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National Health Service

It is inescapable. The cost of care is not going away…
and we will have to dig deep in our pockets to pay for it

By Tim Cocking
Director of Bright Care

Jeremy Hunt is right to highlight the loneliness of the elderly in the UK as “Britain’s National Shame” and to raise the plight of the “forgotten million” older people who have little social contact with family or neighbours.

Tim Cocking of Brightcare

Tim Cocking of Brightcare

The Health Secretary is also justified, in his recent speech to care groups, to call for a change in social attitudes towards the old and urge people to change the way they treat their parents and grandparents.

He would have done well, however, also to emphasise to the current generation of baby boomers that high among their list of priorities should be their responsibility to make financial provision for care – not only for their elderly parents but also, very soon, for themselves – because health care is not free! This is a deep-seated misconception among a generation which has grown up being told that, in the country which invented the National Health Service, care is free at the point of delivery. Everything has a cost, and even if people are not handing over a cheque to their doctors, it is still being paid for indirectly through the common pool of tax receipts – and that pool is drying up. We are running out of money.

Already, we are seeing what we previously considered to be minimum standards of care pared back even further. The controversy over local authorities outsourcing home care visits to the private sector – and limiting them to 15 minutes at a time – is a case in point. It is a consequence of central government’s policy objective – implemented by councils – of attempting to look after the largest possible number of older people while employing the smallest possible amount of money and resources.

The State will not provide care in the future

The State will not provide care in the future

Curiously, to deliver this “free service”, local authorities increasingly outsource the deliver of these services to the private sector. The private sector are being asked to supply full provision at a rate of between £12 and £14 an hour. However, if local authorities provide the same services in-house – as 25-30% are in Edinburgh and up to 50% in places such as South Lanarkshire – the cost to the tax payer can as much as £25 to £35 an hour.

This is, at the root of it, because public sector is not as efficient, care workers’ wages are higher and they have much more generous benefit and pensions packages, which the private sector can simply not compete with. But the fact remains that the private sector is being asked to provide a service at half price.

However, regardless of a local authorities commissioning policy, free care services simply cannot continue. The public purse is emptying fast and the politically desirable concept of universal free personal care is simply unsustainable. It will disappear in Scotland within five years, whether we opt for independence or not. When that happens, as it inevitably will, anyone who wants care will have to pay for it. But the ageing baby boomers are completely unprepared and have not thought through the implications of having to pay privately.

The private sector will have to take up the slack

The private sector will have to take up the slack

Social care is expensive. Even the part which is considered at the moment to be “free” would only comprise about 25% of what would reasonably be considered a holistic care package. So who pays for the other 75%? The reality is that it will have to be funded privately or provided by friends, family, neighbours or local community groups.

Jeremy Hunt, whose wife is Chinese, said that Britons should take a leaf out of China and Japan’s book where residential care is a last, rather than a first option, and most older people are looked after in the family. Again, he has a point, but the reality is that most affluent individuals or people who are in good careers or have their own children or grandchildren to look after, are just going to pay for care rather than taking in an elderly relative.

Care in the home is the preferred option (Pic from a Scottish Parliament report)

Care in the home is the preferred option
(Pic from a Scottish Parliament report)

Fifty years ago we were more like Asia, and care was kept in the family, but families are moving further apart, they have less time on their hands and priorities are changing. There may be an assumption that the government will continue to provide for older people; but it is unwarranted because there is no money left.

The burden passed by baby boomers to the next generation is staggering. It has been calculated at £7.8 trillion. This means that more than £80 billion a year is needed in extra tax in the UK (roughly a 15% increase on current levels).

With the rise of property prices and increasing costs of everyday living can the next generation really cope with this? The simple answer is no, and self-funding of care is now well on the way from possibility to cast-iron certainty.


For further information, contact Tim Cocking,
Director, Bright Care,
Summerside, Old Dalkeith Road, by Sheriffhall, Edinburgh EH22 1RT.
T: 0131 524 8181
Registered with the Care Commission: CS2009232912.

A relatively clean bill of health of NHS Scotland

A report from Audit Scotland warns that the health service in Scotland faces significant challenges and needs to tighten its long-term financial planning if it’s to cope with expected budget cuts in the future. The report made these recommendations despite finding that NHS boards across Scotland had performed well, all of them meeting their financial targets last year. Audit Scotland made the recommendation in a report on NHS finances despite all health boards meeting their targets last year.

