Doing the right thing for a kinder, fairer and greener health service
The cover image of the chief medical officer (CMO) for Scotland’s recently published annual report presents a visualisation of two health systems—one dominated by teal and grey colours, clean and clinical, industrial.  A health worker sits at a desk with a headset on while looking at a screen. A woman lies in a hospital bed, alone. Another stands with her head bowed at the edge of the image. The other side of the graphic presents a different scene of greens, yellows, and blues with patients and staff interacting, surrounded by nature. There’s quite a stark contrast to the settings, deliberately presented to illustrate Scotland’s chief medical officer, Gregor Smith’s vision for a health and care service that shifts away from industrialised, transactional approaches to one that puts careful and kind care at its heart. This focus on careful and kind care is the essence of Realistic Medicine, introduced in Scotland seven years ago, which places the emphasis around what matters most to people.
In the latest annual report, Smith’s third as CMO, he progresses the concept of Realistic Medicine with the simple premise of “doing the right thing.”
He says, “By doing the right thing, we can move away from what often feels like industrial care performed by transactional technicians. By nurturing trust and belonging within our health and social care services we can reconnect to our purpose and deliver the careful and kind care that will create the fairer, more sustainable system that we all wish to see.”
Value-based care—listening and, importantly, hearing what matters to patients, while respecting that we are all human and vulnerable, and valuing care and kindness for each other and our environment—means doing the right thing from a perspective of humanity rather than what’s written in a text book. It is a shift in thinking away from the over medicalisation of care to one that only does what’s wanted and needed for that patient: “The misdiagnosis of disease is tragic, but so is the misdiagnosis of a person’s wishes for their care.”
The report references the Organisation for Economic Cooperation and Development estimate that up to 20% of healthcare spending adds no value to those receiving it, meaning that up to one fifth of resource is potentially wasted.  This waste impacts on people and the environment through the depletion of natural resources, and through the manufacture and use of unnecessary drugs, and emissions from unnecessary travel. Better value, more sustainable care would seek to reduce waste both in terms of resource and in the time taken in providing low value, futile care.
The report is built around four core chapters on being human, value based health and care, turning the tide on health inequalities, and climate and health. The interdependence of all of these elements on each other runs through every chapter.
The construct of value based health and care, for example, is made up of four components—personal value (what matters to the individual); population value (health and wellbeing and prevention of ill health); technical value (how care is provided); and societal value (the impacts on wider society, including the environment). 
This value based approach is consistent with the Scottish Government’s aspirations to become a wellbeing economy that defines wealth through human, social, planetary, and economic wellbeing. Scotland is one of a number of wellbeing economy governments, which also includes Wales, Finland, New Zealand and Iceland, pioneering this approach to put measures of health and quality of life alongside economics in determining a nation’s wealth.  The report highlights the importance of such an approach in the context of stalling life expectancy and a growing gap in health life expectancy between the most and least deprived communities in Scotland.
The climate emergency significantly impacts on societal value and the wellbeing economy through the burden it places on social and environmental determinants of health such as air pollution, extreme weather, and disease. The report highlights the opportunity to develop the advocacy role and connecting power of health and care professionals to gather wider professional groups and agencies to engage around the needs of patients and communities. And to improve societal value by using its dependable and trusted voice to influence and model actions that value people, planet, and health.
By acting as anchor institutions, local health and care settings are also presented as places that can help to address social, economic, and health inequalities by employing local people and using local services, easing access for patients and staff, facilitating active travel and more use of public transport, and ensuring land and assets are used to the benefit of the local community. This vision of health and care settings as anchor institutions is consistent with the aims of Scotland’s Climate Emergency and Sustainability Strategy which seeks to use the principles of the twenty minute neighbourhood and ensure NHS facilities can be accessed by active travel and public transport.
The role of biodiversity and nature in reducing emissions and pollution, and in making the NHS more resilient and better for patients and staff is also highlighted. For example, developing and managing green spaces and other green infrastructure such as green roofs and rain gardens to mitigate flood and overheating risks, will also promote biodiversity and make the grounds nicer places to be for patients and staff.
Emphasis is placed on the triple win co-benefits of action to mitigate and adapt to climate change with the view that taking action to become climate resilient will also improve health outcomes, create safer and more sustainable places to work, and reduce the cost of care. A Health in All Policies approach is promoted in the report, highlighting the potential for measures that seek to address climate change and protect health, to reduce disease spread, improve wellbeing, create better living conditions, and foster relationships with nature. These gains extend far beyond the impact on the environment, but also benefit other population health challenges.
Scotland has set ambitious emissions reductions targets, and while the Climate Change Committee has applauded the focus on a fair and just transition, the government has been criticised for the lack of progress, warning of the targets becoming meaningless and integrity being at risk without clear policies and delivery.  Getting the public engaged and reassured, rather than threatened will be critical to its success. In this regard, health and care professionals and the service they work in can be powerful advocates for delivering an honest, positive, and hopeful voice.
First published in BMJ: https://www.bmj.com/content/382/bmj.p1905
- NHS Scotland. Realistic medicine. Doing the right thing. Chief Medical Officer for Scorland Annual Report 2022-2023. https://www.gov.scot/binaries/content/documents/govscot/publications/advice-and-guidance/2023/06/realistic-medicine-doing-right-thing-cmo-annual-report-2022-2023/documents/chief-medical-officer-scotland-annual-report-20222023/chief-medical-officer-scotland-annual-report-20222023/govscot%3Adocument/chief-medical-officer-scotland-annual-report-20222023.pdf
- OECD. Tackling wasteful spending on health. https://read.oecd-ilibrary.org/social-issues-migration-health/tackling-wasteful-spending-on-health_9789264266414-en#page1
- Scottish Government. Delivering value based health and care: a vision for Scotland. https://www.gov.scot/publications/delivering-value-based-health-care-vision-scotland/
- Wellbeing Economy Alliance. Wellbeing economy governments. https://weall.org/wego
- Scottish Government. NHS Scotland climate emergency and sustainability strategy: 2022-2026. https://www.gov.scot/publications/nhs-scotland-climate-emergency-sustainability-strategy-2022-2026/
- Climate Change Committee. Scotland’s climate targets are in danger of becoming meaningless. https://www.theccc.org.uk/2022/12/07/scotlands-climate-targets-are-in-danger-of-becoming-meaningless/