Scottish health secretary Nicola Sturgeon is not afraid to rattle cages, but one year into the job she admits the move from opposition to government was a culture shock. Jennifer Trueland meets her
Nicola Sturgeon has a reputation for being tough and ambitious. Often described as a "nippy sweetie" - a sharp-tongued person - she is probably the most powerful figure in the Scottish National Party after leader Alex Salmond.
She has been deputy first minister as well as Scottish secretary for health and well-being since last May, when the SNP narrowly beat Labour and formed the government.
One year on, she has certainly made her mark. She has started a phased abolition of prescription charges, published a health strategy - Better Health, Better Care - and set up independent scrutiny panels to monitor NHS boards' redesign plans.
She has also coined the phrase "a mutual NHS", which means closer working with patients, the public and staff, and has launched consultations on direct elections to health boards. Most famously, she has reversed decisions to close accident and emergency departments in Ayr and Monklands hospitals.
But despite her interventions on A&Es, Ms Sturgeon says she will not insist on keeping services local for the sake of it. For example, she recently agreed there should be one national service for cleft lip and palate conditions.
"The case for a national service was clinically very strong, so I made that decision despite representations from people who didn't want it to happen," she explains. "It's about looking at every case on its merits, but not being prepared to sanction creeping centralisation."
Other decisions, including maintaining all current neurosurgery sites (it had been expected the number would be cut), have pleased campaigners and brought happy headlines.
And the Monklands and Ayr decisions even led to the unusual spectacle of the public applauding Ms Sturgeon when she made the announcement.
"I can't stop people clapping me in Parliament," she says with a laugh. But she adds: "I know that some people say it's one of the easy, populist things that the SNP has done, but it was actually one of the most difficult things I've had to do."
It was hard, she says, because it meant going back and redoing a lot of what had already been done in terms of a consultation exercise, as well as the process of setting up an independent scrutiny panel to inform the final decision.
Nobody was in any doubt, however, that the scrutiny panel would back the minister, although she points out that apart from the chair, she had not appointed panel members. "I didn't know what the independent scrutiny panel would say - it was a very robust report from a robust set of people," she says.
Another move that would certainly not have happened had last May's election result been different is the end of prescription charges. This process started last month, when the fee per item was cut to£5 and the cost of pre-payment certificates was slashed.
"I think that's really very important for many reasons," she says. "It's symbolic - we're restoring the NHS to its founding principles in the year that it celebrates its 60th anniversary. More importantly, it matters to individuals. I've met so many people who have told me they have decided to go without the medicines they need because they can't afford them. It has a real impact on people's lives." The likely increase in demand has been factored into cost estimates, she says.
Ms Sturgeon's appointment to the health brief last May was a surprise. Although she was a former SNP health spokeswoman, her most recent brief had been education. As deputy leader of the party, insiders say she was effectively given the chance to pick her own job. When this is put to her, she looks pleased - and does not deny it.
She clearly loves the job, but says it isn't easy. "Every day I have to take tough decisions - almost too many to mention," she says. "The hardest thing about being health minister is just how deeply personal it is to everybody. Everyone has their own experience of the NHS. It just means so much to people. Sometimes that can be quite daunting." What makes it tough is also what makes the job so good, she adds.
The move to government from opposition was a culture shock, she admits. "In the very early stages I did feel like poacher turned gamekeeper. Take the waiting statistics. In opposition, I'd have been poring over them to find the tiny glitch. Now it's all about accentuating the positive."
Just in case she has said too much, she quickly adds that there are lots of positives to accentuate.
"The opposition's job is to point out the negative. I think being in government gives you a more balanced perspective. For every negative event in the NHS, there are a million things that go really well. Part of my job is about telling that good story - because it's really soul-destroying for staff, who know that [the negatives] are the exception."
The biggest surprise, Ms Sturgeon says, is that it has been easy to get things done. She admits she had expected to be fighting an "obstructive" civil service but that this has not happened. Instead, civil servants have been instrumental in making things happen. Again, she gives reversal of the A&E decisions as an example. "If you're clear about what you want to do, it's not that difficult," she says.
Along the way she has made enemies as well as friends. Among the latter is Professor David Kerr, the cancer specialist who authored Scotland's health blueprint, Building a Health Service Fit for the Future, for the previous Labour administration.
Ms Sturgeon's A&E decision was dismissed as "emotional and irrational" by Professor Kerr, who resigned as an adviser to the Scottish government.
Asked about her reaction to this, Ms Sturgeon leans back and laughs. "It was like water off a duck's back. I think the principles of the Kerr report are right - as a general document, it's right. But it didn't look at specific issues like the Ayr and Monklands A&Es."
The NHS in Scotland had been too keen to "badge" policies and initiatives with the Kerr report, she says - almost as if that argument removed the need for scrutiny. "If it had a Kerr stamp on it, it was fine," she says.
That should not be a surprise. Managers wanting to get their proposals accepted cannot be blamed for tying them in with the favoured policy of the day. But now the buzzwords are not so much "Kerr report" as "Better Health, Better Care" and, particularly, the core policy of a "presumption against centralisation".
As a politician in a party whose main aim is to see an independent Scotland, it is perhaps not surprising that she is seeking friends outside London and is prepared to rattle a few cages. Health secretary Alan Johnson, she confirms, was not invited to the recent meeting between the health ministers of the devolved UK nations. That meeting led to a joint letter to Mr Johnson, complaining that the Department of Health was pushing ahead alone with negotiations on a three-year pay deal with NHS staff.
"I have a strong view, and it's shared by Michael McGimpsey and Edwina Hart [the Northern Irish and Welsh health ministers], that we need to remind the Department of Health in England that there are three other countries in the UK," she says. "I think there is strength where we work together."
She relates, however, that the English department has recently been talking more to the Scottish government. "I've invited Alan Johnson to come to Scotland to see what's going on for himself," she says. "The DH is very keen to do comparative studies [between the English and Scottish NHS] and has been asking us for a lot of information about how things are working in the health service.
"It's mainly statistical information around waiting times and so on, but recently it has been more on policy issues - such as our decision to introduce MRSA screening programmes and have a more elaborate catch-up programme for the HPV [human papillomavirus] vaccine."
Although she says she is prepared to listen and learn wherever the suggestions come from, she will not follow England into a marketised NHS. It is unlikely, for example, she will sanction another privately run NHS treatment centre, such as that which opened at Stracathro Hospital near Brechin under the previous administration. "I'm very firm that we shouldn't be using taxpayers' money to build up capacity in the private sector," she says. "We should be using it to build up the NHS."
Yet the finances in the NHS are scarcely bountiful: this year's increase, 1.4 per cent in real terms, is lower than at any time since devolution began.
She knows it is tight: "Even when budgets were growing much faster, there was a lot of financial juggling," she says. "The NHS is good at that. Managers have exceeded their targets and I know they will do so again."