Recently, a perennial idea has re-surfaced in the headlines – that we need a ‘National Conversation’ about the future of the NHS.

For example, Dr Iain Kennedy, chair of the BMA Scotland, said in December 2022 that “the whole health and social care system in Scotland in broken” and that we need a “national conversation now”. This isn’t a new call, as Dr Kennedy’s colleague, Dr Lewis Morrison, the then chair of BMA Scotland, was calling for such a national conversation in July 2020. He described  a “long overdue” conversation that would need to involve the Scottish Government, the public, and health professionals. And following a meeting between the BMA and the Cabinet Secretary for Health the Scottish Government are currently giving consideration to commissioning such a National Conversation. But what would a national conversation actually be about, and who would conduct it? On the first point, Dr Kennedy has said that the conversation needs to “…reflect on what we ask of our NHS and the levels of funding we, as a country are prepared to provide to meet those asks.”

He’s not alone. The Herald in April 2020, in calling for a National Conversation on the NHS, said it needed to address “…what we expect from its doctors, specialists and nurses; we need to assert just how much we are willing to pay.” and that this could be achieved by the Scottish Government organising “…a network of town-hall meetings, online meetings and prime-time television debates in order to solicit the views of Scottish people.”[3]

It is broadly accepted that the problems besetting the NHS both in Scotland and across the UK as a whole are long term challenges that include an ageing population, badly funded and inadequate social care, very expensive new technologies, lack of investment and very poor workforce planning.

These aren’t problems exclusive to the UK. France is also suffering huge problems with capacity, shortages and costs, with President Macron recently talking about a ‘sense of endless crises and doctors saying ‘we are all on the same boat, and it is like the Titanic”.

This is a crisis that has been brewing across the developed world for some time. In 2019 the International Society for Quality in Healthcare (ISQua) published a report advising that new technologies are creating “capacities of health and medicine to do far more than society is willing to fund.”

This in turn leads to healthcare professionals feeling “squeezed between a rhetoric saying that healthcare must deliver the best possible care to everyone and a reality, where costs for drugs and “technology” are consistently, but not openly …. prioritized over time for care and interaction.” ( ISQua Opinion Paper)

And back in 2016 in Scotland the ‘Montgomery Report’ grappled with the cost of new medicines, concluding that in the long term there was a need to agree “the priorities for funding from a finite resource. This will involve difficult choices, but these choices have to be made by the correct stakeholders armed with the correct information.” The report was silent though on who were the ‘correct stakeholders’ and who would decide what constituted ‘correct information’. It seems though that whilst some of the problems currently besetting our NHS may be fixed with more money, competent planners/managers, and better

politicians, the problem that can’t be so easily fixed is that the increasing cost of providing health care is calling into question the ability of any society to provide universal care that is not rationed in some way or another.

‘Rationing’ may not be a politically acceptable term, but waiting lists are a very visible form of rationing and we have those in abundance.  The prioritisation of Covid during the pandemic has almost certainly led to excess deaths in other medical areas – this is an example of rationing. Recently Greater Glasgow and Clyde Health Board announced that it was ‘pausing non-urgent elective surgery’ and prioritising urgent treatment and cancer care – this is also a rationing decision.

 In more normal times rationing can take a variety of forms, including:

• National and regional priorities
• Guidance and standards
• Targets and Indicators
• Cost and clinical effectiveness assessments
• Organ allocation for transplant
• Service Change (e.g., hospital closure, types of treatment)

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• Implicit rationing (e.g., decisions not to do things, or decisions to reduce availability or geographic access)
• Bedside rationing
• Rationing by dilution

‘Rationing by dilution’ is essential the slow and steady (and at times extremely fast) deterioration in quality, such as is being experienced at the moment.

So rationing is happening already, but in ways that are disproportionately affecting some patients, but not others. Even in the present crisis, some patients are reporting extremely positive experiences of receiving care, and that’s great, but that’s clearly not everyone’s experience. It is as if we have a healthcare service that also rations through people’s luck.

But why should rationing be always seen as negative? As the list above illustrates, rationing approaches include guidance, standards, and clinical effectiveness assessments, and these are good things. During WW2 rationing was seen as a way of distributing food fairly and led to the increased general health of the population. By rationing limited healthcare resources in a conscious way there is no reason why we can’t have a fairer system that improves overall population health. But to start having that sort of conversation we need to acknowledge the reality that rationing already happens.

There is a very good chance that a ‘National Conversation’ would end with an agreement to increase funding, through a mixture of increased taxation and cutting back in other areas, as experience shows that the public do not like the idea of limiting treatments when it comes to healthcare. The public may even want to extend coverage, for example by including more dentistry in NHS treatments than at present. And any national conversation about ’health care’ must also include the overlap with ‘social care’.

Perhaps we should also be sceptical about a National Conversation run by the Scottish Government (or indeed any government). Those involved in public engagement exercises and consultations have long known that the power to frame the conversation will shape the results of that conversation. For example, so much depends on how a question is worded (see the results of polling on the question of Scottish independence). The process used for an engagement exercise can also be used to discreetly, or not so discreetly, ensure that the output accords with the views of the organisers. Too often people simply hear what they want to hear from engagement exercises. And also, too often engagement exercises avoid the hard questions and difficult trade-offs that are needed for a truthful dialogue.

Running a large public engagement exercise on such a difficult subject would be fraught with difficulties. It wouldn’t just be a matter of town hall meetings, online discussions and TV debates. It would need very clear parameters, robust independent management, complex deliberative methodologies and lots of critical friends. It could get very messy, it’s conclusions would be controversial, and it would certainly not be cheap. But it’s very difficult to imagine that any politician would even risk attempting a National Conversation about healthcare rationing in the first place, not just because of the complexity but because of the potential political fallout.

That would leave us with a National Conversation that would avoid the difficult issues, focus on generalities that everyone agrees on, and would be a complete waste of time. There remains the persistent myth that we don’t ration healthcare and that we supply unlimited universal healthcare solely based on need.

Challenging that myth would take a very brave politician indeed.