Six manifestos, thousands of words, and in reality, it is hard to squeeze a cigarette paper between most of them. Plenty of slogans, plenty of shared diagnoses, but when it comes to the hard choices on funding, staffing, and the role of the private sector, the differences only really emerge at the margins. Scratch beneath the surface, and what looks like a crowded field of ideas quickly narrows into a handful of familiar, politically convenient positions – with some notable exceptions.
Shared diagnosis, missing solutions
Reform’s health manifesto is brief and devoid of detail. Apart from their flagship policy of reducing income tax, there aren’t any real policy commitments. They do have plans to form a committee so they can make … plans about what to do about the healthcare crisis. I guess we’ll have to take their word that those plans will help patients.
We can glean more information about the intentions of Reform Scotland from the Reform UK manifesto and Lord Offord’s own position paper published at the end of last year. We can expect Reform Scotland to bring in patient charges and invest heavily in the private sector. They will keep the NHS free at the point of care, but this NHS will be separate to an expanding private healthcare sector. Those who can’t afford private healthcare will be left with a defunded, neglected public health service, and face longer waits and a higher chance of dying from treatable diseases. But it will still be “free at the point of need”.
Reading the Scottish Conservative manifesto is like reading a second draft of Reform’s. The same rhetoric about reducing waiting lists and fixing primary care, but no solutions, and zero investment. They have a hard commitment to increasing the proportion of the NHS budget that GPs receive to 12% (p51, Get Scotland Working). No additional money, of course. Such a proposal would inevitably entail defunding some other aspect of healthcare to provide the funds necessary to improve primary care.
Scottish Labour follows a similar line, with lots of “we will end the 8am GP rush” and “end corridor care”, but with few tangible initiatives or substantive investments in the NHS to do so (p.11, Scotland Needs Change). They do commit to a hard 300 step-down beds, also known as Level 0 beds. Better than nothing but still woefully inadequate.
The only notable manifesto promise is a policy that puts Scottish Labour right alongside Reform, the Conservatives, and their UK Labour counterparts: “Reform NHS funding so that funding follows the patient.” (p.12 Scotland Needs Change) This is the same seismic shift in the model of healthcare we have seen south of the border and will undoubtedly see an increase in the private healthcare footprint in Scotland.
Private provision as a pressure valve
Even the Liberal Democrats commit to using the private sector to get on top of waiting lists. They assure us that such use will only be short term. It’s odd how four out of six political parties believe that investing in private healthcare will yield greater bang for the taxpayer’s buck than simply investing in the NHS itself.
The Lib Dems do demonstrate a greater attention to detail than the aforementioned parties. They identify specific areas of the NHS needing attention, for example, rebuilding Belford Hospital in Fort William, bringing back consultant-led maternity care in Caithness General Hospital, and bringing in 24-hour stroke thrombectomy (page 28, “Change with fairness at its heart”). It is an impressive engagement with genuine areas requiring investment. Sadly, there remains little actual financial commitment.
We are then left with only the SNP and the Scottish Greens who have put forward manifestos that do not include the expansion of the private sector in Scotland.
The SNP manifesto is more specific on investment. They are promising £1bn per year capital investment each year for ten years to update and modernise hospitals, surgeries, and equipment. They also pledge a rolling £200mn investment to create additional elective (routine operations) capacity. A further commitment to increase to NHS capacity comes in the form of a £530mn deal over three years for expanding GP staffing – arguably the most impactful pledge of them all (p31/32, Always on Scotland’s Side).
Overall, the SNP manifesto has a clear commitment to protecting and expanding the NHS, and while this will likely see a gradual recovery of the NHS, it lacks urgency and ambition. The SNP will argue this is due to the fiscal constraints of a lack of Scottish independence. The only real fiscal lever the Scottish Government has immediately available is to raise taxes to fund investment in the NHS. The SNP has made no such commitment.
However, the Scottish Greens did. The Scottish Greens have committed fully to health services being fully funded through “progressive taxation” ”(p.85, Let’s Demand Better). Of all the manifestos, the Scottish Greens’ was perhaps the only one that seemed to grasp the urgency of the NHS crisis and the chasm we need to traverse to bring back an NHS that is fit for purpose and the future.
Primary care – GPs are the lynchpin
The Greens offer a clear commitment to expand GP numbers so that the GP to patient ratio goes from 1:1500 to 1:1000. This would finally put Scotland on par with most other comparative nations. It would also allow the Scottish Greens to realise their other commitment of increasing GP appointments to 15 minutes. Again, we are way behind our European peers in appointment times.
A commitment to significantly expanding GP numbers, if realised, would likely do more to improve care in the NHS than any other policy. We can’t have continuity of care without enough GPs. We cannot “beat the 8am rush” without having enough GP appointments. We cannot pursue an early intervention strategy without the primary care staff to do so. GPs are the lynchpin, and it seems the Scottish Greens appreciate this basic tenet of healthcare.
There are other commitments that can make a difference to the NHS crisis. Promising a community link worker in GP practices is a clear recognition that poverty is a key driver of disease. Additionally, introducing defined nurse-to-patient ratios is a long overdue measure that will improve safety, retention, and patient experience.
But perhaps the more ambitious commitment is to bring dentistry into the NHS.
A radical rethink of NHS dentistry?
NHS dentistry is set-up as fee for service. This means that dentists are effectively self-employed with various subsidised NHS payments for specific treatments. Unless receiving certain state benefits, we will all face significant dental bills. The Scottish Greens propose to bring dentists into the NHS as employees and take public ownership of dental practices.
It is bold. Even Nye Bevan failed to bring dentists into the NHS fully, despite his considerable efforts to do so.
It is unfortunate that the Scottish Greens’ manifesto lacks such ambition and detail in other areas. Instead, the Greens default to the same vague rhetoric about palliative care, cancer treatment, and specialist care. Given their commitment to funding the NHS through progressive taxation (and a wealth tax), it would have been useful to add some weight to their commitment to palliative care and cancer treatments.
The political fault lines on healthcare
Overall, the manifestos confirm what was suspected. Reform, Conservatives, and Labour all intend to bring private healthcare into the Scottish NHS. The Lib Dems will likely do so as well. The SNP will continue to shield the NHS from the lack of funding from Westminster and against privatisation. They promise to slowly recover the NHS, at a slightly quicker rate with the additional GP funding but have not committed to the consensus of expert opinion: the NHS isn’t big enough to meet the needs of the population because we don’t pay enough for healthcare in the UK. It is a politically inconvenient position to take, although the Scottish Greens are not afraid to make the case. For most of us living through the NHS crisis, it is the type of ambition and courage we will need to tackle this healthcare crisis.
More from Dr Daniel Goyal
Bylines Network Gazette is out!
The latest Bylines Network Gazette is out now. Become a Friend of Bylines Network or upgrade to a paid Substack subscription, and you will get access to a vital collection of citizen articles and stories.
Journalism by the people, for the people.
