Scots are proud, and protective, of the NHS.
Polls reveal that voters regard it as the last area that should face the axe when public spending cuts are required. Successive Scottish governments have responded by protecting the health budget.
In spite of having avoided the worst of the Government's austerity cuts, the NHS is facing a gathering crisis, due to unprecedented pressures caused by Scotland's ageing population. Older people are more likely than the young to have complex medical needs and are typically more susceptible to severe infection and falls requiring hospital admission, factors which are stretching the NHS's capacity to cope. All it takes is an outbreak of disease and the system can – and does – become overloaded.
Last winter, hundreds of patients had to wait more than 12 hours in accident and emergency departments because of bottlenecks in casualty and a lack of beds in wards. Many more were moved from ward to ward in search of a suitable bed. The situation may have eased to some extent now summer has arrived, but there is clear evidence many hospitals have periods all year round when they struggle to cope.
Today we report that ministers knew long before last winter's crisis the vast majority of A&Es were regularly unsafe. A report showing 21 out of 24 A&Es were unsafe on a weekly or monthly basis was sent to the former Health Secretary Nicola Sturgeon last spring by the College of Emergency Medicine in Scotland. While the Scottish Government opened discussions with doctors' representatives on how to improve the situation, details of the report were kept quiet until today.
Last winter, Ms Sturgeon's successor, Alex Neil, often responded to reports of patients waiting half a day in A&E by highlighting a seasonal upsurge in norovirus. It now seems clear that simply made an already bad situation worse.
The Scottish Government did respond to the winter capacity crisis: 18 extra emergency care consultants are to be hired, which means Scottish hospitals will go into winter 2013/14 better prepared than last year. A £50 million Unscheduled Care Action Plan has been drawn up to ensure people are "seen quickly and treated effectively" following an emergency admission, and the action plan is to be delivered by a new task force.
Is that enough? Not in the view of this newspaper. The problems go beyond the accident and emergency department and require more than a quick fix. Scotland's public finances are projected to be squeezed for another five years. Even if the NHS budget stands still, current resourcing will be insufficient given the growing demands upon it from the ageing population.
That is why The Herald is calling for action to support the nation's most beloved institution. In our series, NHS: Time for Action, which launches today, The Herald is recommending a beds review to ensure Scottish hospitals have the right beds with the right staff in the right place at the right time to cope with the ageing population and surges in ill health.
Going forward, The Herald also believes there must be a review of community care capacity, to find out how provision for personal care, community-based nursing care and residential care will need to expand to look after the ageing population outside of hospital.
More than 1400 beds have been cut from NHS hospitals since 2007. There are logical reasons for the fall: for instance, fewer patients than in the past are required to stay in hospital overnight before or after operations and more elderly people are recuperating at home. Yet while having beds that are empty some of the time may seem inefficient at a time of funding constraint, flexibility is essential for hospitals to cope during upsurges in demand.
The Health Secretary has signalled that the NHS in Scotland cannot manage in future if bed numbers continue to fall: agreed. The decline in bed numbers is unsustainable and a freeze on reductions of acute hospital beds is required. The outstanding question is, will more beds be needed in future or can steps be taken to bear down on demand so much that the NHS of the future will be able to cope with the same number of beds it has now?
A beds review should consider how much more can realistically be done to prevent older people needing hospital treatment. It should not assume such measures will solve the problem, but should consider how much more capacity hospitals will need to cope with the ageing population if steps taken to prevent and shorten hospital stays are successful, partially successful or unsuccessful. The difficult truth is that it is likely more beds, with staff trained in assessing the elderly, will be needed.
How much capacity will be required depends on a number of factors. The integration of health and social care is underway, designed to ensure elderly people are not left languishing in hospital (unkindly termed "bed blocking") when they could be looked after at home or in residential care. This will be essential to relieving pressure on hospitals. The way existing beds and staff are used also requires close scrutiny. If a patient cannot be discharged at weekends, due to a lack of support services such as ambulance drivers, how much pressure does that put on hospital capacity?
The NHS continues to manage thanks to the magnificent dedication of its staff. It is not the nurses, doctors, auxiliaries, managers, secretaries, orderlies and receptionists who are responsible for the pressure on the system but they make it work. They know better than anyone how stretched resources are and it is for them, as well as for patients, that a beds review is required. Relying on ever harder work by staff to meet a shortfall in resources is not the way forward.
Given the changing age profile of the population, the NHS cannot deliver the range of services it does, within the timeframes set for it by Government, without it costing ever more. The majority of Scots wish to preserve a healthcare system that is free at the point of delivery, but may not be willing to pay greater premiums though taxation for the system to grow according to its current model. It is essential that the public joins together with public policy experts, NHS staff and politicians in discussing what it is right to expect of the NHS and how to meet those expectations.