Caroline Gardner Auditor General

Caroline Gardner
Auditor General

The Auditor General for Scotland, Caroline Gardner, explained that the organisation’s financial performance “…was good in 2012-13, with all boards meeting their targets to break even and the service finishing the year with a small surplus. However, the health service needs to increase its focus on longer-term financial planning so that it is prepared for the challenges it faces.”

There are 14 territorial, and 9 specialist NHS boards in Scotland which, between them, spent £10.9 billion over the year, almost a third of the total Scottish budget. They ended the year with a surplus of £16.9 million and savings worth about £270 million. However, the auditors pointed out that 22% of the savings had been ‘one-off’ and similar levels would have to be found again next year. The worry is that the boards did not achieve their forecast levels of recurring savings. In Audit Scotland’s view, there will be a challenge in the future as it becomes harder to identity further opportunities to save money.

“While budgets are getting tighter, demand for healthcare is rising due to an ageing population,” it said, “more people with long-term conditions and the impact of factors such as increasing rates of obesity. This presents significant challenges for the NHS boards delivering services both now and in the longer term.”

NHS Health ScotlandSo far, the Scottish Government has resisted the market-orientated reforms which have been introduced south of the Border. Instead, it’s increased the overall health budget in real terms over the past decade. The boards have managed to meet their financial targets for the past five years. But Audit Scotland warned that real-terms cuts of 1.6% are in prospect over the next three years.

The Auditor General praised the financial performance of the NHS, stressing that it had made good progress in improving health outcomes, notably in relation to deaths from heart disease, cancer and stroke, and in respect of patient safety. “However,” she added, “the health service needs to increase its focus on longer-term financial planning so that it is prepared for the challenges it faces. The move to integrated health and social care services from 2015 will also be a significant change for the NHS and its partners. Strong longer-term planning and analysis are central to meeting these challenges.”

Alex Neil MSP Health Secretary

Alex Neil MSP
Health Secretary

Responding to the report, Scottish Labour’s health spokesman Neil Findlay said that it confirmed “everything we’ve been saying for the last few months about the increasing build-up of pressure across health boards because of SNP cuts. Audit Scotland have reinforced the need for an immediate review of the NHS so we can come up with a long-term plan that will support hard-pressed staff and ensure patients are properly cared for.”

However, the Health Secretary, Alex Neil, said that, despite increasing budgets, it was “right that the NHS is as efficient as possible with taxpayers’ money which is why we have asked boards to make savings. I want to be very clear that these savings are not a reduction in budget – all money saved will be reinvested in frontline services. This improves the quality of care patients receive.”

Sir Robert Peel, 1788–1850

Sir Robert Peel, 1788–1850

By Elizabeth McQuillan

Scottish physicians, as early as the eighteenth century, recognised that poverty was inextricably linked with poor health. Whether in the overcrowded industrial centres, or working the land, the effects of poor diet, overwork and inadequate shelter led to “debility”.

In 1846, the potato blight that had caused the Irish poor to suffer the pain of starvation arrived in Scotland. The areas hardest hit were the Highlands and Islands, where the people relied on a successful crop for sustenance. The result was a Highland famine.

The humble potato provided a high yield on the small plots of land left for cultivation due to the Highland Clearances. With little other food being grown to sustain the local people, the failure of the potato crop proved disastrous.

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The crofters looked to their chiefs to provide help at their time of greatest need, but help was often not forthcoming, with the landlords by now looking to replace their tenants with sheep at the earliest opportunity. Many turned a blind eye, some simply evicted their tenants (many were reduced to living on the streets of Inverness), and a few hired boats to transport their tenants off their own land to foreign territories.

The government did eventually intervene and provided rations of oatmeal – 680 grammes for men, 340g for women and 280g for children – but not without the crofters showing that they were still working for their food. Despite having a calorie input that barely sustains basic physiological function, the crofters were expected to work eight hours per day, six days per week.

Unsurprisingly, the people suffered terribly with the many medical problems that famine brings: malnutrition, scurvy, typhus and cholera. This lasted for a full ten years while the crops failed. There was little, if any, medical help available.

