On the question of NRAC and the Arbuthnott report, we had the best intentions and the best methods and statisticians. To some extent, we had the best data—although, as Pauline Craig points out, the data that we get is not necessarily the data that we want.
Systematically using activity as a proxy for need takes no account of unmet need. The deep-end practices are unable to generate activity that reflects need, so it goes unrecorded. NRAC specially commissioned health economists in York to find unmet need, but they could not do so because they were sitting at a desk in York. If they had been sitting at a desk in Govan, Possilpark or Easterhouse, they would not have had a problem in finding unmet need.
The trouble is that using other measures of need, such as mortality, frightens the horses because the arithmetic implies very substantial changes that would be politically undeliverable. The argument has to be for progressive change over a period of time, not change overnight.
The points that Andrew Buist makes about recruitment are important. That will have impacts across the service, so it is not a particularly deep-end issue, although it is particularly important for the deep end. We have an advantage in Scotland in that the areas of most severe deprivation are concentrated around Glasgow, where lots of people want to work. We do not have the problems of underdoctoring there that exist in south Wales and in parts of London and Birmingham. We have a high-quality workforce in deprived areas in Scotland, and we are probably better placed internationally than anywhere else to show what a needs-based service could deliver. That is one of the challenges for Scotland to address.
What we need at the deep end are models of professional careers and opportunities that inspire the next generation. That will require not financial reward so much as professional reward.
The leadership role in deprived areas must be recognised and supported, in addition to the clinical role, so that in 10 or 20 years’ time we will have a cohort of people who are leading the development of hub-based local health systems at ground level, in partnership with other leaders in healthcare. We do not have that at present although we have the potential to build on the deep end.
It is not just about the deep end, however. Everything that is argued for the deep end should be applied pro rata across the system. If we simply solve the deep-end problems, that will not address Scotland’s inequalities, which are patterned across the population. The policy must be a pro rata one across the board, although the deep end is a place to start.
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I would like to see much more support for leadership roles in that area of the health service, because the role cannot be imagined from far away; it can only be developed locally on the basis of local knowledge of premises, populations and colleagues, and that approach must be enhanced. The type of leadership that is required is not the same as that which is required of a clinical director in a CHP or of someone on a secondment to the Scotland Office who works in a big bureaucracy. It involves leadership in the local microeconomy of a general practice within a local community. At present, leadership in such contexts tends to be exceptional and notable because of its novelty. We should make it more mainstream.