A rich tapestry: hopes and fears for the Scottish NHS

The Great Tapestry of Scotland is a tremendous community project that brought together more than 1,000 stitchers to create a visual representation of 12,000 years of Scottish history. Its 160 panels now hang in a purpose-built centre in Galashiels in the Scottish Borders.

In the fourth panel, showing the ice age, two tiny green stitches – part of a tree – are the work of Joanna Bredski, chair of the BMA Scottish consultants committee.

‘I had a family member who was involved in the project from the beginning, and she worked on two panels,’ explains Dr Bredski, a consultant in rehabilitation psychiatry with NHS Borders. ‘She brought the ice age panel to my mother-in-law’s house and let us both put some stitches in a tree. I’m very, very proud of that.’

Ahead of the Scottish Parliament and Welsh Senedd elections on 7 May, The Doctor magazine has been travelling to meet doctors and take the temperature of health services. We asked interviewees to consider the situation since the last elections, but also to share their hopes for the next five years.

As leader of Scotland’s consultants, Dr Bredski (pictured above) understandably talks about working conditions for Scotland’s senior doctors but she also wants to see improvements across the health service as a whole, including better IT.

She paints a picture of a consultant workforce that wants to do its best for patients, but which has been increasingly demoralised by increasing workload, demand and the moral injury of feeling that whatever they do, they can’t deliver the service they feel patients deserve.

Improving NHS performance, specifically waiting times, where most targets are being consistently missed, should be a priority for the new Scottish Government, she says. ‘There’s definitely potential for harm for patients who are on waiting lists, and it’s very difficult for GPs as it is for doctors in secondary care. Some of the waiting lists are so incredibly long that you might as well not have a service. If your waiting list is several years long, it’s pretty much the same as no service.’

Examples include neurodiversity assessments, and orthopaedics, where waits of two years or longer are common. ‘Some of them have got slightly better, but they’re still extraordinarily long. There are instances where you can imagine a solution that just doesn’t happen. We’re hearing of doctors who have completed training in orthopaedics who can’t get jobs, because the jobs aren’t being made and advertised, while services have very long waiting lists for operations or are outsourcing the work to private providers.’

She explains the effects on patients and doctors of long waiting times.

‘It might be that sometimes had they been seen earlier, treatment might have been more possible, or more likely to achieve a better outcome. That’s very difficult to sit with as a clinician. And when someone who has waited all that time actually gets to hospital there’s almost an expectation on clinicians to apologise to patients for how bad things have been for them when it’s not of the doctor’s making.’

That’s a lot of work for consultants but also is a barrier to the ‘therapeutic alliance’ because the patient is so upset by the long wait, she adds.

Scotland has traditionally had a smaller private practice than England but it’s growing, says Dr Bredski, with people who previously wouldn’t have considered going anywhere but the NHS biting the bullet and seeking private care.

‘I’ve been fortunate that I’ve not had to do this yet in my family, but I know lots of people who work within the NHS and are very committed to the principles of the NHS, who have paid for private healthcare for themselves or their families because it seems the best and most reasonable option for them. I don’t believe I’d be any different. I think if I had the opportunity to pay for a treatment privately that could happen in the next couple of weeks versus six months or a year, I would probably do that, even though it does go against my core values.’

That’s not to say there weren’t successes in the years of the last Scottish Parliament, says Dr Bredski. ‘The headline was 2024 when we had direct negotiations with the Scottish Government and got a pay uplift for consultants with a total pay envelope that was equivalent to an 11 per cent increase in pay. There was also an uplift in discretionary points for the first time since they had been introduced and the uplift has continued in subsequent years.’

Consultants are not, however, happy with this year’s recommendation from the DDRB (Review Body on Doctors’ and Dentists’ Remuneration) that consultant and specialist, associate specialist and specialty doctors’ pay should rise by 3.5 per cent.

‘It’s almost certainly going to be sub-inflationary on some, if not all measures, pretty soon, and it takes us no further to pay restoration. We’re still massively down in real-terms pay to where we were in 2008.’

Consultant vacancies in Scotland are running at around 20 per cent, and the DDRB acknowledges in its report the pressure that secondary care doctors are under, she adds.

‘After the election, we think it’s necessary that the new Scottish Government meets with consultants and SAS doctors to talk about the DDRB recommendations. We’ve written to them saying we cannot accept them being imposed without discussion.’

Consultants are also hoping to negotiate a shorter working week – in line with that agreed for staff on Agenda for Change contracts.

Politicians might talk about clinician wellbeing, Dr Bredski says, but she wants to see action rather than words. ‘I’ve no doubt it’s well-intentioned, but the fundamentals of wellbeing for doctors is having an appropriate workload, having generally good relationships with colleagues, having the ability to exercise at least some choice in your job, so that at least some of it aligns with your values. And for some people it’s important to have additional flexibility, for example people who are carers, or have children, or have disabilities or health conditions.