The Poor Law in Scotland did not make provision for the care of the walking sick (which most of the victims were) in the local parish. William Pulteney Alison, Professor of Medicine at Edinburgh University, along with other Scottish social reformers of the time, demanded in the House of Commons that the Poor Law must be altered to ensure that every parish had the services of a resident medical officer.

Sir Robert Peel, the prime minister, was not keen, but the pressure remained on and Peel eventually (in 1848) conceded a compromise. An annual grant of £10,000 was made to the Board of Supervision of the Poor Law to finance a subsidy for any parish that agreed to finance the formal appointment of a medical officer.

The people of the Highlands and Islands needed particular help. Following the Napoleonic wars, cattle prices had dropped to make their meagre stock worthless, the kelp industry that provided employment collapsed, herring fishing failed and there was a general recession in Scotland. The potato blight simply compounded the problem of abject poverty.

Ultimately, the Poor Law did not help much. The doctors who relocated to the Highlands and Islands as medical officers, hoping to make a living, soon realised that life was tough. Attending patients was difficult due to the large distances and inhospitable landscape, as well as bad weather and the problems of having to often travel by boat. Most patients were so poor that they could not afford to pay. Many doctors returned home.

Sympathy for the plight of the suffering Highlanders was not overwhelming from lowland and English quarters, and the notion of state handouts was not encouraged. Many ideas were put forward to deal with the problem, but the physician Coll MacDonald could see the way forward:

“The simplest and cheapest plan to give medicines and medical aid to tens of thousands living in the Hebrides would be to employ a few sober men of good character and energy, provided with medicines and instruments and a small steamboat (as the Marquis of Salisbury has done for Rum) to move constantly about among the people when they could conveniently assemble to be cured of their diseases. By this plan [salaried medical practitioners] would more economically and efficiently be brought into contact with the sick and the maimed than by the establishment of stationary practitioners.”

This idea was ahead of its time, but in 1913, the same ideas reappeared in the creation of the Highlands and Islands Medical Service, the first comprehensive and free state health service in Britain. Though the advent of world war one delayed the roll-out of the Highlands and Islands Medical Service, more than 300,000 people across Scotland were covered by the 1930s. It offered a model for the wider national scheme, the National Health Service, which finally came into being on 5 July 1948.

Reference: Royal College of Physicians, Edinburgh

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NHS Scotland logoPatients who have suffered as a result of healthcare treatment could be compensated without having to take the NHS to court under plans to reform the system.

The Scottish government has accepted the recommendations of a review group headed by renowned law and medical ethics expert Sheila McLean, which says the current adversarial court system should be changed to one of no-fault compensation.

This would mean that patients would still have to prove that they suffered loss, injury or damage as a result of healthcare treatment, but would not have to prove that negligence was involved.

Doctors said the proposed changes would benefit patients and mean an end to “defensive medicine”.

The review group said that the proposed system would cost around the same as the NHS currently plays in compensation and legal fees, but would benefit more people, who would receive fair and adequate compensation for harm suffered in a more timely way.

Wider benefits would include greater scope for the NHS to learn from mistakes so that care could be improved, and more efficient use of time and money, the review group said.

The move was welcomed by doctors’ leaders. BMA Scottish secretary Martin Woodrow said: “Over the past decade we have seen an increase in cost of clinical negligence claims against the NHS. The BMA has been advocating a system that avoids the blame culture and but still enables patients to make complaints and receive compensation.

“The BMA believes that no-fault compensation offers a less adversarial system of resolving the process for compensating patients for clinical errors. A system of no fault compensation with maximum financial limits would benefit both doctors and patients, speeding up the process and reducing the legal expenses incurred by the current system. More importantly, however, it would address the blame culture within the NHS which discourages doctors from reporting accidents and would end the practice of defensive medicine.”

Health secretary Nicola Sturgeon said it was in nobody’s interests to have precious NHS resources spent on expensive legal fees, nor to have redress delayed because a compensation claim can take years to go through the courts.

No-fault compensation would be a sensible way to ensure people who have been affected are compensated without tying up either patients or the health service in years of litigation. The next step now is to investigate thoroughly how such a scheme would work in practice – including further analysis of any cost implications – both for the benefit of individual patients and the good of the health service as a whole.”

