The NHS in Scotland is run by one of the country’s most senior and experienced civil servants – closely tying operational and policy management together. Paul Gray tells Richard Johnstone about the benefits of integration, and the need to plan for tomorrow
Photography by David Anderson
As the UK commemorates the formation of the National Health Service, it is important to remember that this singular national institution isn’t a single national institution.
Since its foundation in 1948, the NHS has been run differently in Scotland. It was created by a separate act of parliament from its English and Welsh equivalents, and first administrative and then political devolution allowed for different structures to develop. While this did not make much difference in the service’s formative years when, to paraphrase NHS founder Aneurin Bevan, a bedpan dropped in a hospital would have echoed the same way in Edinburgh’s St Andrew’s House as in Whitehall, the two decades since the creation of the Scottish Parliament have seen the services move apart organisationally.
Among the differences were the abolition of the internal market for health services in Scotland in 2004, with hospital trusts absorbed into health boards to act as the single tier of governance and accountability, while the head of NHS Scotland remains – unlike in England – a civil servant.
Whereas NHS England chief executive Simon Stevens runs what has been described as “the world’s biggest quango” thanks to a 2013 move intended to take politics out of the running of the health service, in Scotland the director general health and social care remains the chief executive of NHS Scotland.
That man is Paul Gray and he meets CSW at St Andrew’s House to reflect on the 70 years of the NHS in Scotland and how he manages what is – at 163,000 people – one of the largest number of operational employees under any civil servant’s direct management in the UK.
Gray, who has served in the post since 2013, reflects that it is important to “look back to what has been achieved” since the NHS’s foundation.
“It is an institution that means a great deal to the people of Scotland, and I know it means a great deal to the people in the other countries of the United Kingdom as well,” he says.
“They value it and I think they particularly want to see the staff who have worked so hard to make it what it is recognised. The 70th anniversary of the NHS is not about people like me, it is about people at the frontline who have worked in the NHS for many, many years and who have given selflessly at time of pressure and of trial to ensure that people who need our care been given it.”
His jobs are “not completely distinct” roles, he says, as “every day I do bit of both”.
“I have in effect three roles,” he explains. “I’m the principal advisor to the secretary for health and wellbeing, and I’m a member of the government’s corporate and executive team [and] so as a director general I have a corporate responsibility that spans across government, I’m not simply responsible for what in old speak would have been called a department. And as chief executive of the NHS I’m responsible for delegating to the chief executives of the 22 health boards [14 regional NHS boards, seven special boards and one public health body] financial and operational responsibility for both strategy and delivery.
“In a sense, trying to separate out those three roles would be both difficult and probably unnecessary.”
Although the Scottish Government has large operational delivery units in areas like agricultural policy and, increasingly, welfare delivery, Gray’s role at the head of the health service is different from his previous posts, which included being director general of rural affairs, environment and services, and DG governance and communities.
“The operational element is significant,” he says. “It’s not that we don’t have other policy delivery areas, but the NHS in Scotland employs 163,000 people – it is a pretty substantial operation.
“So the real distinctiveness about my role, and one of the key elements of it, is finding the right balance in ensuring that I attend to the corporate responsibilities I have as a member of the corporate board of the Scottish Government while also attending to the corporate responsibilities I have as the chief executive of the National Health Service, and it is important to keep these things in balance.”
“When the NHS chief executive and department are separate they can interact, but I can’t really ask myself for more money”
The NHS in Scotland, like its counterparts elsewhere in the UK, is faced with record levels of demand and in May statistics showed a quarter of eligible NHS patients were not being treated within the Scottish Government’s 12-week time guarantee.
Asked how he would characterise the condition of the NHS in Scotland at its landmark birthday, Gray is proud of the record. “I believe our record on patient safety is outstanding,” he says. “We have seen significant reductions in hospital standardised mortality ratios since the Scottish Patient Safety Programme was introduced in 2007. We have seen an ability to sustain good, if not perfect, performance on a range of areas, our A&E performance continues to stand comparison with the best.
“I think Scotland is performing well, but I’m absolutely not complacent. There are areas where we could be performing better and are working very hard to do so. We’ve reduced our waiting lists for outpatient appointments, for example, very substantiality and we continue to work on that.”