These are often things that are not available to senior doctors in the NHS, yet they work more hours than anyone else. Agenda for Change staff went down to 36 hours for a normal working week in April but a normal working week for consultants is 40 hours, and most would work out of hours on top of that.’

Speaking personally, Dr Bredski believes that previous Scottish governments have genuinely cared about social justice and have wanted to make things better. She also believes they have tried to protect the Scottish health service – for example from creeping privatisation – more than has been the case in England. But she also points out areas where Scotland lags behind, partly because it doesn’t enjoy the same benefits of scale as in their neighbour south of the border.

‘For example, AI scribe technology is potentially really game-changing and labour-saving for consultants – there are trusts in England that have already made this available to their staff, whereas in Scotland we’re nowhere near agreeing the governance let alone the funding for that.’

After the interview, we take a walk round the tapestry exhibition, marvelling at panels showing significant moments and people in Scotland’s history. These include the founding the NHS, and the reconvening of the Scottish Parliament in 1999. Importantly, it’s a living project, giving more and more people the chance to be part of the national endeavour. Dr Bredski points to ‘her’ tree. ‘I didn’t realise that the intention had always been for it to grow and update, so I like that it’s still growing and changing. We’re pretty proud to have it in the Borders.’

At that moment it’s not entirely clear whether she’s talking about the tapestry or the NHS.

One of BMA Scotland’s biggest successes in the course of the last Parliament has undoubtedly been around resident doctor pay, specifically, progress towards ending pay erosion and restoring it to historic levels. Like the rest of the UK, resident doctors in Scotland were balloted in strike action back in 2023. Unlike England, Wales and Northern Ireland, however, strike action was called off when the Scottish Government offered a 14.5 per cent pay rise over two years, with a promise of making credible progress on pay restoration.

Threatened strike action was called off again this year when the Scottish Government offered a deal on pay uplifts and contract reform which amounted to 9.9 per cent this year and 9.4 per cent next.

But although this is welcome, it doesn’t mean that everything is rosy for Scotland’s doctors in training.

‘Over the past four years we’ve negotiated an average 50 per cent increase in base pay for Scottish resident doctors, without losing a single day to industrial action,’ explains Chris Smith, chair of the BMA Scottish resident doctors committee. ‘That takes us nearly to where pay levels were in 2008. In that regard, we feel that we’re on the right path, and people do feel happier at work because of it. But we’re not there yet, and there are many other issues we need to deal with.’

Not least of these is the question of training posts. Dr Smith is himself caught up in the current ‘bottleneck’ which has seen doctors struggling to access specialty training after completing their foundation years. He has ambitions to be an oncologist and has applied to do IMT (internal medicine training) as the necessary first step – but has not yet been successful. Currently, he is working as a clinical fellow in gynae oncology, based at the Western General Hospital in Edinburgh.

‘Unfortunately, I’ve not been able to secure a training place for the last two years and I’ve been unsuccessful this year, which is a shame,’ he says. ‘I met the cut-off point for the portfolio, and was deemed appointable at interview, but didn’t rank highly enough to get a job. With my partner being in training locally, I wanted to be in the central belt [of Scotland] and unfortunately there was no match for that. It’s a shame, but I’ll keep going.’

He is far from alone. ‘People are really worried securing secure employment, not just relying on rolling annual contracts,’ he says. ‘They want to get into specialty training to progress their careers, and know that they are working towards something they want to do. There just aren’t enough places for the number of doctors that are applying, which means there are more and more people not getting in – and that means roles like clinical fellows are becoming more competitive as well. People are being left relying on insecure local work if they can get it or being un- or under-employed and having to look elsewhere.’

Aged 32 – he did a first degree in biomedical science and worked in research before going back to study medicine – Dr Smith is at a stage in life where doesn’t want to be on the move all the time. ‘I want to be sticking roots down. I’d like to be more settled than I am.

‘It’s crazy. I feel that the social contract has broken down a little. We work hard, we make sacrifices, we work difficult hours in conditions that aren’t the best, but for that we expect to be secure, stable, and well-remunerated and it just doesn’t feel like that side of the bargain is being upheld anymore.’

Over the course of the next Parliament, he wants to see these issues addressed. ‘The most important thing is seeing a joined-up workforce plan that takes people from medical school to being a consultant, GP, or specialty doctor,’ he says. ‘That means that the education at the start is excellent and equips you to do the job, then when you’re in the job, you’re well-supported, and when you’re ready to progress, there are posts for you to go into to develop yourself and also keep the service running the best it can for patients.’

It’s also vital to fill consultant vacancies, he adds. ‘There are people who want to work as consultants and aren’t able to, and we’ve got consultant vacancies. It’s mad – we need a plan to join it up.’

