Issue 22


By Andy Maciver, Director, Message Matters

“During times of universal deceit, the truth becomes revolutionary.” So said George Orwell, whose quote applies perfectly to one of Scotland’s most important and sometimes controversial policy areas.

In our national discourse on the NHS, we are far from reaching the revolutionary truth, however we are certainly living in a time of universal deceit. Healthcare is the single devolved policy area in which there is effectively no policy discussion.

Every party’s policy is depressingly identical - laud ‘our NHS’, throw more money at it and pray that it works. As we edge closer to the 2021 Holyrood election, we are entitled to expect our politicians to do better than this. However, we - in the media and in civic Scotland - need to give them the space to have an adult discussion about how we provide healthcare for the rest of this century, without the hysteria usually associated with a healthcare debate.

We are capable of this. We have five health spokespeople at Holyrood - Cabinet Secretary Jeane Freeman, Miles Briggs, Monican Lennon, Alison Johnstone and Alex Cole-Hamilton - of sense and decency who can conduct a great debate on the NHS.

I have four simple rules of engagement to help such a debate might take place; four pillars which all parties, I believe, should be able to accept as facts rather than assertions.

1 - The NHS is not free

We’ve all seen it in our Facebook feeds. The friend who posts something like this:

“I love the NHS. I fell last night and hurt my arm, I went to A&E, they x-rayed me, it was broken, and I’m now home in a plaster having a cup of tea. We’re so lucky in this country to have the NHS. #lovetheNHS.”

I read these posts and think “so what?”. In my view, what happened to this person is precisely what I would expect. No more, no less. It’s what would happen in every country in the EU, for example, none of which have a healthcare delivery system like the NHS.

So why do we have this semi-religious, near cult-like obsession with the NHS? With what is a system; a delivery mechanism for state-funded healthcare, just like the DVLA is a delivery mechanism for vehicle registrations.

In my view, the root of the problem is the labelling of the NHS as ‘free’. This lazy label - used by the media, politicians and, well, everyone really - has a subliminal impact of making us feel grateful for what we have, protective over it, and reticent to question it or demand value.

This debate-stifling ‘free’ label should be eradicated. The NHS is not free, nor is it free at the point of use.

If we take the average salary in Scotland to be £25,000, the average earner will pay around £5,000 per year in income tax. Expenditure on the NHS comprises, conservatively, around one-third of total Scottish Government expenditure which means that, again being conservative, the average worker pays over £1,500 per year towards their healthcare.

Or, I should say, their health insurance. For that is what the NHS is - a national health insurance system, operating like any other insurance system whereby a group of people pool their risk. The only difference between the NHS and, say, car insurance, is that there is a welfare element guaranteeing that nobody is uninsured. In other words, those of us who work and pay tax agree to pay the medical bills of those who do not, should they need it. And instead of premiums based on risk, premiums are based on income - if you earn £50,000, you’ll pay well over £3,000 a year for your healthcare.

Like all insurance cover, as individuals we sometimes get value for money, and we sometimes don’t. Those years when we don’t crash our car and don’t need to claim, but we still pay? Those are the same as the years when we’re not in hospital. We pay more in to the pot than we get back. But those years that we do crash the car - or that we need an operation, for example - are the years when we get back much more than we pay. That’s insurance.

But it’s not free. It never has been, and it never will be. So let’s stop pretending it is.

2 - Don’t deliberately confuse privatisation with profit

The easiest, laziest, argument-ending slur that can be thrown at an opponent is that they support the ‘privatisation of the NHS’. It’s the argument that’s designed to end the argument; a bit like calling someone a Nazi in a debate about Brexit.

The trouble is that the issue they’re discussing is almost never actually privatisation, which would involve the removal of the right of treatment without payment. This doesn’t happen, it never has happened, and I have never heard any political party arguing that it should.

Instead what is being described is either contracting out, or the provision of services for profit. Without a profit motive, the NHS would shut down. The most obvious reason for this is that almost every GP in the country runs, or works for, a profit-making private enterprise. You visit your GP, and instead of billing you directly your GP bills the NHS, which you’ve paid for in your tax. The NHS provides its service; you get your treatment; the GP makes a profit. That’s how it works.

