Joan McAlpine: Jobs or healthcare: someone has to choose

A FRIEND of mine signed up for an evening class in photography at his local college recently. It wasn't a life-changing career decision, just a means of getting out of the house one night a week and injecting a bit more artistry into his holiday snaps. Plus it was free.

On arrival, instead of getting stuck into the business of pixels and apertures, he found himself and other "adult learners" subject to an induction course. Specially trained staff had been employed to explain the workings of the college and all the other opportunities it offered in continuing education. They were there to help. Pastoral care was always on hand and if the "students" needed assistance with childcare or travel costs - "Just ask!"

It wouldn't be fair to name the college, which is clearly providing excellent customer service. But my friend, a typically left-of-centre Scot keen to preserve public services, wondered whether his part-time pursuit of an enjoyable hobby really merited an army of support workers. At a time when we are bracing ourselves for deep and unprecedented cuts, should the state be subsidising leisure pursuits?

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Everybody has a similar story about waste. We all know what we can live without. Classes in cake decorating, yoga and holiday Spanish could be sacrificed. That means losing teaching and the administration staff who co-ordinate these courses. It would involve the bosses identifying priorities and choosing the unspeakable option, at least in the public sector: compulsory redundancies.

There, I have dared say its name. Perhaps that's because I have recently been through the pain of redundancy myself. It's horrible. You know it is a financial decision involving many fellow workers and no reflection of your personal ability. Yet it is difficult not to feel anger, rejection and a sense of failure.

That was how many journalists on my previous paper felt when management in London decided to cut the successful Scottish edition to a skeletal operation. Although we were doing well in terms of our circulation, it was felt that amputating one relatively small part of the business was the least worst option during a recession.

Salami-slicing across the board had been done before and another round would have damaged the quality of the core edition. Since most of the readers were in England, it made sense to concentrate investment there. I cannot say I like it, but I understand how the decision was made.

The private sector, with an eye on self-preservation, is always likely to put the needs of the business first and go for compulsory redundancies, which reshape the company while hanging on to the most valued customers.

The public sector, constrained by political pressures and well-organised trade unions, prefers salami-slicing. This is effectively what happens when you opt for recruitment and pay freezes, allowing numbers to reduce through natural wastage. Every area feels the same pain. Compulsory redundancies are harsh on those experiencing unemployment. But do they still seem harsh if a frail old lady still gets her home care or a person on chemo has access to a specialist nurse?

All this is complicated in the Scottish context, because cutting is our only option under the present constitutional arrangements. The block grant system means Scotland has no ability to raise money, or set fiscal policies that stimulate the economy, or change individual behaviour. Right now we have a simple choice, salami-slice or tell some people to do without. The former is, in many ways, a form of inaction. But it is the path we appear to be taking.

It would be a brave politician, senior manager or professional representative, who decided to amputate part of, rather than salami-slice, the NHS, which is suffering the consequences of PFI schemes and inflation, although its budget is protected.

We are concerned about losing nurses, but because they are the largest sector of the workforce, it is easy to make savings by not replacing them. It might be better for patient care to sack admin staff or withdraw a non-essential service - but that is unspeakable because it involves redundancies.

We all support first-class cancer care. Are we prepared to cut other aspects of health spending to protect this? What about the 16 million a year spent on methadone prescriptions for drug addicts? Rates of prescribing this heroin substitute have risen by 19 per cent in Scotland in the past five years.

The wider cost of treating addiction is staggering. The annual bill in Scotland, taking in social services, healthcare, benefits and criminal justice, is estimated at 3.5 billion. It would be worth it if it worked, but Scotland still has a higher number of addict deaths than any other European country, and more children living with drug addict parents as well.

Treatment of drug addiction is probably the most extreme example of preventive health, which has become fashionable and consumes more of the NHS budget.

Stopping problems happening makes a great deal of sense. But soaring rates of obesity and alcoholism, as well as drug deaths, make you question whether public education campaigns are money well spent… As for the recent pilots which pay people to stop smoking and lose weight… I think we can all guess where they sit on a top ten of taxpayers' priorities

One group questioning the Holy Grail of health spending are local councils, who point out that ring-fencing it will mean cuts of around 25 per cent elsewhere. Councils do not get a great press, on account of overpaid executives, self-serving bureaucracies and the junketing of some elected members. But they are responsible for the care of some of the most vulnerable people in our society - those with serious physical and learning disabilities.

Is it right they should suffer while smokers get cash to quit, because it comes from an NHS pot and not a council one? Should the jobs of all public-sector workers always come first?

Unless politicians, and the public, get real about setting priorities, the most needy will have to queue up beside everyone else.