Like many of his peers, Dr Smith is also paying back large amounts of debt accrued as a student – all the more so in his case, as his two degrees were completed in England so he had to pay fees (tuition fees remain free in Scotland for now). ‘I think I have around £128,000 in student debt and it’s going up, although I’m paying it off every month.’

Back in 2016, when he began his medical degree, he thought the financial hit and extra years’ study would be worthwhile – but has it been?

‘When I’m on the wards and doing the work and interacting with patients, it’s worth it, because I do feel I’m doing good work and it’s the right thing for me to be doing. But then I go home, and I’m doing all the additional work the job now requires to get into training, and I can’t find a job that offers more than a year of security, and I do think to myself that I did have an alternative career path [academia] that I could maybe have been a bit more stable in.’

Many doctors in similar situations have moved to Australia, he adds – and are loving it. ‘They say the work isn’t as demanding, they’re paid much better, the terms and conditions are better, they’ve got more time off, and there’s sunshine,’ he says, looking out at the somewhat cloudy Edinburgh skies (although at least the rain has stopped).

He stresses that he’s not an unusual case, referring to difficulty in getting a training post. ‘There are plenty of people out there who have worked for longer than me, who have more degrees than I have, who have families and dependants, and who can’t get work and are looking outside medicine. I’ve been lucky that I’m able to stay in my post next year if I want to, so I’m not looking at unemployment. At least that’s something.’

As of last month, Sine Steele has a new job title – specialist doctor in anaesthetics in NHS Tayside. She hasn’t moved role as such, but she is one of the first in Scotland to undergo a regrading process now open to specialty doctors to recognise their levels of experience and expertise.

It means a bit of extra cash in her salary each month (although not that much, because she was previously at the top of the specialty doctor scale), but importantly it better reflects the work she is doing, and her seniority.

‘There’s such a broad church in SAS,’ says Dr Steele, who chairs BMA Scotland’s specialist, associate specialist and specialty doctors committee. ‘You can come into a specialty doctor post with five years’ experience, or you can be someone who has almost completed training and has 20 years in post, but you’ve got the same job title. I think it’s useful to be able to say I’m a specialist rather than a specialty doctor – it’s just that little bit of extra recognition of that seniority.’

For SASC, winning the right to regrade has probably been the biggest success during the term of the last Scottish Parliament, Dr Steele says. But although the new senior role was agreed as part of the last contract negotiations, which concluded in 2022, it has taken some years to get to the point where doctors already in post can easily apply.

That’s owing in no small part to reluctance on the part of employers to give their existing staff the opportunity, she says, which means the committee has had to work hard to get it off the ground for those already in post, rather than just for new jobs.

‘Two years down the line only about 50 posts had been created in total in Scotland, and not all of them had been specialty doctors,’ Dr Steele says. ‘So, when we were negotiating pay two years ago with the Scottish Government, we pointed out that if you have someone who is doing the more senior job, but for lower pay, there’s no incentive for the employer to create these posts because they’re already getting the work for the cheaper rates.

'At that point, Wales had just announced that they were creating a regrading policy, so we had an agreement in Scotland that we would create something that would recognise that people who were already doing the work should be paid and recognised at that level.’

Regrading provides a worthwhile opportunity for SAS doctors to progress in their careers, without necessarily going down the route of applying to become consultants, she adds, and this is something that she would like to see expanded throughout the next Parliament.

‘When you go back and look at the numbers when there were staff grades and associate specialists, which is the last time there was an established senior SAS grade, the proportion in that senior grade was quite high at around 20 per cent. I would hope that with regrading in place, we can push to get back close to that. It’s easier to attract people into an SAS career if they can see there’s a chance of progression. There’s a lot of people who talk about moving into a consultant role from an SAS role, but that’s not the only kind of progression. Some people want to stay as an SAS doctor but be recognised as senior members of their departments.’

She also believes an expanded senior SAS grade will improve for recruitment and retention – and with vacancies running at around 20 per cent, similar to consultants, that’s a big issue. ‘We were starting to have real issues in Scotland because more specialist posts were being created in England, so people were beginning to talk about moving,’ she says.

Outside the regrading issue, there are still many challenges SASC will be bringing to the new health minister, when he or she is appointed after the election. Pay is one of them. Although the latest contract negotiations pushed up the starting salary for SAS doctors in Scotland, increases in resident doctor pay mean they are beginning to lag behind, says Dr Steele.

‘Some resident doctors with a lot of experience who would be eligible for an SAS post would probably face a pay cut because the starting salary would be lower, and without banding, the pay cut becomes significant. So having made a big step forward, the goal posts have moved again.’