Professor McLean said: “It is important that the aim of any compensation scheme should be to facilitate access to justice, provide appropriate compensation for injured patients and ensure proper and timely adjudication of claims.

“The members of the review group were clear that the current system is not meeting the needs of patients, and will welcome the Scottish Government announcement.”

Read the Scottish Government no fault compensation review group here

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By Elspeth Atkinson – director for Scotland, Macmillan Cancer Support

“Treatment is the easy part of cancer. Living with it is the hard part. Treatment for me took six months, living with it is going to take 40 years. As soon as the treatment finishes, the NHS is finished with you and pushes you back into society. That’s when the real stress and pressure begins.”

These are the sentiments of Alan Clarke, a father of two young children who was diagnosed with head and neck cancer just over a year ago.

Alan is far from alone in feeling abandoned by a health system that took such good care of him when his cancer was being treated. People who have survived a cancer diagnosis frequently tell Macmillan that they feel isolated once they stop attending hospital, with little idea where to begin getting their lives back on track.

As a result of better treatment and screening is that the number of cancer survivors is growing. In less than 20 years, this number is set to double – from two million to an incredible four million people in the UK.

This opinion piece is part of The Caledonian Mercury’s ongoing debate about Scotland’s national life and is part of our commitment to raise the level of debate in Scotland. If you or your organisation would like a platform to voice your views then please contact us at stewart AT caledonianmercury DOT com.

The sheer size of this population brings into sharp focus the pressures that will be brought to bear upon the National Health Service. It is apparent then that cancer services will require an overhaul to cope with the ever increasing – and indeed changing – demands upon them.

At the moment, cancer patients who survive initial treatment attend regular hospital appointments to check that the cancer has not returned. However, this one-size-fits-all programme of clinical appointments does not meet the needs of individual patients, such as their emotional well-being or any practical support they might need to get their lives back on track.

There is also little evidence that this method is the best way to spot recurrences of cancer or the other possible long-term health consequences of cancer treatment.

We know that the needs of cancer survivors do not end when their hospital treatment finishes. That is why it is imperative that the NHS moves away from the current model of follow-up care which focuses solely on physical symptoms and illness to one that also considers health and well-being.

Reform of the health service is needed to ensure that patients are given the tools to understand their illness. If patients are equipped with the information to know when they need to see a health professional or when they may need a diagnostic test, then this will reduce the need for unnecessary follow-up appointments at hospital.

This development would free up resources which could be reinvested in new services that support people with cancer in the long run. It costs much less to provide a person with the skills and knowledge to self-manage their condition, and provide support if needed from a nurse in the community, than it does to make them travel to hospital for a follow-up appointment that doesn’t take into account all of their needs.

Effective rehabilitation services are also needed to support people back into work. As well as improving the quality of life of the cancer survivor, helping people who are able to go back into the workplace would also mean fewer people claiming benefits, more people paying taxes and employers retaining experienced staff.

To be efficient and effective, the health service must start treating cancer survivors as individuals. The key to this is providing every patient with a personalised assessment and post-treatment plan which should ensure that their emotional and practical, as well as their health needs are being met.

As part of this new plan, patients would also learn where support is available, whether they need a listening ear, more information about their diagnosis and the consequences of their treatment, help to get back to work, or assistance paying their mortgage or fuel bills.

We know that the challenge of creating cancer services to meet the needs of patients in the future is significant. That is why reform will require the support and collaboration of health and social care providers, the charity sector, and of course the Scottish Government.

Macmillan is highlighting this issue in a short film we are launching today called Change Cancer Care Today (see above.

The video, which features several patients, including Alan Clarke, calls on the next Scottish Government to commit to transforming the cancer care to meet the challenge of cancer as it is today.

We hope the video will inspire people to join our e-campaign and flag up the need to transform cancer care after treatment to candidates ahead of the Scottish Parliament elections in May. Certainly, with the population of cancer survivors growing at such a speedy rate, their collective voice is one that politicians cannot afford to ignore.

What we’re proposing makes sense. The cancer care system must move with the times to meet demands on it – the lives of cancer patients and their families, and the sustainability of the health service, depends on it.

To find out more or to join the e-campaign, visit macmillan.org.uk/scottishelection

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NHS Scotland logoScotland’s NHS is facing the worst financial pressure since devolution, according to watchdogs.

