I HEARD the story about Scotland’s NHS board chief executives pondering the possibility of better off people paying for their treatment via Kaye Adams’ phone-in on BBC Radio Scotland.

All credit to the BBC’s James Cook for breaking an important story. However, by yesterday morning it seemed there was an edict to issue a pronunciamento at three-minute intervals distancing the Health Secretary, Humza Yousaf, from any such policy. This seemed a little excessive since nobody attributed the idea to him in the first place.

Anyone who listened to the programme might have concluded that Mr Yousaf was protesting too much. It may, as he said, be “abhorrent” that people should be asked to pay for treatment nominally available through the NHS. However, it is also the reality that this is happening on a rapidly growing scale.

That is not due to ideological choices on the part of patients or the Scottish Government. Overwhelmingly, it results from the inability of the NHS in Scotland, for which Mr Yousaf is responsible, to deliver the prospect of treatment within any reasonable timescale. Calling the logical outcome of that failure “abhorrent” does not make it go away.

The private healthcare sector is booming while the NHS is struggling under the weight of demand and under-staffing. For the great majority who cannot, even in extremis, turn to private provision, the alternative is often the burden of ongoing pain, distress and deteriorating conditions. There are a lot of “abhorrent” outcomes when our NHS is unable to provide.

In these circumstances, it was right for Caroline Lamb, chief executive of NHS Scotland, to give the "green light to present what boards feel reform may look like" and advise that "areas which were previously not viable options are now possibilities”. That, at least, is what the minute attributes to her and such open discussion should be welcomed.

Now it is in the public domain, the content of that discussion can serve a useful purpose as a launchpad for debate. It clearly allowed views to be expressed which are normally withheld for fear of offending the politicians but which are actually much closer to reality than the PR that comes out of St Andrew’s House. Insofar as we already have a two-tier health system, that should be acknowledged.

While it was understandable that the headline coverage highlighted the “better-off should pay” aspect of the chief executives’ think-in, there was much else in the leaked minute which Mr Yousaf cannot dismiss through rhetoric or mere abhorrence.

The fundamental challenge was set out succinctly. Describing a "billion-pound hole" in the budget, the minute warns that it "is not possible to continue to run the range of programmes" the NHS currently offers while remaining safe "and doing no harm” … “Unscheduled care is going to fall over in the near term before planned care falls over."

Other extracts read like a counsel of despair from health board chief executives about the relationship with their political masters in Edinburgh. There is a "disconnect from the pressure that the boards are feeling and the message from Scottish Government that everything is still a priority and to be done within budget".

Furthermore, the minutes note "concern" about an alleged lack of clinical input into political decision-making which, they say, leaves the Scottish Government often "divorced from reality of life and purpose of service”.

There is an intriguing reference to “siloed discussions ongoing within Scottish Government” that exclude health professionals. “Fundamental reform" of the primary care model "must be on the table", while the success of the NHS has been built on a model "that no longer works today".

The depth and range of these sentiments will come as no surprise to anyone who speaks to people who work in the NHS. They know that the structure around them is becoming more fragile by the month and, no matter how long, hard or caringly they work, the odds are increasingly stacked against them.

Money alone is not the problem, though it always helps and that “billion pound hole” needs to be explained. Last year, the Institute for Fiscal Studies reported that whereas the gap between per capita spending on health in Scotland was 22 per cent higher than in England pre-devolution, it had now narrowed to three per cent. Why has this happened?

From the day it was created in 1948, the NHS in Scotland had autonomy to set its own priorities, influenced by our scattered geography and industrial history. The Barnett formula helped ensure it was well funded in both absolute and relative terms. Now the same formula brings the same proportionate share to Scotland but it is up to the devolved Government to decide how it is spent.

The translation of Barnett consequentials into budget headings is infamously opaque but has certainly contributed to that “billion pound hole”. The least Scotland was entitled to expect was that every penny generated by NHS spending elsewhere in the UK should be committed to NHS spending when it reached Scotland. That did not happen.

Like everywhere else, we have an ageing population which demands a coherent vision for the future. One key element is staffing yet, despite years of warning, we neglected to train enough nurses, so Scotland is now 10% short, with the exodus accelerating. Why did Scotland stop training its own nurses and how can this be reversed? These are practical questions that must be addressed.

Scotland, like everywhere else, needs an honest, fundamental review of how health care is to be funded and provided for years ahead. Just as in the NHS chief executives’ meeting, there must be room for radical thinking, not least about how much we are prepared to pay for a 21st century NHS whether through taxation or by other means.

Whoever leaked this document has performed a real public service. Let’s now see how Ms Sturgeon – who was Health Secretary for five fateful years – and Mr Yousaf respond to it. There must surely be more than denial and cliché.

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