Why Scotland’s Health Strategy Needs to Grow Up — and Get Real

I recently filled in the Scottish Government’s “consultation” on long-term conditions.

You know the kind — optimistic buzzwords, infinite tickboxes, and a vague sense they’re looking for affirmation, not actual challenge.

So I naturally went off on one at it. Professionally of course, is used ChatGPT to iron out all the swearing...

Because if you’re going to ask professionals working in the mess — in the bits where policy stops and patient reality begins — then you’d better be ready to hear what we see.

So here it is. Desanitised. Undiluted.

Stop Designing Healthcare for Unicorns

Long-term conditions don’t exist in silos. They overlap. They multiply. They refuse to behave. And yet we still build services as if every patient arrives with a single neat diagnosis and a user manual.

Multimorbidity in Scotland is the norm, not the exception — especially in deprived communities, where people live longer with more conditions and poorer outcomes. Yet our care models are still built for the one-problem-at-a-time fantasy.

Integrated care isn’t just a nice-to-have — it’s the only thing that works. People with multiple conditions don’t fit condition-specific pathways. They need care that’s joined-up, human, and capable of dealing with complexity.

Stop Asking GPs to Be Gatekeepers when the gate is Shut

We’re still pretending general practice is “the front door” to care.

It isn’t.

It’s the last open window after every other service has bolted themselves inside with a Do Not Disturb sign.

• Physio is waitlisted.

• Mental health services triage by risk.

• Social care is rationed into oblivion.

Meanwhile, patients show up with needs, hopes, letters — and when we can’t deliver, they blame us.

We’re not imagining this pressure. The King’s Fund has documented it. GPs are now the holding line for every unmet need in the NHS — with dwindling time, support, or authority to make it work.

Let’s be frank - it’s not a fair cop.

“Back to the GP” Is Not a Care Plan

Every time a specialist runs out of options, the patient ends up back with us. No further plan. No shared review. Just a letter that says, essentially: “Not our problem anymore.”

And no, a token “you can re-refer if you like” cuts little mustard in reality.

Because even at that moment it is still a problem — still sick, still scared, still unwell.

This is the reality of “clinical bouncebacks”, which are particularly high in older people with multimorbidity. When the system fragments, general practice doesn’t just absorb clinical tasks — it absorbs the fear.

Integration Isn’t Innovation. It’s the Bare Minimum.

You know what doesn’t help?

• Eight login systems for four different services.

• “Digital front doors” no one can find.

• Portals that crash every third click.

• Having to phone someone special for your special password reset having been on hold for 10 mins. All because this one didn’t need a number.

We don’t need more branded platforms. We need one that works.

Shared records aren’t utopian. They’re basic infrastructure — a prerequisite for safe care in complex systems. Single sign-on. One truth. Not five partial ones and a stack of printed letters.

Poverty Isn’t a Lifestyle Choice

Stop asking why people with long-term conditions don’t make better choices. That’s demeaning at best and straight out elitist at worst.

Start asking why they don’t have better options.

We know that people living in deprivation face more barriers to managing long-term conditions — everything from transport to food access to digital exclusion.

“Choice” isn’t meaningful without capacity.

You can’t choose to swim in water out of your depth - you do or drown.

You want prevention? You can already fucking do that:

• Ban junk food ads

• Take Fructose out of fucking everything

• Subsidise veg. Make it seasonal and local

• Build safe housing, not ones that look safe

• Give people enough money to heat the house and still afford basic meds.

• Make people who can afford it, pay for it

• Ban junk food. I’ll miss it but we’ll live

Real example - I shouldn’t be spending an appointment arguing with patients over 38p Paracetamol because the cost of food is so high. It’s really quite unsettling how it’s not entitlement that comes from these conversations, is existential.

Lifestyle advice is not a substitute for structural change — and no amount of motivational interviewing will undo decades of disadvantage.

Where’s the Real Education?

Staying healthy, saving lives, maintaining your mind - I needed these more than anything I learned from Biff, Chip and Kipper in School. Real health starts young, allowing time for normal to look healthy.

Even higher than that, Medical schools still treat long-term conditions like side quests. An optional module. A CBL theme if you’re lucky.

I should know - I teach it and it’s a god damn mess still.

If we don’t put time into this area though new doctors walk into surgeries full of people who aren’t acutely ill, but aren’t okay either. People stuck in the grey zone — chronic fatigue, endless referrals, no clear plan.

They panic, learn stigma, label - all sorts of nonsense they don’t mean just to rationalise the dissonance.

We don’t teach:

• How to de-prescribe

• How to help people live with pain - instead of just “kill” it

• How to work with housing, benefits, community services and speak their language

• How to really advocate for a patient in their messy world

And so we graduate clinicians trained for the sharp end, when most of what we now face is slow and sticky. There’s clear critique of this in the NIHR’s multimorbidity research agenda — and still, we wait for the curriculum to catch up

So What Would Help?

Beyond just throwing shade, I’m nothing if not willing to give my ten cents, as likely as it is I’m off the Dunning-Kruger curve somewhere.

To that end, here the more honest, though out list — each one backed not just by experience, but by evidence:

Time

Ten-minute appointments aren’t enough for complex care. They never were.

Continuity

Continuity of care reduces mortality, improves satisfaction, and lowers hospital admissions. But we’ve designed systems that shred it.

Backup

GPs can’t keep absorbing failure from elsewhere. A King’s Fund briefing makes it plain: if general practice is expected to do everything, it needs the resources and protection to say no when necessary.

Integration

The case for shared care plans and interoperable records is longstanding — and yet every service builds its own portal, with its own logins, and its own blind spots.

Community infrastructure

We keep talking about “social prescribing” but the actual community services? Underfunded. Overwhelmed. Vanishing. If we want care to happen outside clinics, we need to fund where it’s actually happening. Put us in the same bloody building.

Lived experience.

Co-production can’t be a checkbox. It’s very clear: services are better when built with the people using them. Not just patient advocates - usually a battle hardened sufferer with an axe to grind - no. REAL patients, the kind that don’t cause a stink but could do if given an easy window and a softened tone.

Truth

In that same vein, Policy keeps skewing toward the loudest voices - those with the most to gain individually but with blinkers firmly on to the bigger picture. Targeting by clinical need, not campaign volume is the only way to keep services equitable — and grounded in reality, not politics.

One Last Thing

This is for the questionairre writers themselves, something outside the fucking leikert shielding for you.

• If you’re going to ask professionals what’s not working, be ready to hear it.

• Don’t bury the messy bits in bullet points (DEI, mental health, intersectionality etc)

• Don’t wrap every reality in optimistic policy foam.

• Dont throw in token diversity questions if you can’t hear specifics.

• And please — for once — design a system for the messy, scared, complicated real patients we actually have.

Not the ones you wish existed.

Stay Questionable

—DW