How does Scotland decide what it can promise? – Andrew Elder

The Scottish Government faces some uncomfortable choices about healthcare.

How can maternity services in Caithness provide safe, high-quality care while minimising the need for women to travel long distances? Should single women be eligible for NHS-funded IVF? Can round-the-clock access to thrombectomy for acute stroke—a commitment in the recent Programme for Government—really be delivered wherever someone lives in Scotland?

Although these might seem to be distinct, independent issues, they are not – all directly compete for resources with one another and with all existing services.

That fact underlines a fundamental, unresolved and largely undiscussed issue for the NHS in Scotland – how we manage escalating demand for “comprehensive” health care coverage in the face of finite resources.

The NHS has never been fully comprehensive, never done everything, for everybody, everywhere, all of the time. We have paid for our spectacles since 1951; some people get IVF and others don’t; some services are provided in all localities and others aren’t; and some services are available around the clock, rather than in weekday working hours only.

Prioritisation of how we spend NHS funds has always occurred. And as new drugs, procedures, and technologies appear, and the expectations of people of all ages rise, doctors and patient groups will not hesitate to lobby for more services – on demographic, geographic or condition-based grounds. The need to prioritise who gets what, where and when can only increase.

But none of our politicians seem to want to speak about prioritisation – we focus instead on how we might reduce demand for and costs of care, or how we might increase funding.

Restructuring of NHS administration, governance and bureaucracy – a live issue – could produce some financial efficiencies of scale. Prevention not only requires medical interventions but also substantial societal change; but if started early enough in life and sustained throughout might eventually produce a generally healthier population.  But prevention won’t stop us ageing and can’t stop us dying – each of which has a considerable health and care cost.

On the funding side, our politicians will continue to wrestle over the ideological pros and cons of increasing taxes or the equally contentious issue of the best distribution of the public purse. We will undoubtedly continue to argue about how much Scotland should spend on health and care. What we cannot sensibly argue is that resources are infinite.

Which takes us back, inescapably, to prioritisation. For every new initiative funded from a pot of finite size, what other use of money, staff and facilities are we forgoing? When we say we will do more of something, what will we do less of? There is no organised constituency for opportunity cost.

So, just how will the Scottish Government decide whether the three example services noted above can be funded? What principles are applied? How do those principles translate into transparent decisions between competing services? And if new services are funded, who, what or where will miss out? New drugs are reviewed by the Scottish Medicines Consortium, but what about everything else?

The government may point to Realistic Medicine and Value Based Health and Care. Both offer relevant principles. But how are those principles used to weigh maternity provision in Caithness against wider access to IVF or thrombectomy? Where can we see the alternatives considered, the trade-offs accepted and the reasons for the decisions? Having a framework is not the same as showing how it governs the choices made in our name.

After forty years working in the Scottish NHS – and leading a medical royal college for the past six – I don’t know the answers to these questions. We all should.

Norway attempts a more transparent approach. It has adopted three common national principles for prioritisation—benefit, resource use and severity—covering both specialist and municipal health and care services. Applying explicit common principles across Scotland’s health and social care would not only make decisions easier to scrutinise but also force us to confront the increasingly anachronistic, illogical and unfair boundary between their funding arrangements.

As we embark on another review of “social” care we should surely ask whether there is any defensible principle for funding different needs differently because one is labelled a “health” care need and the other a “social” care need. If we accept personal contributions for some social care needs, what principle rules such contributions out for healthcare—or justifies retaining them in social care? The distinction deserves an argument, not merely a history. If there is a principle underlying, let’s articulate it. If there is not, we should establish one before reorganising services around that boundary.

Before any restructuring of Scotland’s NHS and social care we should decide and explain what they are expected to provide, to whom, and on what terms.

Otherwise, we risk giving new organisations responsibility for promises nobody has established they can keep.

No care system can do everything, for everybody, everywhere, all of the time. Scotland already makes choices about who gets what, where and when. The question is whether those choices can be explained and defended in public.

So how does Scotland decide what it can promise—and who will tell us what it cannot?

Professor Andrew Elder OBE is the immediate past president of the Royal College of Physicians of Edinburgh