Rule number one of the children’s handbook on what to do when caught red-handed by an angry parent is to first deny, then scrabble around for some flimsy argument to mitigate the offence.
It’s an instinct many of us never outgrow, though we expect better from adults and certainly from those elected to represent us on the big issues like health.
And yet “whataboutery”, as this technique of argument is known, has become a common recourse for politicians, not least the likes of Health Secretary Shona Robison and the SNP government, when in response to the “worst ever” A&E figures during the recent flu outbreak, they boast that NHS Scotland performs better than NHS England.
One of those who is particularly frustrated by this tendency to compare the health service north and south of the border is Dr Peter Bennie, chair of BMA Scotland, although he has sympathy for the Scottish Government over the lack of funding and the impact of Westminster austerity measures.
Bennie laid bare his thoughts in a recent interview with Scotland on Sunday.
“The whole comparison to England thing – I do find that very difficult,” said Bennie.
“I mean first and foremost it’s not a great thing to compare yourself to, because the health service in England is in a very, very serious way.
“There’s no doubt about it that part of the reason why things are even more difficult in England is the insistence by the UK government on sticking with market forces within the health service and the Scottish Government has always come out against that and that’s helped towards what we see as being the proper way to run the National Health Service and the way that the NHS was conceived. Public money – publicly provided.
“Private and competition both end up costing more for getting the same service.
“There’s an ideological dogma about that with the UK government. That’s one of the reasons why it’s not very ambitious to be wanting to do better than the English health service at this point in time – at a moment when they actually cancelled all elective surgery for the entire month of January in England.
“If all you can manage is to be a wee bit better than that then you want to be a bit more ambitious.”
Bennie acknowledged that Scotland cannot escape the consequences of the Tories’ squeeze on public spending.
“I do have sympathy with the Scottish Government’s persistent position of saying that they are constrained by UK funding, because that’s true,” he said.
“However, in a circumstance where we are pretty clear on what we’re going to get and what we’re not going to get, you would be looking for the Scottish Government to be recognising the shortfall and taking more action.
“It’s something I’ve said a few times – I do get very frustrated with the kind of soundbites from government about us having more nurses and doctors than ever before.
“Of course that’s true, but we need that and more because of the increasing demand on the health service every year.”
Bennie, a consultant psychiatrist, has grabbed the newspaper headlines in recent months with his open and frank views on a wide range of issues. His has been a stern critic of the current administration and last month described the NHS in Scotland as being stretched to “breaking point”.
While he supports SNP measures such as the introduction of minimum unit pricing on sales of alcohol, he is no fan of the target-driven culture that currently operates in the NHS and is on record as saying health inequalities that persist between the richest and poorest parts of Scotland should “shame us as a society”. He bemoans the lack of funding for the health service in Scotland and says more needs to be invested to enable the NHS to just “stand still”.
“One of the main concerns is that in Scotland we are being expected to run a health service without the necessary resources,” said Bennie.
“It just never stops being one of the major issues for us because it’s the day-to-day reality of what we’re working in.
“A really core aspect of this is the funding. A ballpark figure to keep the health service running and not falling behind what’s required is about 4 per cent growth in funding per annum and that’s partly because of the increase in demand each year as our population ages: you’ve got multiple morbidity, so you’ve got older people with two or three serious illnesses at one time.
“There are various different ways of counting what funding the health service got this year in Scotland –which is classic government tactics – but at the most optimistic it was about a 2 per cent increase.
“Now that’s not enough to keep us going,” Bennie insisted. “Inflation within the health service runs at a higher level than general inflation. That’s primarily on account of the price of drugs and medical equipment. It simply goes up at a faster rate than general inflation and the health service has to be able to buy the correct drugs and enough of them to treat the population.”
This problem of underfunding is nothing new, Bennie explained.
“Since 2010 we’ve not been coming up to 4 per cent, so there’s been a cumulative reduction in the increases over those seven years. That of course correlates with the introduction of austerity policies in the UK by the successive governments, the Coalition government and then the Tory government.”
Bennie expanded on his previous concerns over what he sees as the target-driven “blame culture” which distorts patient care in Scotland and puts excessive pressure on medics, which can result in bad decisions.
Former chief medical officer Sir Harry Burns presented his review of targets and indicators last November after spending a year examining their impact on health and social care on the back of a string of serious failings.
He recommended that the requirement to treat patients within 18 weeks of referral to hospital be dropped and said it was important to look at the wider picture of available beds and staff as well as patient outcomes throughout any hospital in conjunction with A&E figures.
His review found that current NHS targets in Scotland are too fragmented and need to follow patients through their whole journey of care.
Bennie said: “We’ve got real concerns about the relatively simplistic way the health service is measured.
“Most frequently politicians and media are measuring the performance of the NHS in Scotland by reporting where we’re at with the four-hour wait in Accident and Emergency.
“At one level that is a simple barometer of broader systems within the health service. One of the really core things that decides how long you wait in A&E is the availability of an appropriate bed in the hospital for you to move into and often even that is determined by whether there are sufficient resources in the community to be able to discharge people.
“So, it’s a really crude measure of overall performance,” said Bennie.
“The trouble is, because that’s become the headline figure on which everyone decides the performance of the NHS – with it getting reported on a weekly basis – it seems really difficult, particularly for politicians, to raise their heads above that and look for more meaningful ways of measuring what the health service does.”
Even more pernicious, Bennie noted, is the pressure to make improvements in performance against the target that don’t necessarily improve patient care.
“It basically transpired in Lothian that these targets were being manipulated,” he said. “In some ways it’s not surprising that happens because the target has become such a be all and end all, but that illustrates the difficulty with this.
“I certainly think one of the key recent decisions to move to reporting the performance against the A&E target weekly has been particularly unhelpful. It’s led to that being the political focus on a weekly basis and it gives far too much prominence to that one single measure.”
Unlike the chair of the BMA, the SNP Government’s opponents have been keen to draw comparisons between the health service north and south of the border, claiming that, in terms of investment, NHS Scotland has come off worse.
Shadow health secretary Miles Briggs MSP said health spending in England had increased more than in Scotland in the past five years.
“In relation to funding, the SNP has been in total control of Scotland’s NHS, including its budget since 2007,” said Briggs. “Between 2012-13 and 2016-17 health spending increased by 10 per cent in England and only 5 per cent in Scotland. This has not been caused by a reduction in the Scottish budget, but by the priority choices of SNP ministers. They need to be held accountable for those decisions.
“There also needs to be a recognition of the fact that since 2010 the UK Conservative government’s protection of the NHS budget and indeed investment in extra NHS resources south of the border has meant Scotland’s NHS has benefited substantially in Barnett consequentials to the tune of £2.154 billion extra since 2011/2012.
“SNP Ministers like to distract from their own failings by constantly comparing Scotland’s NHS with England’s while they should instead be focusing on improving things here and making progress in areas where they have responsibility.”
A Scottish Government spokesperson said: “We are pleased Dr Bennie has highlighted the constraints put on our health service by the UK government’s continued, unnecessary, austerity measures. Here in Scotland we remain absolutely committed to the founding principles of an NHS free at the point of delivery.
“We are providing record funding to Scotland’s NHS, and recently announced further investment of more than £350 million in Scotland’s health boards with additional investment in service reform and improvement of £175m. NHS staff numbers are also at historically high levels, with more doctors and nursing staff now delivering care for the people of Scotland, helping the health service meet the challenges of an ageing population.”