This week’s budget had a noisy political backing track. The cynical (or Hugh MacDiarmid) might have called it a wheen o’ blethers.

However, let us be charitable and say that our elected tribunes were simply reflecting popular economic anxiety.

Consider tax. The revenue changes in this budget are relatively – I stress, relatively – slight, if complex.

However, there was broader substance for Opposition parties to attack.

The First Minister, Humza Yousaf, said the tax hike for higher earners was in line with his administration’s values. But why then freeze a regressive council tax? Where is the consistency?

Similarly, why refuse to curb business rates, as in England, while providing relief to hospitality firms in the islands?

I get the concept: a fiscal apology for absent ferries. But, again, consistency? If it is value driven?

This budget was motivated rather by pragmatic necessity, not least decisions taken by a pre-election UK Government.

It was smothered by a persistent crisis: the UK again at risk of recession and Scotland’s onshore GDP contracting in October.

But, boy, was it loud. Labour’s Anas Sarwar condemned the budget as “devastating”. For the Tories, Douglas Ross lampooned the FM as “High Tax Humza”, drawing a mild rebuke from the chair. In response, Mr Yousaf appeared at one point to be visibly snarling.

Amid all this clanjamfrie, the dog that didn’t bark. Or, rather, the hound which generated little more than a surreptitious whimper.

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That susurrating canine whelp was first discerned when Shona Robison set out her Budget in the chamber.

Tax, she noted en passant, was insufficient. She had to ensure that services were “sustainable”. By which she means reform, most notably in the NHS.

The National Health Service has replaced organised religion as an article of faith. Wonderful and glorious.

Except it’s not. The prognosis? Ailing and unlikely to survive in its present condition.

To be quite clear, that is in no way to denigrate our NHS staff. Entirely to the contrary. It is incredible they make things work at all, given soaring demand. Plus, many hate being eulogised, given that can create unrealistic expectations.

We have learned, as a species, to prolong life. We have not yet learned how to sustain life tolerably for our oldest citizens. Hence the huge pressures on health and care.

Consider the sundry challenges facing our health service. At the most fundamental level, there is substantial over-prescription of medicines. Such drugs may be free to the user – and I understand why – but they are very far from free to the NHS.

I know, I know, it must be intolerably difficult to tell an individual patient, perhaps already afflicted by angst, that their script is being halted or even altered. The easy route is simply to sign the prescription, adding yet another chemical remedy to the mix.

Patients end up with a blister pack of bewilderment. They take their blue pills and their pink pills – with little discourse as to their continuing efficacy and their interaction.

Added to this potent mix, there are the pharmaceutical companies whose interest lies in vigorously promoting ever more drugs, with ever higher bills attached.

These appeals will commonly be accompanied by pleading from community groups. Just this one drug. Just this one exception.

I understand. Trust me, I understand. If I were campaigning for a relative, I would do the same. But, more generally, the NHS has long since passed the point of sustainability.

It is not just drugs, of course. There is comparable pressure to adopt new medical kit or testing equipment, again advanced vigorously by companies.

We cannot afford it all. We do not have the money. It is inconceivable that we will find sufficient money in the foreseeable future. Demand is outpacing supply.

And yet more. Waiting lists and times, especially in A&E, also reflect increased demand. From an ageing population, yes, but also from ever more fretful citizens.

Once more, I understand. I empathise. But we have to find ways of reducing that over-weening demand. Through public appeals, as currently happen. But perhaps also by enhancing the NHS 24 system to offer an extended listening ear where that might pre-empt a hospital visit.

Then there is bed blocking. Hospital slots are occupied long beyond clinical need because there is little alternative provision in the community.

The notion of a National Care Service was advanced as an innovative and substantive way to address that problem.

Not sure it works, though, as I have noted in this column previously. Too grandiose, too bureaucratic. Concerned with structures rather than much-needed care teams in our towns and cities.

I suspect that view is now shared by incumbent ministers. Hence the plan has been delayed by three years and substantially scaled down.

Might be wise to drop the scheme entirely. Praise the ambition, but focus instead upon hiring (and rewarding) staff to clean up and attend to folk in need.

However, that will not solve bed blocking. We cannot sanction individual patients, but could hospitals start charging councils who fail to provide alternatives, as they are required to do?

I am aware that this in itself could add a layer of bureaucracy, which I would deplore. But we have to put pressure upon councils (and, let’s be frank, individual families) to provide options to hospital beds.

I appreciate that NHS reform will be exceptionally difficult. There will be instinctive public resistance. Opposition parties will be quick to condemn while privately aware that they would face identical problems in office.

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But we require a step change. The mantra of the health service is “free at the point of need”. I would definitely keep the “free” bit. Folk should not have to pay for vital medical care.

However, I would examine the word “need”. How do we define it? Is it any service which a patient perceives as useful? Which a patient demands? Or is it genuine clinical need as assessed by a doctor?

It should be the latter. And we need to scale back on the scope of that need, in order to reduce demand. That will be tough. Really tough. But it is essential. The dog needs to bark. Loudly.