Prioritisation in NHS Scotland by Ewan Bell

I have to make it clear from the outset that the views expressed here are my own – these are my personal views.  They are nothing to do with being Associate Medical Director in NHS Dumfries and Galloway and do not reflect any local management or Board view! I’m writing this as an avid armchair follower of politics, current affairs and economics! I should also stress that I am a member of no political party.

To put my views in context, I should state that I believe that there are 2 fundamental and essential pillars of a fair society;

  • Equality of opportunity; in real terms this means free access to education and zero tolerance of discrimination
  • Free healthcare; people should not suffer or die because they can’t afford to pay for health-care

I am a passionate believer in the concept of the NHS and free health-care for all. My mum and dad tell me stories about how their grand-parents couldn’t afford to go to see the Doctor. In my view this is unacceptable, incompatible with a fair society and must remain in the past. 

On one hand we have increasing costs due to advances in health-care technology, changing demographics, increased expectation and the costs of prescribing. And on the other hand we have limited resources. Demand will always outstrip capacity. Just about every health-care system in the world is wrestling with this challenge, no matter whether they are publicly or privately funded. There will never be unlimited resources, or indeed adequate resources, to provide all health-care, free of charge, for all people. So how should we, as a society, respond to this challenge?

Let’s consider an analogy.  All households have a defined income. We might moan about it and complain, but there’s not much we can do about it. So how do we respond to this? Most organised households will budget and align expenditure with income. There are fixed essentials, such as tax, national insurance, council tax and rental (or mortgage) payments, over which we have little control. But there are other outgoing costs which can be varied and influenced by the household (maybe not enthusiastically), such as, for example, food, clothes, heating, alcohol, etc. If times are hard, then a household will pull back to the fixed essentials and moderate spending in other areas, or to put it another way, the household will prioritise its spending.

If we apply this approach to health-care, then we need to start debating and defining the essentials of health-care and what can we pull back from. In other words, we really are going to have to start discussing what we should be focusing our limited resources on and what we should stop doing, as not all interventions are equal.

I suppose this goes back to my initial views on the pillars of a fair society. To maintain free health-care for critical, core services in the NHS, we are going to have to start redefining what health-care means and acknowledge that we can’t continue to provide the current range of interventions and services, if we want a sustainable NHS for the future.

So, what are the essentials and what should we stop doing?

Dr Ewan Bell is a Consultant Biochemist and Associate Medical Director for NHS Dumfries and Galloway







11 thoughts on “Prioritisation in NHS Scotland by Ewan Bell

  1. I completely agree. We also need to manage public expectation and perception of being denied services far better.Consultation needs to involve frontline staff too.

  2. Interesting and brave question! This is something that many will shy away from asking but the current state of affairs demands that we look into it. There will be no easy answers and, sadly, the realist in me sees us losing our free healthcare long before any resolution of this type will be found. We, the public, don’t want to think about what this route would mean for us and our families but are still unwilling to accept more responsibility for the state of our health and will continue to place unrealistic demands on an already strained health service by maintaining our high expectations. Also, we are continually striving to improve and to make services better and safer. Laudible aims but what if the actual bare bones provision of services suffer as a result of these goals? When do we need to re-examine what the ultimate aim should be?

  3. Agree whole‎heartedly  Ewan. Current mess is due to relative disinvestment in primary care and crazy concentration on surrogate outcomes rather than holistic care. Add in starvation of funds to local authorities social care being underfunded as result and you get inappropriate hospital admissions and bed blocking. I hope integration can improve matters but haste with which it is being imposed and the difficulty in recruiting management to implement it especially down here in Wigtown do not fill me with confidence.John Macdonald Sent from my BlackBerry 10 smartphone. From: dghealth‎Sent: Friday, 13 Novemnnber 2015 10:14E‎To: jonmacbladnoch@gmail.comh‎Reply To: dghealthSubject: [New post] Prioritisation in NHS Scotland by Ewan Bestic carell

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    dghealth posted: “I have to make it clear from the outset that the views expressed here are my own – these are my personal views.  They are nothing to do with being Associate Medical Director in NHS Dumfries and Galloway and do not reflect any local management or Board vie”

    • I have to say I take exception (but then I would wouldn’t!) to your citing the increasing costs of healthcare technology as a net loss. There are many cases where new technology is substantially contributing to the efficiency and efficacy of healthcare.
      Simple things like the reminder service for out patient appointments have significantly reduced the number of DNAs – resulting in substantial savings of clinician time. Has anyone ever calculated the savings associated with the use of email over countelss pieces of pink paper consumed by the NHS in days of yore? Increasing use of such things as video conferencing will further save patients time and travel costs. The list is almost endless.
      I believe that, whlst there is no denying increased cost of technology does bring associated costs, the net effect is an overall saving which can re-invested in providing better and safer care.

      • Sorry – wasn’t talking about Information Technology – I was meaning Health Technology costs which is different Andy.

      • Understood – good blog and thought provoking. Glad i don;’t sit on any Ethics committees. National Public Benefit and Privacy Panel is hard enough!

  4. Good one Ewan. This is perhaps the biggest question around for the NHS, bigger than the new hospital or health and social care integration – how can we make it sustainable in future. We can’t leave it to Govt to decide what should and shouldn’t be provided, we all need to engage with this question in D&G too and, yes, play a part in some difficult decisions.

  5. I wholeheartedly agree, especially with your thoughts about the household budgets. Isn’t that what we all do when times are hard and I have had that for the last 4 years!! You have to re- look at your outgoings and incomings and adjust to suit and cut out all the items that you dont really need to have and especially the luxuries. With being a member of the environmental meetings team I have been pushing this subject for years and even won an efficiency award in 2010 for my efforts. The problem is that it is hard to do when there is only a small team we need everyone on board not just looking at the clinical side of this but as an overall picture. If everyone coming to work everyday (as we spend more time at work then home) looked at working practice whether that be from a clinical, admin, domestic, catering, transport point of view as they do at home we may not be in this mess. After all iIT IS OUR TAX PAYING MONEY and we wouldnt just waste it at home so why waste it at work. Turn off those lights, computers, equipment if not needed, stop chucking items in the bin re-cycle what we can, question your working process and how you do things (YES you can do this) and make a difference. I have seen alot of waste within the NHS and had some ideas put into practice with the help of Chris Lyons but we all need to wake up and smell the coffee if we want to keep our precious NHS.

  6. Totally agree with this Ewan. Probably should have been discussed at the time of the economic turndown but not really a vote winner. Shame that politicians have the Comical Ali approach to this debate!

  7. Pingback: Clinical Efficiency by Ewan Bell | dghealth

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