Another priority is ensuring that SAS doctors are given the respect they deserve and the opportunities to make a real difference to patients, she adds. ‘I always find it slightly difficult when people ask if I’d recommend a career as an SAS doctor because it depends on the department – not the health board, but the department. My own department is excellent – from the day I started, I’ve been treated as a senior, permanent member of the department. But in some places, SAS doctors are treated as rota fodder – they’re just there to turn up, do the work, not have an opinion, and not get involved in anything outside that.

‘If all departments recognised their SAS doctors as senior decision-makers, I think that would make a big difference to morale.’

Lailah Peel moved to Scotland from the south of England for her foundation years because she saw it as a more positive and inclusive place to work and live.

Ten years on, she still thinks that’s the case – but that’s not to say it’s perfect.

Having held a number of BMA roles, she is now co-chair of the Scottish local negotiating committees – an appointment typically held by a consultant or SAS, whereas she is a resident.

This national role gives her an excellent overview of the concerns and challenges facing doctors in secondary care, and very strong views on what she would like politicians to do over the course of the next Parliament.

Likewise, her job – as an emergency care doctor in a training post in Clyde, just outside Glasgow – means she is literally witnessing what happens at the NHS front door, day and night. Suffice to say, she sees the need for improvement.

‘A&E has been in crisis now for five years,’ she says. ‘The target of trying to get 95 per cent patients seen and dealt with in four hours hasn’t been met in five years. It’s nowhere close; it’s been below 80 per cent. And what have we done about it? Nothing. People have been dying in ambulances, people have been dying in A&E, and there’s so little action. Yet some of it is so simple.’

She would like the new Scottish Government to take a broader, more holistic look at the health and social care system. ‘Maybe we need to pay carers more, maybe we need to have difficult conversations, maybe we need to have a different set-up where there are more supported living set-ups where people can be supported to stay independent.’

As an LNC co-chair, her priorities include better monitoring on equality – and how that affects things such as job planning and who receives discretionary points. But she would also like BMA committees to be more diverse, believing that lived experience leads to more effective representation. ‘We’ve never had a female chair of Scottish council, which I think is kind of shocking,’ she says.

She also wants to see a more diverse group of people involved in committees and working groups in wider society. ‘I’ve been to meetings where it’s been a majority of men of a certain age that are white, and they have no concept of what it’s like to be from a culture that’s different to theirs. I’m not saying I’m loads better – I know I probably struggle to represent things that are very different to my experience, but because I probably cross a lot of boundaries of intersectionality, I can understand what it would be like to be slightly different to my circumstances.’

By the time she moved to Scotland, Dr Peel had years of experience of working or being a student in the English health service. Having originally studied dentistry, she discovered a love for maxillofacial surgery, and decided to study medicine, working all the while in what was effectively a maxillofacial registrar role in a variety of local services. Realising that one of her main strengths and interests was communicating with people, she then shifted tack and moved into emergency medicine.

Like so many of her peers, Dr Peel has not yet moved into a formal training programme, something she finds a little frustrating. But she has no regrets about moving to Scotland.

‘I definitely felt in England that patients were treated like a number or statistic, not with the holistic approach I’d like to take as a health professional,’ she says. ‘Whereas I felt in Scotland there was a much better attitude to that. I remember around the time I moved there was a small increase in income tax, about a penny in the pound, and I remember patients telling me they wished it was more, to fund services better. There just seemed to be more camaraderie in the system.

‘I also felt there was more community cohesion. People would hear I had an English accent and would ask where I was from, and I’d say Birmingham, and the conversation would move on. They wouldn’t focus on the colour of my skin, they wouldn’t ask where I was really from.’

There are, however, areas where she believes Scotland lags behind England, specifically in the use of technology in the health service. ‘There are some areas in Scotland where we’re behind the curve. Technology is better down south. The NHS generally is really bad at not doing systematic improvements where they are needed because there’s too much bureaucracy and things just don’t happen quickly. But I can see there’s been some improvements in England. For example, my mum was showing me her stuff on the NHS [England] app, and I thought it was really good – it made sense.’

She also believes that Scotland needs to get better in how the health service treats people nearing and at the end of life. Although the last Parliament didn’t pass a law to legalise assisted dying, it came closer to doing so than any previous attempts, and it’s quite likely to come up again in the future.

‘I hoped the assisted dying debate might actually lead to people saying, “let’s improve this, let’s not rely on hospice care being funded by charity, let’s have it funded by the NHS”. But we don’t even have those conversations.’

As the election approaches, Dr Peel wants politicians to think long-term about the health service, rather than merely from one election to the next. ‘I made the mistake of listening to the leaders’ debate on Sunday and just got really angry with them,’ she says. ‘They were just men talking over each other, and not listening, and there was very little about action, about what they wanted to do to make things better. It was just the NHS being used as a political football. This needs to change.’

• BMA Scotland launches manifesto for the NHS