As a senior manager in the health system in Scotland, managing a large budget and a substantial number of staff, I have the same challenges as my counterparts in England. But – though I’m not a nationalist – the Scottish National Party deserve an above-average score for their management of health and care.

My biggest everyday challenge, however, is balancing four competing demands: keeping within budget, treating people inside 12 weeks, maintaining service quality, and ensuring patient safety. With demand for services, multiple morbidities and drug prices constantly rising, I can’t achieve all four goals; they’re simply mutually exclusive. I have to make choices – and those are really lonely decisions. It’s like walking a tightrope every day, with crocodiles on one side, lions on the other, and someone behind me with a knife. My response is always to focus on quality and safety: while I might lose my job for overspending, if something goes badly wrong on safety then I could be responsible for a patient being harmed, or end up in court.

In Scotland, we have no purchaser-provider split or competition between health providers. Regional health boards run both primary and secondary care, and we view ourselves as one service and work together, which is a more collaborative model than England. That’s particularly helpful at the moment, as in April 2016 we merged health and social care and created integrated joint boards (IJBs) at local authority level to manage combined budgets. With unified strategic management across health and social care, we have a fighting chance of being able to build sensible plans for the next crucial steps.

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The government’s strategy is to move more money into the IJBs, which I support – but it means that acute budgets and services will take the pain. Therefore, we need to ensure that demand for acute services decreases by working jointly with our IJB partners in provision of non-acute models of care; for example, by creating new care home places and elective care centres.

Quite bravely, the SNP also has a realistic medicine agenda (pdf), which is about having an honest conversation with the public about tackling over-medicalisation of care – trying to ensure that all the treatments we deliver have real benefits for patients. That agenda provides an opening into difficult conversations about our ability to meet competing expectations on waiting times, quality, safety and budgets.

The SNP recognises the huge pressures we’re under, and the need to reduce demand for acute services. If the opposition brings up a patient’s case in first minister’s questions, the heat can turn up quite quickly and it all gets a bit political on this particular tightrope. I have to say that they do attempt to be supportive, particularly when the media try to whip up a non-story. I was glad to be in Scotland after the recent NHS cyber-attack, when the UK home secretary’s language was about who was to blame, while the Scottish government was more supportive in tone.

Demand for health services is going to outstrip supply for a generation – unless there is a significant change in taxation, we will always be climbing a very steep hill. On balance, I do think the policies the Scottish government are pursuing are the right ones to minimise the steepness of that hill.

It is a leap of faith, though – will we be able to transform our services? Will the public accept the ideas behind realistic medicine, even if it means that patients won’t always get the treatment they feel they need? Will politicians be prepared to stay the course?

Staffing is another major obstacle. There are simply not enough medical and nursing professionals coming through the system. Despite putting full-page ads in professional journals, we struggle to get quality applicants. We try to plug the gaps with agency locums, but they’re expensive, and it’s even harder to recruit into services that are already reliant on temporary staff. The problem is partly rooted in our education system’s failure to train enough healthcare professionals, and partly due to Brexit – our EU staff are concerned about their futures here. This is a serious threat to our delivery and transformation plans, which depend on EU staffing in our health and social care facilities.

I’m no fan of the SNP, but they’ve been really positive and encouraging in relation to protection for EU nationals. However, in the end, our ability to recruit will depend on the final settlement with the EU – and that’s in the hands of the UK government. So, it looks like I’ll be walking that tightrope for a long time yet. Its far end is anchored to the SNP’s health policies; but they’re built on a leap of faith. If they don’t work out, I won’t be choosing between the lions, the crocs and the knifeman – I’ll be facing them all at once.

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