In a report published today, Audit Scotland forecasts trouble ahead, with NHS bodies forced to find significantly more financial savings to deliver the same level of quality provided in previous years.

In its overview of NHS Scotland’s finances for 2009/10, the organisation congratulates health boards for a good financial performance, with all ending the year within budget.

But the Auditor General, Robert Black, added: “They have had to find significant savings to balance their budgets and will need to find even more to continue to do so.

“While the NHS budget will rise in 2011/12, this will be a far smaller increase than in previous years and is likely to be outstripped by rises in demand and cost pressures.”

He said the NHS was taking action to meet the longer term financial challenges, which include increased demand from patients, and rising costs of fuel, drugs and staff pay.

“For [the action] to be successful, it needs good workforce planning, better information on costs, quality and activity, close partnership working and sound leadership.”

Nicola Sturgeon, the health secretary, said the report “recognises the excellent financial performance on the NHS” and pointed out that the health service had exceeded the government’s two per cent efficiency target.

“It is clear the pressure on NHS finances will continue to increase but I am confident that the health service is prepared for the challenges ahead. We will work with health boards to eliminate waste and encourage modernisation programmes to increase productivity and efficiency gains, while enhancing the quality of care.”

Unions and opposition politicians were less impressed, however. Labour, the Lib Dems and Tories all called for savings realised through efficiencies to be directed at frontline services. And Theresa Fyffe, director of RCN Scotland, said the report backed up the union’s own findings on the financial pressures facing boards.

“With demand for health services growing and healthcare costs increasing, the NHS is far from protected from the cuts that the wider public sector is now grappling with,” she said. “This is particularly so as the NHS may end up providing healthcare for the people who need more support as a result of cuts by local authorities. However, if health boards keep cutting away at staff numbers to deal with these pressures, there could be serious and costly repercussions for patient care in the future.”

Brian Keighley, chairman of the BMA in Scotland, said that making indiscriminate cuts was short-sighted and that the government should plan to make savings. “Plans so far have included cutting nursing staff numbers, imposing a recruitment freeze and attempts to undermine the terms and conditions of NHS doctors,” he said. “These may deliver a quick reduction in financial spending but they are not the long term solution. There are areas where there is a genuine need to examine ways of working and service delivery to ensure that they are delivered in the most cost effective manner – without affecting the quality of patient care. Government can only do this if they work in partnership with the profession.”

Audit Scotland points out that funding increases for the NHS in Scotland are slowing compared with recent years. Between 2001/02 and 2009/10 NHS spending rose by 38 per cent in real terms. The increase between 2009/10 and 2010/11 was 2.6 per cent and the proposed 2011/12 budget of £11.4 billion will be up just 1.7 per cent on the current financial year.

NHS Scotland logoNursing leaders have accused Scotland’s health boards of providing reports which are inconsistent, generally inaccessible and which “obscure what’s really happening on the ground”.

This makes it difficult for the public and for campaigners to scrutinise what health boards are doing and whether their decisions take into account patient care and safety, the Royal College of Nursing Scotland says.

In a report published today, the RCN says that there is not nearly enough information publicly available to judge whether health boards are acting in the best interests of patients.

And it calls on health boards to make their financial plans and reports public “in a transparent and timely manner” so that difficult funding choices can be fully understood and debated.

The report, Taking the Pulse of NHS Scotland, tries to build up a picture of NHS boards’ financial and workforce issues. The union concedes that the document has some limitations – partly because of a deficit of available information.

Nevertheless, it reveals some interesting snippets. For example, although official figures show that all NHS boards broke even (financially) in the year 2009/10, 10 of the 14 built up a recurring deficit over the year, which they had to offset with underspends in their non-recurring budgets.

The report also says that boards’ own local delivery plans raise clear warnings about financial challenges, particularly in how they will achieve the required efficiency savings at a time when public sector finances are being squeezed.

The report also queries the apparent inconsistencies in approach taken by different boards. For example, the planned pay bill for NHS board employees ranged from 39 per cent to 61 per cent of expenditure at March 2010.

Theresa Fyffe, the RCN Scotland director, said: “Despite claims that the NHS is protected from the budget cuts now facing the wider public sector, what we were able to find out shows that many health boards are already facing real financial difficulties. Demand for health services is rising, key healthcare costs are running ahead of general inflation and GP prescribing budgets, for example, were overspent last year by over £20m.

