NHS: In need of surgery or therapy?

Ideas for reform of the NHS and its funding are going public to challenge the political consensus that it can go on as it is.

That's not just an issue for the Scottish government, as some have portrayed it. The consensus across parties and across governments at Holyrood and Westminster is that the NHS must be funded to do what we think it should be doing, even if the evidence suggests that may no longer be possible, if it ever was. And money can only be part of the solution.

In last week's autumn statement, social care reform in England was postponed yet again. Trying to avoid the need for people to sell their homes to pay for residential care is proving too expensive while the UK government budget is so tightly squeezed. There's a problem with workforce planning and with retention, some leaving because of the pressure of their jobs, some because of a pensions tax incentive for the highest paid NHS staff - mainly doctors - to retire earlier than we might wish them to.

Ministers swipe aside the suggestion. But the private sector is already part of the solution - easing the pressure on waiting lists. And if senior NHS managers were looking at an element of private funding - with the idea being discussed of better-off patients contributing towards their hip replacement - what do they get for that? Preferential treatment? Can they jump the queue? Better hospital food? You can see that being very unpopular.The issue may be less about public or private providers. The issue may be more about the use of patient funds, beyond tax funding, to manage demand.

Those in need of social and nursing care routinely have to depend on unpaid carers. and not only to dig deep for self-funded care homes, but to subsidise those in neighbouring rooms whose fees from councils do not meet the costs. These are commonplace payments for basic health needs.The international dimension is often overlooked in this debate. Every country's health needs profile is unique, the development of its health service is also unique and Scotland has particular health challenges.

More useful comparisons are with closer neighbours or those with similar histories. There is always a tax element to fund at least a minimum level of support net for those without resources, sometimes directly linked and ring-fenced, though that can be problematic, and attempts to link British taxes that way have crumbled.

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