To address fully the challenges in the provision of health care and social care in Scotland, we may need a paradigm shift. In other words, a fundamental change in our way of thinking about how we deliver health care and social care. To paraphrase Einstein, it may not be possible to solve our problems with the same thinking used when the NHS was established in the 1940s.

To achieve such a shift is not easy. It may mean examining some of the very foundations of how things are currently done and challenging some of the basic precepts upon which present thinking is based. That doesn’t necessarily involve throwing everything out of the window. But it does mean having the courage to ask important questions about what we have been doing and what we take for granted, to look at things in a way we may perhaps not have done before.

This also requires humility, and an admission that we don’t have or know all the answers. Perhaps only then can we embark properly on a process of exploring change. We might conclude that some form of top-down solution cannot be imposed, that central control and hierarchical management is not the way forward. Things are too complex, uncertain and multi-faceted for a one-size-fits-all approach. That may mean enabling people in different settings and localities to make decisions, based on their own experiences and knowledge. That carries the risk that some of these decisions may turn out to be wrong. It’s a balance. But we learn from what doesn’t work as well as what does.

New thinking would require genuine collaboration in practice, not just talking about it. It could mean a shift from what some may see as a transactional, incentive-driven, reward/punishment model, in which individuals sometimes feel like cogs in a wheel, to one founded on strong, respectful relationships throughout the system. It might entail a move from targets, possibly unachievable, to greater trust and empowerment, perhaps acknowledging the illusion of centralised competence and permitting fallibility and vulnerability in the quest for vision, innovation and creative leadership. Financial resources may be limited; imagination and ideas are not.

Fear cannot be the driver. We can encourage a culture of taking responsibility, not avoiding blame. Political point-scoring, hyperbolic language, the narcissism of small differences – all of these can undermine.  Setting aside some well-established interests for the sake of the common good may be necessary. We need to work together, enabling people within the system to thrive and feel valued, recognising the inescapable network of mutuality, inter-dependence and reciprocity upon which a properly functioning health and social care system surely depends. Easy to say … achieving this may be a national imperative.

John Sturrock, The Times, 6 January 2025