John Lister begins what we hope will be regular Lowdown coverage of the NHS in Scotland, with an overview of current key issues and an interview with UNISON’s Scottish Head of Health Matt McLaughlin.

The news media in England carries little information on the NHS in Scotland, which is controlled by the Scottish government, which is not due to face an election until 2026.

As a result insofar as many campaigners south of the border are aware of the Scottish NHS, they will probably be most aware of the apparent differences that should make things better in Scotland than England:

  • free prescriptions since 2011 (a positive difference underlined by the recent further increase in the prescription charges – paid only in England, and not in Wales, Scotland or Northern Ireland – to a massive £9.90 per item since May 1)
  • Scotland spends more per head on health than England, although the difference has narrowed. IFS figures show that in 1999–2000, Scotland spent 22% more per person on health than England, but by 2019–20 this had fallen to 3% more per person, and Scotland will spend around 3% more than England per person in 2024–25.
  • Scotland provides social care funded through taxation rather than the English system centred on means tested charges – although many residents in nursing homes still contribute, at least in part, to their care.
  • Scotland has a Safe Staffing Act, which came into force on April 5, following on from and going further than the similar legislation in Wales – while no such protection exists in England.
  • After devolution Scotland abolished the “internal market” created by Margaret Thatcher’s “reforms” – so NHS Trusts do not exist in Scotland. Instead, Scotland has 14 regional “health boards”. Health boards are then further subdivided into Health and Social Care Partnerships (HSCP), and there are now 31 HSCPs across Scotland. Each of the boards are responsible for delivering acute and primary healthcare services.

However despite ditching the competitive market and its expensive trappings of trusts, contracts and commissioners, a closer view of the way the system works in action reveals that many of the problems faced in England also apply.

Asked to sum up the biggest issues facing the NHS in Scotland, UNISON’s Scottish Lead Organiser for Health (Bargaining and Campaigns) Matt McLaughlin pointed to chronic failures of workforce planning and failure to address vacancy levels “across the board, including porters and cleaners”; and government failure to plan for proper provision of social care, “not just to reduce waiting times in A&E but also to improve primary cate including  mental health provision and addiction services”.

Social care

Social care is funded differently in Scotland: free personal and/or nursing care is available to all adults in Scotland who have been assessed by the local authority as eligible for these services.

But it is still heavily reliant on private sector provision, and there is just as strong a focus on holding down costs – not properly filling vacancies, and the nonsense of 15-minute visits to vulnerable clients from domiciliary services.

A 2022 Scottish TUC report Profiting from Care underlined the problems arising from private ownership of care homes:

  • It leads to care homes that are too big: “Big providers run older people’s care homes that are double the size of those not run for profit. A quarter of homes in our sample of big providers have at least 80 registered places.”
  • The care is worse: “Nearly 25% of care homes run by big providers had at least one complaint upheld against them in 2019/20, compared to 16% in the rest of the private sector and 6% in homes not run for profit.”
  • The staffing and pay levels are worse: “In older people’s care homes, staffing resources are 20% worse in the private sector compared to the not for profit sector.  … Over the last six years, the public sector has paid on average £1.60 more per hour to care workers.”

Official statistics show that in March 2022 just 10% of care home residents in Scotland were living in a facility run directly by a Local Authority or Health Board, while for-profit provision accounts for 82% of Scotland’s care home residents.

However the level of public provision of home care is much greater than England (where it has been almost completely privatised): 41% of Scottish clients receive care only from a private sector provider, and 35% from a local authority.

But as Matt McLaughlin points out, pressures on local authority budgets have meant “perceived cash savings have been prized more highly than quality of care.”

There are also problems arising from government refusing to tackle deep-seated problems and inequalities facing social care staff.

In April workers from Scotland’s three biggest social care unions, UNISON, GMB and UNITE protested outside the Scottish Parliament accusing the Scottish Government of “betraying” social care workers after a Freedom of Information request revealed £38 million ringfenced funding for maternity, paternity and sick pay for social care workers in Scotland had been secretly cut from the latest Scottish Government budget.

Safe Staffing

In 2019, the Scottish Government passed the ground-breaking Health and Care (Staffing) (Scotland) Act. The Act which “took bloody years to get through a legislation” was the first in the UK to set out requirements for safe staffing across both health and care services and most clinical professions.

The Act came into effect on April 5, but its effectiveness has been undermined by the Scottish government’s ludicrous delays in issuing guidance, meaning the majority of staff have still received no training or guidance on the new rights and obligations under the Act.

A UNISON survey released on May 7 shows the widespread failure of the Scottish government to prepare for the new Safe Staffing Act. It reveals:

  • Almost two thirds (65%) of staff were unaware of the NHS Safe Staffing legislation
  • An overwhelming majority (89%) of staff had received no training on the new regulations
  • Eight in ten staff no longer have confidence in existing procedures for dealing with inadequate staffing

Matt McLaughlin said: “The government has had over four years to prepare for this new law, yet guidance was only made available four days before it became law.

“There’s a direct link between staffing levels and high-quality outcomes for patients. Our members repeatedly tell us they do not have enough staff or enough time to give patients the care they need and deserve.

