NHS bosses in Scotland discuss having wealthy pay for treatment

Health services across the UK have come under unprecedented pressure in recent years

NHS leaders in Scotland have discussed abandoning the founding principles of the service by having the wealthy pay for treatment.

The discussion of a "two-tier" health service is mentioned in draft minutes of a meeting of Scotland's NHS leaders in September.

They also raise the possibility of curtailing some free prescriptions.

Scotland's First Minister Nicola Sturgeon said the principles of the NHS were "not up for debate".

She acknowledged the "very significant pressure" facing health services worldwide but added that the process to "redesign and reform" would "take place - for as long as I have got anything to do with it - within the confines of these founding principles".

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The minutes of the meeting seen by BBC News are marked "in confidence not for onward sharing" and highlight the degree of official concern about the sustainability of Scotland's NHS in its present form.

They include suggestions that hospitals should change their appetite for risk by aiming to send patients home more quickly, and pause the funding of some new drugs.

According to the minutes, the meeting began with an update about "recent conversations" with NHS Scotland chief executive Caroline Lamb.

The group were then advised that they had been given the "green light to present what boards feel reform may look like" and that "areas which were previously not viable options are now possibilities".

Describing a "billion pound hole" in the budget, the minutes warn that it "is not possible to continue to run the range of programmes" the NHS currently offers while remaining safe "and doing no harm." And they warn that: "Unscheduled care is going to fall over in the near term before planned care falls over."

The minutes note "concern" about an alleged lack of clinical input into political decision-making which, they say, leaves some Scottish government suggestions feeling "divorced from reality of life and purpose of service." Scotland's Health Secretary Humza Yousaf told the BBC he disagreed with that assertion.

He added: "I meet with the chairs and chief executives on a very regular basis and we have very good conversations about reform of the NHS which I think can happen within a space but those parameters cannot compromise the founding principles of the NHS."

Last month the BMA in Scotland said the country's health service was in a "perilous situation" and urgent action was needed to tackle work load pressures. Official figures show about 6,000 nursing and midwifery posts are unfilled while A&E waiting time targets continue to be missed.

The meeting minutes go on to highlight an alleged "disconnect from the pressure that the boards are feeling and the message from SG [Scottish government] that everything is still a priority and to be done within budget".

They also state: "Concern was noted that there may be siloed discussions ongoing within Scottish government that do not include CMO/CNO (Chief Medical/Nursing Officer)."

There is a suggestion that "fundamental reform" of the primary care model "must be on the table", and that the success of the NHS has been built on a model "that no longer works today".

However, the minister Mr Yousaf said: "The Scottish government's policy could not be clearer, our National Health Service must be maintained to the founding principles of Bevan - publicly owned, publicly operated, and free at the point of need."

It may be unusual to see these sorts of thoughts written down by NHS bosses, but the discussions in Scotland are - by and large - ones that are being had across the UK. Wherever you look services are struggling. And while plenty argue the NHS has seen its budget squeezed too much over the past decade, funding is only part of the issue.

An ageing population, coupled with ever-more expensive drugs raises some very difficult, uncomfortable questions for decision-makers about where the boundaries of a health service should lie. They boil down to three key issues.

1. Does there need to be more rationing? Many drugs that come on to the market now are not treatments that cure disease, rather therapies that can extend life. The NHS pays a premium for these. It's why some are suggesting cutting back.

2. Should the NHS charge more? Payments are always controversial. But it's worth remembering in the early 1950s when budgets were tight charges were brought in for dentistry, prescriptions and spectacles. Northern Ireland, Wales and Scotland have subsequently scrapped prescription fees, but it is noticeable reversing that is one of the proposals floated in this meeting. Beyond that charging for everything from bed-and-board while in hospital to missed appointments have been suggested.

3. And what about waste? Arguably the single biggest inefficiency in the NHS is patients being kept in hospital when they are medically-fit to leave. Everyday around half of hospital patients in England who are ready to leave don't. The biggest cause is the lack of support in the community. Interestingly, the Scottish NHS chiefs ponder whether hospitals are too risk-averse in these situations. There is evidence to suggest they are and what is more there are the obvious trade-offs with new patients who need beds coming to harm because they are kept waiting in corridors and in the backs of ambulances.

The NHS was established on 5 July 1948 after Labour Health Secretary Aneurin Bevan promised "a universal health service without any insurance qualifications of any sort...available to the whole population freely".

But controversial charges for dental and eye care were introduced within three years, contributing to Bevan's resignation from the government.

In recent years health services across the UK have been beset by immense challenges including the Covid pandemic, an ageing population and staffing shortages.

• What is the state of Scotland's health service?

Chancellor Jeremy Hunt said in his Autumn Statement on Thursday that the country must ask "challenging questions" on how to reform all public services for the better, including the NHS.

He was speaking as Scotland's first minister, Nicola Sturgeon, told Holyrood that the pressure on the NHS is greater than it has ever been at any point in its history, but the amount the Scottish government is able to invest in the health service is dependent on decisions taken at Westminster.

'Two-tier system'

The concept of free universal healthcare has been at the heart of the NHS since it was created in 1948

The minutes of the NHS Scotland meeting summarise "themes, issues and ideas" during 45 minutes of discussions on Wednesday, 21 September, about "what a transformed NHS could look like".

They ask "what can be done with the financial constraints that we have?", and point out that some members of the public "are already making the choice to pay privately" while the NHS is "picking up the cost for life enhancing not life-saving treatments".

It is in that context that the suggestion to "design in a two-tier system where the people who can afford to go private," appears.

At one point the minutes note that it is "almost easier to identify what it is not possible to do anymore than what is/will be".

There is a proposal to change "the risk appetite from what we see in hospitals," suggesting a target for patients to be discharged to their home for treatment after a maximum of 23 hours.

"It is not gold standard but what other countries can do without an NHS," it adds.

According to the draft minutes, other points noted at the meeting included:

• A potential "review" of the "cost of long-term prescribing [of drugs] where there are alternative options"

• An option to "Pause funding of new development/drugs" unless they can be proved to save the NHS money

• The potential for efficiency savings because "there are still vast areas of waste in service in governance and all-day meetings etc"

• Considering applying a charge for freedom of information requests

• Stopping care services altogether and instead sending patients home for care

Mr Yousaf, who praised the "exceptional work" of NHS staff, added: "There is also frequent engagement between ministers and NHS board chief executives, and daily discussions between the Scottish government and individual health boards on service performance and pressures.

"Our NHS and care services continually evolve to meet the changing needs of the people of Scotland, and reflect changes in practice and medicine. In our five-year NHS Recovery Plan we have outlined our commitment to continued investment and reform of the NHS, alongside delivering the National Care Service."

'What is the real focus?'

The minutes of the September meeting also detail discussions about the government's proposed National Care Service (NCS), and state that: "There are a group within SG who recognise that it may not be possible to provide what it was initially proposed within NCS.

"Their challenge is how to get off that promise and do something different."

They also suggest that "£800m for NCS does not make sense" given the huge funding challenges for the NHS,

In recent weeks ministers have been under pressure about exactly how the new care service would work and be funded.

In its final section the minutes include a suggestion that clearer priorities must be established for the NHS.

"Everything is a top priority, what is the real focus?" they ask, with the summary of the discussions concluding, bluntly: "The fundamental model of healthcare is not working for us."