“With NHS funding under a great deal of pressure, we’re already seeing health boards cutting their staff, particularly nursing and midwifery staff, as they are the largest staff group at just under half of the NHS Scotland workforce. What is not clear is whether the consequences of such headline cuts to staff have been properly assessed – or whether they are simply short term solutions to financial pressures.”

Ms Fyffe rejected any suggestion that the RCN might be motivated to challenge what’s happening because it is its members which are affected. “We do not believe you can keep cutting staff in this way, without affecting patient care. It’s not protectionism that’s driving us to challenge what’s happening; it’s for the protection of the public. Rather than short-term, financially-driven responses – which focus on reducing the workforce – we need to find longer term, sustainable solutions. This means we have to have enough clear and consistent information so that a proper debate can take place about what kind of future we want for our NHS.”

<em>Picyure: Waldo Jaquith</em>

Picyure: Waldo Jaquith

The health secretary Nicola Sturgeon has today angered doctors by announcing a freeze on distinction awards for consultants.

Ms Sturgeon said that no new awards would be made this year, saving the NHS up to £2 million, pending the outcome of a UK-wide review of the scheme.

The news came as a shock to the BMA, which has consistently defended distinction awards as a means of rewarding consultants for going above and beyond the call of duty, and for attracting and retaining talent in the NHS.

Ms Sturgeon said: ‘It is no longer possible to justify paying significant bonuses even to highly skilled members of the NHS workforce. Bonuses across other areas of the public sector have already been cut and NHS consultants are not exempt from the need for budgetary restraint.’

She said the money saved would be reinvested in frontline services.

Dr Lewis Morrison, chairman of the BMA’s Scottish Consultants Committee, said it was a particular blow, as the first minister and health secretary had consistently defended the award scheme in the face of criticism from politicians. “Consultants are therefore stunned by the Scottish Government’s U-turn,” he said.

“Doctors recognise that savings need to be made in the NHS, but freezing awards will be a substantial blow to the morale of overstretched consultants at a time when the health service needs more innovation and clinical leadership to maintain high quality patient care.”

He said that the awards had been part of the defined pay structure for consultants for many years and were often an incentive for working beyond their required roles.

“The cabinet secretary talks about reinvesting the money saved in front-line services. Consultants are clearly on the front-line of patient care delivery every day and the Scottish Government should not therefore be saving money by attacking the agreed pay and conditions of service of front-line staff.”

Ms Sturgeon said the move would effectively halt the scheme which has been in place since the NHS was founded in 1948 and that 2011/12 would be the first year since devolution that the budget for distinction awards had declined.

“In the toughest financial climate since devolution, there is no doubt that the health service, like the rest of the public sector, faces serious challenges in the coming years.

“I recognise the significant cost of distinction awards and my decision to freeze the bonus scheme reflects the need to free up valuable resources that can be redirected to frontline healthcare.

“I have already made clear my view that the current system of consultant distinction awards should be reformed so that we can achieve a fairer and more cost-effective method of rewarding excellence across the NHS.”

<em>Picture: Carmella Fernando</em>

Picture: Carmella Fernando

Politicians have been warned not to make unrealistic promises on health services as they campaign in the run-up to next year’s Scottish Parliament elections.

In a manifesto published this morning, the BMA calls for an “honest debate” on what the NHS can and cannot do – and says that hospitals may have to be closed or downgraded.

“While care should be delivered as locally as possible, this needs to be balanced against the need to maintain safe, affordable and sustainable services, even if this means providing some services on fewer sites or with restricted hours,” the manifesto says.

The BMA’s words – based on its current policy and on a survey of some 600 doctors – recall one of the main battlegrounds before the last Scottish Parliament election.

While Labour had backed hospital reconfiguration – including the controversial downgrading of A&E departments at Monklands in Lanarkshire and at Ayr Hospital – the SNP promised a presumption against centralisation. One of its first acts in taking power was reversing the decisions on Ayr and Monklands, and setting up a mechanism whereby scrutiny panels would be appointed to consider such reconfiguration proposals.

With health service budgets looking increasingly tight, however (whether they are ring-fenced or not), the question is bound to arise again.