Gray has identified priorities for the years ahead that include improving child and adolescent mental health services and ensuring any slippage in cancer waiting times is tackled.
Although Gray jokes that there are downsides to not having a separate chief executive for the NHS, as in England – “in a place where the chief executive of the NHS and the department are separate, they can interact with each other and the chief executive of the NHS can say, ‘I need more money or things done differently’. I can’t really ask myself” – he says the upside is being able to align policy decisions and operational implementation.
One example of how he seeks to do this is the forthcoming financial framework for the health budget, which is being developed as part of the Scottish Government’s overall framework for public spending.
This sets out a five-year trajectory of the areas where Gray and his colleagues believe there is increasing demand and what they will do to meet it.
The framework will then be matched to regional delivery plans for the first time, giving details of how to deliver the next level down as part of a five-tiered structure.
“We’ve set ourselves a strategy for delivering nationally – we call that Once for Scotland – but then regionally and then locally, and then in communities and individual cases. We’re stratifying our services to ensure they are appropriately targeted in these five strata. That is important as that gives everyone in Scotland a frame in which to work, so through the regional delivery plans we are setting out to describe what it is we’re going to be doing over the next three-to-five years, so everyone can have a sense of what it is that we want to deliver.
“The core focus of ensuring that care is delivered at home or in a homely setting wherever possible remains, ensuring that people can have care as close to home as possible, but then to have specialist care in specialised centres where that’s needed, and that involves that stratification of what can be delivered in the community in that homely setting against what needs to be delivered in a structured or planned way in a hospital-based or a tertiary care setting.”
Add to this the development of a longer-term strategy focused over the next 10-15 years to take account of likely advances in both medicine and technology, and the management challenge becomes clear.
Gray insists that while current issues in the NHS are vital – “today’s issues matter, they affect real people, they affect patients today” – it would “be a dereliction of my leadership duty if I allowed us to focus only on today’s issues”.
“Change doesn’t happen by me writing a letter telling people to transform ”
“We do set aside time to think constructively on what our strategy should be, and so do ministers,” he says, adding that the ministerial focus on the long term is “extremely helpful”.
How is he able to transfer such plans across the whole of a large organisation?
“What we don’t do is change by edict. Transformation doesn’t happen by me writing people a letter and telling them to transform,” he says. “Change has to be implemented locally and that is the point about setting the framework for the change, so that people understand what the strategy is, what that the trajectory is and then are working to change within that.”
One of the areas where Gray has been able to lead change was the integration of health and social care. Implemented in 2016 after a year of shadow running, the move brought NHS and social care services together into 31 local partnerships was “the biggest transformational change of delivering health and care services that this country has seen for decades”, says Gray.
“I would say that a key benefit of having the role as it is has been that the responsibility for health and social care integration has not been regarded as a separate entity, and the issue I think we now need to tackle is ensuring that we have the senior leaders, from all of the sectors that are involved in health and social care integration, together with one set of objectives and a common purpose.”
He reflects that although the NHS is celebrating seven decades, integration of health and care – which is key to the health service’s future – is a toddler by comparison.
“I’m often telling people that although we are at the 70th anniversary for the NHS we’ve had two years of health and social care integration, and people tell me it is not yet perfect, I ask them to give us the other 68 years, although I don’t expect it to take that long, I genuinely don’t. I think there has been serious progress in health and social care integration, but let’s allow that progress to bed in rather than taking the stance that it is not yet perfect and therefore there must be something wrong with it. There’s a great deal that is working very well.”
Indeed, people are coming to Scotland to see how integration – a policy holy grail across the UK and internationally – is working, and Gray is keen to share and gain knowledge.
The night before he meets CSW, Gray was at an event with representatives of 16 countries who have come to Scotland to see what is being done both in the NHS and in the wider health and care arena.
“I’m also a great believer in learning from other countries – we’ve very interested in what is going on in Greater Manchester and the devolution of health and care services there, and we have learned a lot from the way that health and social care services are delivered in Alaska for example,” he says. “It is not that we simply believe people should come here to see how it is done, but we also believe we can continue to learn from what other countries do as well.”
This is doubtless a sentiment of which Bevan, who called the creation of the NHS a milestone in history that saw “the eyes of the world turn to Great Britain”, would approve.