Without a profit motive, primary care would shut down. And so would hospitals. When you go to the hospital, you are met by a receptionist with a Bic pen and a Dell computer, and by a doctor with a Littman stethoscope who sends you to a radiologist using a Siemens MRI scanner, before treating you with drugs researched and made by GSK. None of these multinational corporates provides free equipment to the NHS - they all work under contracts and they all make a profit.

Unless there are some very clever people at St Andrews House who can make pens, computers, stethoscopes, scanners and medicine, we will always need private companies to supply to the NHS for a profit.

Additionally you may, in some cases, be sent to a Spire hospital for your procedure in order to alleviate a waiting list, and Spire will make a profit. Indeed you have the option of doing this yourself if you have money or private insurance. But, critically, you don’t have to.

Not a single element of any of this constitutes privatisation because it leaves the principle of a universal right to taxpayer funded treatment untouched. So let’s stop trying to stifle debate by pretending that it does.

3 - The alternative to the NHS is not a US healthcare system

As well as the ‘privatisation’ accusation, a favourite finger-point towards those who see the need for reform of our healthcare system is that they wish to import the American healthcare system. I have never, however, actually heard any Scottish (or British) politician advocate this.

The American system and the British system should be seen as two ends of the spectrum, with ours almost entirely nationalised and centralised, with a universal right to access, and theirs a localised, independent system with no right to access for a large group of ‘in the middle’ people who are neither poor enough to qualify for Medicaid nor wealthy enough to have occupational or private insurance.

However there are dozens of healthcare systems clustered around the centre of this spectrum, many to be found in continentail Europe. These systems share aspects of both the UK and US systems. They tend to have universal access, like the UK, but they are more explicit about the fact that they run an insurance service, and they also tend to encourage localism and competition, like the US, giving the patient more choice and control, and sometimes more ability to ‘top-up’ for better or quicker care.

The number of people who believe we need to think again about what we want to pay towards the NHS, and what we expect to receive in return, will inevitably increase over the coming years. Many of them will want to look more closely about what we can learn from Europe, and they deserve to be heard without their opponents yelling “America” at them.

4 - The NHS is average, at best

For those who have an emotional, even religious attachment to the NHS, accepting that there is absolutely no evidence that we have the best healthcare system in the world will be difficult.

Similarly, for those who see the NHS as a Stalinist creation which mirrors 3rd world outcomes, the acceptance that the system is not quite the rich world’s worst will also grate.

But both must face this truth: the NHS is evidentially average, at best. There are, of course, lots of indicators of outcomes, but if we look at outcomes for the most common cancers, heart attacks and stroke, the NHS usually ranks in the 20s, according to OECD data.

I have never seen data based on quality or outcome which places either the Scottish or English NHS at or anywhere near the top of OECD countries.

The NHS is not the #envyoftheworld, and frankly it is cringeworthy to watch doctors, politicians and academics tripping over themselves to claim that it is, without even a shred of supportive evidence.

I am confident in our ability as an intelligent, open, confident, outward-looking nation to behave in a reasonable way about this most important, but least debated issue. The NHS faces existential challenges; more people, living longer, with more complex problems, and a limited willingness amongst the population or our governments to ask taxpayers to pay more towards it.

It’s time for some adults in the room. It’s time to talk.

By Andy Maciver, Director, Message Matters

Issue 22

Issue 22


Scotland's public sector challenges are everyone's responsibility

Twenty years on from the establishment of the Scottish Parliament, much is made of Scotland’s distinctive approach to public services. There’s no doubt that there are some real successes, like the Scottish Government’s approach to social security, where the rhetoric of dignity, respect and fairness has so far been matched by the reality. But Scotland is facing the same headwinds that are affecting public services all over the world. And we are more exposed than ever before, as the Scottish Government is now responsible for taxes that fund around 40% of devolved spending.


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