IT did not last for very long, this glimmer of grown-up debate about the sustainability of the NHS. No sooner was it detected than the shutters came down, and the earnest shibboleths about founding principles were dusted down and hurried into the open.

Leaked minutes of a meeting of NHS Scotland directors included the suggestion that the Scottish Government create a two-tier NHS, with wealthier patients paying for NHS care. Other proposals included the funding of new drugs, and hospitals potentially discharging patients more quickly than is currently the case.

Two key phrases stood out from reports of the leaked document; the group had been granted the “green light to present what boards may feel reform looks like”; and “areas which were previously not viable options are now possibilities”. Additionally, a lack of clinical output in the SNP’s political decision-making had left Nicola Sturgeon’s administration “divorced from reality of life and purpose of service”.

The sensitivity of the matter stems in part from the fact that the directors had been briefed about recent conversations with Caroline Lamb, chief executive of NHS Scotland, who works closely with the Scottish government’s health secretary, Humza Yousaf.

Ms Sturgeon swiftly asserted her opposition to the notion that wealthier people might pay for NHS treatment . The founding principle – free at the point of delivery – was not up for discussion (Rishi Sunak said the same thing at the CBI). Cybernats predictably then rounded on BBC Scotland, which had exclusively reported the leaked document. BBC bosses at Pacific Quay were commendably quick to defend their right to report on NHS matters.

People are wearyingly familiar with news stories about waiting lists, widespread patient dissatisfaction, delayed ambulances, overcrowded A&E departments, and grievously over-worked doctors and nurses. NHS Forth Valley has even been placed in special measures amid worries about its leadership, out-of-hours service and unscheduled care.

Further accounts of bed shortages and waiting-lists will emerge as we move deeper into winter. The exceptional NHS response to the global pandemic naturally impacted upon its ability to carry out elective services; but can this lost ground ever be recovered?

You can’t blame NHS workers from seeking better lives abroad. Our health correspondent, Helen McArdle, has spoken to one nurse, from Perth, who is now enjoying a much more rewarding life in Perth, Australia. Others will assuredly follow in his wake.

Would that such serious problems were all that the NHS has to deal with. The SNP government might have rebuked the directors for having that contentious discussion about a two-tier NHS, but we are fast approaching the point – if, that is, we are not already there – when we really need to have a frank national discussion about the sustainability and future of the health service.

What exactly do we want from it? Are its 1948 principles now out of date? What, if anything, are we willing to pay for? Would we be willing to countenance higher taxes, especially in the light of the tax rises unveiled by the Chancellor? Should we, as a retired consultant surgeon pondered in a letter to The Herald this week, write off the founding principles and adopt a European model supplemented by social and top-up private insurance?

There’s evidence that Scotland already operates a two-tier NHS system, with 40,000 patients undergoing private procedures in the last year. At an average cost per patient of £12,500, hip and knee surgeries are formidably expensive but they indicate that for many people it’s better to bear the cost of going private than waiting for the NHS to help, even it means remortgaging your home.

To a degree, initiating an honest national debate about the health service – and, more importantly, agreeing in advance to give serious thought to any of its conclusions or recommendations – would be a genuinely bold political move. The mere act of establishing it, and agreeing its frame of reference, would take considerable time and effort. But anything has to be better than doing nothing, better than the inane repetition of cries to ‘save the NHS’, whatever that means in these straitened times. And, in the meantime, services such as dentistry will continue to be reduced without any big fanfare.

Would any government in Edinburgh or London have the courage to say that we should adopt some kind of insurance model, pointing to the success of such programmes on Europe or Australia, which tend to have better outcomes on such matters as cancer survival? Or would they write off such an idea as an instant vote loser?

We do at least need an urgent reappraisal of NHS spending. Part of the vast sums devoted to healthcare could be diverted into social care or preventative healthcare, in order to ease pressure on the NHS in the first place. Complicating this, however, is the fact that Britain has an ageing and increasingly obese population, which means that demand is likely only to increase in the next decade or two.

In the immediate term, the workforce is the biggest problem facing the NHS. One quick fix that the UK could make is to address the pension tax problem that is driving senior doctors to slash their hours and retire early. Doing more to retain existing staff should be the top priority for Edinburgh and London, especially as it is more expensive to have staff quit then NHS and return as agency staff.

This might be a more easily attainable solution than publicly debating the sustainability of our national health service. But surely it is time that those founding principles, jealously guarded for so long and at such expense, came up for debate.

Keeping the indy dream alive

IN the light of this week’s UK Supreme Court decision Nicola Sturgeon hopes that a pro-independence majority at the next election will help her pressurise London to begin talks on ending the Union. This assumes, however, that London will pay any heed.

Should such a majority fail to materialise, where can the independence movement go from there? Unionists may hope that the issue simply withers, especially if Keir Starmer as Labour PM devolves further powers to Scotland. But independence will remain the defining political question of the age. How can the SNP keep its independence diehards onside when there’s no prospect of a second referendum? Some activists say, darkly, that the Union cannot be a voluntary one if there is no way out. They have a point. But keeping the dream alive will take considerable ingenuity.