Given that the NHS forms half of the £20bn-plus public sector in Scotland, it is disappointing that the Christie report makes only tangential reference to it, and then mostly to plead for better integration with social services. But, however much of a political shibboleth it is, however well loved and groundbreaking, the NHS is a monster by anyone’s standards. Taken as a UK whole, if it were a country, it would come in at No.67 in the world—behind Hungary, but ahead of Morocco and Vietnam.

Dealing with even the Scottish 10% of it is daunting. Quite apart from powerful interests like the BMA, the NHS here is divided into a dozen or so Primary Health Trusts and a myriad of supporting orgainsations like the Scottish Ambulance Service, none of which have so much as a sniff of democratic control, other than by ministers.

NHS "Structure"—There Will Be a Quiz at the End of this Article

Leaving aside NHS24 and actual patient information, finding anything out is hard as you’re bamboozled by a myriad of websites, such as the so-called ‘information’ site:

http://www.ic.nhs.uk/statistics-and-data-collections/publications-calendar

This site is UK wide and might serve as a lesson in information overload all by itself. They have so many TLAs (three-letter acronyms) that they have an entire section of alphabet soup called ‘jargon-busting’. Of the 168,000 who work for the NHS in Scotland, a reassuring 67,000 (around 40%) are nurses and midwives. But a further 30,500 (18.2%) are in ‘administration’, plus a further 20,000 (11.8%) in ‘support’. So, for every worker directly involved with patients there is another who is not.

All modern organisations need some logistical ‘tail’ and cooks, cleaners and porters are obviously necessary in any hospital. But 30,500 administrators? What are they doing? In another life, I had some experience of NHS Trust backroom operations. They had all the trappings of modern management—KPIs (‘key performance indicators’ to those who don’t speak TLA) meetings, supervisors, budgets, the works.

But, lift any rock and some ugly beasties emerged. They counted meals as satisfactory if they had been touched (reminded me of a joke sign outside a hamburger stand: “17 billion served; 14 billion eaten; 9 billion digested”). They thought their porters were efficiently used because their logging system showed they were over 75% active—turned out they were only measuring 45 general porters, not those in X-ray or sorting mail or delivering pharmaceuticals, etc, etc (a total of almost 100 not being logged). Best of all was the utility bill for their main hospital paid from a single pot. No department had any incentive to save energy. When Ward 2 got too warm, they opened the windows while their electricity bill went through the roof.

Having a quarter century of management experience here and abroad, it was not rocket science to see where the NHS could make real savings and keep frontline services. But in their rush to hire administrators in the nineties, the NHS was naive and hired third-rate ones who could not hack it in the private sector boom at the time. Whether we have the political stomach to hack away such waste while the NHS is held as a shibboleth remains to be seen. But no tightening of public sector belts can be effective without starting with the half of public money that goes here.