Launching the manifesto, the BMA said that almost two thirds – 63 per cent – of consultants questioned in its survey believed that the quality of care could be improved by reconfiguring hospital services to provide inpatient services on fewer sites. Around the same proportion – 64 per cent – of doctors are not confident that the NHS can make required efficiency savings without damaging the quality of patient care.

Top-down targets in the NHS also come under fire. Three quarters of the doctors questioned believe that patient outcomes, not waiting times targets, are a better way to measure NHS performance and the manifesto says it may be necessary to review the number and range of targets, particularly in times of financial restraint.

The BMA sees value in some targets, however, adding in the manifesto: “While a reduction in the number of centrally driven targets would be welcomed, the benefits of some clinically driven measures should not be underestimated … There needs to be enough flexibility in all targets to let clinicians do what is right for individual patients.”

The BMA backs the policy of the current health secretary Nicola Sturgeon to rule out compulsory redundancies in the NHS and says that 80 per cent of doctors oppose a blanket recruitment ban.

It also says that politicians should appreciate and use doctors’ leadership skills when it comes to deciding what is best for patients and the health service.

Dr Brian Keighley, the chairman of the BMA’s Scottish Council, said: “An honest debate is needed in this election campaign. Our politicians need to recognise the reality of the choices facing NHS Boards and cannot afford to make unrealistic commitments to secure votes.

“Doctors are committed to an NHS that is properly resourced, comprehensive, free at the point of delivery and provides equal access for all. These are the principles upon which the NHS was based and upon which it must continue. However, the range and level of services available now are more comprehensive and complex and patient expectations are higher. To protect the principle of universal free healthcare, politicians must lead an open and honest debate with the public about what the NHS can and cannot deliver.

“This manifesto forms our contribution to public debate on the challenges facing the NHS in these uncertain times and how these challenges should be met. Running throughout the document is a call to recognise the leadership that doctors can provide. During times of financial pressure, this leadership can help maintain the standards that our patients rightly expect. Indeed, it can drive an improvement in quality across the NHS.”

The manifesto also makes specific recommendations on priorities for public health, including tackling obesity and calls for investment in research to improve health and prevent ill-health.

A stethoscopeGPs’ leaders have warned that there is no going back to the days of Dr Finlay model of general practice, but have acknowledged that out-of-hours care is “by no means perfect”.

The BMA in Scotland urged the Scottish Government and health boards to do more to develop and implement quality standards in care at nights and over weekends, and to improve co-ordination.

In particular, the BMA said that more needed to be done to promote NHS 24 as the first point of contact for non-emergency calls.

Doctors were speaking out ahead of a planned debate on rural out-of-hours services, which was due to take place in the Scottish Parliament today. The issue was to have been debated two weeks ago, but was postponed due to the need for emergency legislation on police questioning.

Dr Andrew Buist, deputy chairman of the BMA’s Scottish GP committee said that there needed to be a comprehensive out-of-hours system which did not rely on “over-tired GPs bearing the brunt of the work”.

He also stressed that the new GP contract – which allowed GPs to opt out of 24-hour care for patients – was not to blame for problems with services.

“There is a perception amongst politicians and the public that the problems with out-of-hours care stem from the introduction of the GP contract in 2004. This is not the case. In many areas, such as Greater Glasgow, the service that operated prior to 2004 is the same service that continues to operate, albeit the service is now directly managed by the NHS board.”

He said that prior to the new contract, morale among GPs was at an all-time low, that GPs were planning to retire early and recruitment was becoming “impossible”.

“Doctors were working excessively long hours, and rural communities in particular were at risk of losing daytime GP service at the expense of out-of-hours availability. There is no going back to the old ‘Dr Finlay’ model of general practice. In today’s modern service much more complex care is provided to patients in hours and there needs to be a comprehensive out-of-hours service that does not rely on over-tired GPs bearing the brunt of the work.”

He said that patients continue to receive high quality health care round the clock, but that it was “by no means perfect”.

The BMA added that NHS 24 had improved significantly but that more needed to be done to educate patients about who to call when surgeries were closed.

The organisation also said the Scottish Government should commission research to find out why demand for services out-of-hours was increasing, in particular what beliefs prompted decisions to call.

In its report into rural out-of-hours healthcare, published in April, the Health Committee warned that trust and confidence had been lost and needed to be rebuilt.