“The Scottish government does not have a true picture of the scale of the short-staffing situation in the NHS because incidents of short-staffing are chronically under-reported – staff simply do not have the time. And an obvious weakness is that key support staff are not included.

“The Act is potentially a powerful tool for driving up standards – but it can only make a difference if people know how to use it. And if when incidents are reported, there is help from health boards to fix the situation.”

The new legislation has not been linked to any serious workforce planning, and it is obvious Health Boards which are already facing growing delays in emergency departments are not going to close wards, even if they are short staffed. “They will rob Peter to pay Paul, moving staff around between wards to tackle shortages, but this may not necessarily be safe,” says Matt McLoughlin.

Another big problem is that the recording tool, Datix, is time-consuming and cumbersome, meaning many incidents of short-staffing are not reported. And staff have little confidence that reporting an incident achieves anything: as one staff nurse in Lothian told UNISON: “No point in doing Datix as nothing gets done.”

UNISON has devised a reporting tool that enables staff to alert the employer, but also their branch of staffing shortages and the potential impact on patient care.

For the union the key issue is to identify where the key pressure points are, and seeking to ensure there is a commitment to a long-term solution rather than just lurching from one crisis to the next.

A&E delays

More familiar to readers in England is the growing problem of long delays in Scotland’s emergency departments: the Royal College of Emergency Medicine has highlighted official figures from Public Health Scotland which show a staggering 6,260% increase in patients waiting 12 hours or more in A&E.

The figures show March 2024 was the worst March for performance on the 4-hour wait target in A&E since records began in 2011: one in three patients attending Scottish Emergency Departments waited 4 hours or more.

And, as in England, the underlying problem causing these delays is the lack of sufficient resources out of hospital to ensure patients can be discharged promptly when they are fit to leave hospital. Instead March saw 58,646 days spent in hospital by patients who were well enough to be discharged.

Matt McLaughlin said “This follows on from two decades of the political mantra that keeps telling us our performance is not as bad as other parts of the UK. But if we are not performing well it’s no comfort to know others are doing worse. I think it’s disgusting that the NHS has now embraced the phrase ‘corridor care,’ effectively accepting there are not enough beds.

“We also have another problem you have in England – ambulances lined up outside A&E, which not only leads to delays for the patients in the ambulances but also means the ambulances can’t respond to other calls – leaving more patients waiting.”

Mental health

Another area where Scotland’s NHS seems to be replicating the worst failures of the English system is mental health services. Police Scotland has recently warned that it is being “overwhelmed by the “appalling” demands made on officers by failing mental health services” and a failing court system.

Police forces in England last summer agreed a new policy in which the police will step back from responsibilities they are not funded or trained to undertake, leaving council social services to theoretically fill the void – but with no extra funding.

Now, according to the Guardian, Scotland’s chief constable, Jo Farrell, has called for more engagement by the NHS in tackling mental health problems on the streets, arguing:

“If somebody’s threatening themselves or a danger to other people, that’s absolutely where the police should be. But we are babysitting people who are not criminals, they don’t meet the threshold to be sectioned under the Mental Health Act but we feel the need to wrap around them because there’s nobody else.”

Other problems include addiction services that are under-resourced and under pressure, a reduced number of staff in post as demand for services has increased, and long delays for children and young people seeking mental health support.

“Too many services are relying on bank staff, leaving staff burned out,” says Matt McLoughlin. “And as services fall short we have too many people in mental health crisis attending A&E departments or winding up in the criminal justice system.”

The bank staff include heavy dependence upon locum doctors, with campaigners raising the alarm over the quality of services across the country.

Under funding

The long years of austerity since 2010 have also taken their toll on Scotland’s NHS, which accounts for just over a third of Scottish government spending from a pot of cash allocated from Westminster.

So in Scotland, Health Boards are being asked to deliver the same level of service with reduced real terms funding – just as ICBs are in England.

And growing numbers of Health Boards have been applying for “brokerage” (soft government loans) to help balance the books – in the same way as trusts and ICBs have been borrowing and dipping in to capital budgets to tackle revenue deficits.

Scotland’s Health Secretary Neil Grey has blamed reductions in funding from Westminster for the decision in March to suspend an interest-free loan scheme which has provided vital support for the cost of running GP surgeries since 2018. Thirty GP practices in Scotland warn they are at risk of collapse after the Scottish Government announced the scheme is “currently oversubscribed.”

With many of the same problems as England, it’s clearly a fallacy to believe Scotland’s NHS is performing much better, says Matt McLaughlin. “Politicians are quite good at warning us not to ‘talk down’ the NHS, but we have to be free to raise rightful criticisms.”

The Lowdown agrees that it’s vital to flag up issues, and we think it’s time to try to establish regular coverage of issues in Scotland’s NHS.

To help us do this we urge Scottish readers and activists, from UNISON, other trade unions and any Scottish campaigns committed to defending the NHS to flag up stories and issues which may well not be included in the very limited coverage available south of the border. Contact us in confidence at [email protected].



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