put through 5000 nurse placements, because to uplift the capacity you need the staffing we’ve got now, plus those who are in student placements and are going into University, plus allowing for the amount of people who are going to leave,” she explains. “I’m at a total loss about how they think they are going to do it.”

Just as important as recruitment is ­retention, with three-out-of-five nurses considering leaving their job due to the intense and growing pressures of NHS life, according to a recent RCN ­survey.

Colin Poolman from RCN told a ­Scottish Parliamentary committee in ­November that “every day, people who are leaving the profession tell us about the demands that are placed on them incessantly. Because they can see no change in the situation, they are making that decision for the good of their own health and wellbeing.”

Dr Andrew Buist from the British ­Medical Association (BMA) spoke at the same meeting about the “enormous strain” on GPs in Scotland.

“Many of my colleagues are extremely tired and their morale is down,” Dr Buist said. “I am worried that they are burning out.”

Increasing the number of GPs is a long-established Scottish Government ­priority, with a 2017 target set for 800 new GPs by 2027. Dr Buist was clear that “we have not made any progress towards that … four years into the process, we are largely where we were at the beginning of it.”

A recent BMA survey found that there are currently 225 whole-time-equivalent GP vacancies across Scotland.

Whether it is doctors or nurses, the staffing crisis in the NHS is profound, and Brown believes it pre-dates Covid-19 by “many years’.

“It’s been an ongoing problem through the whole years of austerity,” she says. “We have never been properly staffed. We have always ran short.”

Brown believes a shortage of staff is a key reason behind the current difficulties to retain nurses and doctors, creating a “vicious circle”.

“The staff want to give the full care you are supposed to give, but you can’t do that if you are understaffed,” she says. “That’s what the staff are feeling at the moment, that they are not working in an environment that allows them to deliver the optimum patient care. And that plays on their conscience.”

Harding-Edgar has a similar view of what is needed.

“I think it is largely about resources,” she says. “You’ve got an incredible workforce who are willing to go above and beyond, but could do with a bit of extra support and extra staffing.”

What kind of change?

IT’S not all negative. Harding-Edgar, who is part of the Scottish Deep End Project, a group of GPs serving the 100 most deprived populations in Scotland, explains that the increasing use of phone and online consultations by GPs during the pandemic has meant that they have seen many more patients and opened up GP services to people who found it difficult to access them previously.

“For example, people don’t need to leave their office to speak to the GP, they can have a phone consultation and then only come in if it’s absolutely necessary,” she says, “or people who are carers don’t need to find someone else to take over their caring responsibilities in order to speak to a GP.”

Harding-Edgar believes that ­after the pandemic GPs will move to a ­“hybrid ­model” of online and ­in-person ­consultation, but said that getting the ­balance right between the two is ­critical, as there is “a real risk of digital ­exclusion” for “the people that most need ­healthcare”.

Just 65% of households with an income below £10,000 per year have internet ­access, compared to 99% of households with an income over £40,000 a year.

“We really need good evaluation of everything that’s happening; we need to know what services are working and what’s not before we just go for things that seem like a good idea,” she argues

Harding-Edgar believes such a data-led approach is essential for the inquiry into “alternative pathways” into primary care services, launched by the Scottish Parliament’s health, social care and sport ­committee last month.

According to the inquiry, possible ­alternatives to the GP could include ­“seeing a different ‘health practitioner’ who works in the GP practice or in the local community”, such as a physiotherapist, a nurse or a podiatrist, or being directed to other types of support to improve health and wellbeing, such as walking clubs and community groups, a practice sometimes called “social ­prescribing”.

Harding-Edgar, who’s GP practice is in the Gorbals area of Glasgow, is open to new approaches as long as they are backed by the data and – crucially – ­patients are fully on board, but is dead-set against social prescribing. She points to NHS England, where some patients have even been referred to foodbanks, as an example not to follow.

“It’s not our job to prescribe food or ­exercise,” she says. “It’s the politicians that need to have the policies to let ­people access food, green space and ­exercise ­facilities.

“I really don’t want to ever have to ­refer someone to a foodbank. Its ­medicalising social life: poverty is not a medical ­problem, it’s a social problem.”

The pandemic has put a spotlight on the major problems facing the NHS and change is clearly needed, but we should be vigilant that change defends, ­rather than dilutes, the original purpose: ­high-quality universal healthcare, from cradle to grave.