Health board elections

The Scottish Government has published the reports from the evaluation of the Health Board elections and alternative pilots.  The research describes the statutory evaluation of the pilot projects, arising from the Health Boards (Membership and Elections) (Scotland) Act 2009. Two NHS boards, Dumfries and Galloway and Fife held elections for 10 and 12 members respectively. Two other boards, Grampian and Lothian explored alternative ways of recruiting and selecting two new appointed members each.

The main finding is that it is possible to successfully hold direct elections for NHS health boards and members of the public are prepared to stand in considerable number.

The elections did not radically change the demographics of board members but an approximate gender balance was achieved. In some cases, candidates’ motivations for standing were very different from the motivations described by non-executives who had come through the appointments route. Specifically, those who stood on electoral platforms such as planned hospital closure or transfer of services. Most elected board members were not strongly political (including some with long experience in politics) and acted in ways that were similar to appointed non-executive directors.

Electoral turnout was low. 16 and 17 year olds had notably lower turnout than voters aged 18 or over and only one ran for office. Focus groups suggest that this group felt uninformed about both the role of health boards, and about their ability to stand for election and vote. The costs of mounting the elections for the two boards totalled £773,256. It is difficult to predict the cost for all boards, but it may be £11 to £12m - modest compared to the size of NHS Scotland.

Candidate profiles and election subsequently impacted the way board business was conducted. In one of the elected Boards, votes on issues became more common and dissenting opinions were more likely than previously to find their way into the press. There was also more challenge to Executive Director's.

Alternative pilots that sought to broaden recruitment methods without changing the selection procedure did expand the range of applicants beyond those who apply for appointment under the existing system. The effects of the new board members were much smaller, primarily because they added two people each to large and well-established boards.

An international literature review suggests that the Scottish experience is not unusual; New Zealand, some Canadian provinces, and English Foundation Trusts all had relatively low turnout but did not experience predicted problems with politicisation and division.

The research found that direct elections have both considerable advantages and drawbacks. They directly address issues of local democracy and accountability and thus have the potential to change the way boards function through increasing the level of challenge to Chairs, Chief Executives and indeed the Scottish Government. One counter argument is that elected boards may not be able to function as effective corporate entities. However, the researchers saw no evidence of this during the pilot period.

The research is unlikely to change minds on this issue one way or the other. You either believe that public services should be locally democratically accountable, or believe that they should be run by political appointees and others picked for their expertise.

Audit Scotland on health inequality

Audit Scotland have published a report on health inequalities. I appeared on the BBC Call Kaye programme this morning to debate it.

Auditor General for Scotland, Caroline Gardner, summed up their findings:

“Health inequalities are long-standing and entrenched in Scotland. Tackling this has been a priority for successive governments but most indicators show the problem remains substantial. On average, people in Scotland’s poorest neighbourhoods die earlier and children in the most deprived areas have significantly worse health. Across the country, there are particular areas of poverty where people have higher healthcare needs. Resources should be better targeted at those who require them most.”

The report doesn't tell us anything new about the scale of health inequality in Scotland. As usual auditors want more data and targets, but not everything is measurable in the way they would wish. They do emphasise that the solutions are not just down to the NHS. This is certainly the case as the NHS Scotland long term monitoring report concludes "Inequalities in income are the most obvious point for action. Clearly, the economic recession and welfare reform are pushing in the wrong direction. Health policy is important, but it plays a 
minor part.”
The report therefore calls for action by Community Planning Partnerships. Chair of the Accounts Commission for Scotland, John Baillie, said:

“Reducing health inequalities is challenging and requires effective partnership working across a range of organisations. Community Planning Partnerships have a key role to play and need to provide strong and supportive leadership for local organisations. They should also ensure all partners are clear about their roles and responsibilities, and improve their evaluation and reporting of progress in reducing health inequalities.”

Well yes they do, but the solutions are wider than that. CPP's have limited powers to tackle inequality in society. As the Spirit Level shows us, more equal societies do better on almost every area of policy including health.

We should also recognise that it is not just physical but mental health that is impacted by poverty. This makes health education initiatives challenging. One in five people in the UK suffer from poor mental health compared to one in ten in Germany and Japan.

The response from the Tories and some others on the programme was to put the focus on behavioural factors. In essence blame the feckless poor even if, as one caller pointed out, that means the consequences fall on poor children. Behaviour issues are a factor and targeted programmes such as the Dundee smoking cessation scheme have a role to play. But the Tories need to move on from their 1980 position when they tried to block the publication of the Black Report. There have now been some 200 studies showing the link between income inequality and health.

Finally, we had the Tax Dodgers Alliance popping up to tell us that the solution is a low tax economy. Well they don't pay much tax in Somalia, but it hasn't done much for their health. More equal countries with better health are also countries with higher taxes to redistribute wealth and pay for public services. That's the way forward for Scotland.

Dave Watson

Scotland's alcohol strategy

NHS Health Scotland have published their second annual report on Scotland’s alcohol strategy, the evaluation plan and the analyses of price, consumption, affordability and alcohol-related harms.

They found that the volume of pure alcohol sold per adult in Scotland increased between 1994 and 2005, followed by a broadly stable trend to 2009. Analysis of the most recent data shows that per adult sales decreased by 5% between 2009 and 2011. Although a similar decline was observed in England & Wales, the decline between 2010 and 2011 was greater in Scotland. Nonetheless, per adult sales of pure alcohol in Scotland remain a fifth higher than in England & Wales.

The affordability of alcohol has increased by 45% since 1980. Plus, 66% of off-trade alcohol sold in Scotland in 2011 was sold below 50 pence per unit (ppu). This compares with 81% in 2008.

Mortality rates in Scotland are over two and a half times higher than they were in the early 1980s and remain nearly twice as high as those in England & Wales. In addition, alcohol-related harm in Scotland is disproportionately experienced by those from more deprived areas.  In 2011, 50% of prisoners report being drunk at the time of their offence, while alcohol was a known factor in 73% of homicides.

The report concludes:

"Although we are beginning to see improvements, Scotland still has a high level of alcohol-related harm compared to the rest of the UK and Western and Central Europe. Until further work is completed on the wide range of possible explanations, it is not appropriate to draw conclusions as to what factors, or combination of factors, are responsible for the recent improvements identified in alcohol consumption and alcohol-related harms in Scotland."

Organisations from the drinks industry have used the research to argue that pricing legislation was no longer needed because consumption and sales were falling. Miles Beale, chief executive of the Wine and Spirit Trade Association, said: “This decrease reported here is almost as much the Scottish Government predicated would be achieved by a 50p minimum unit price. The vast majority of Scots must therefore be asking why the government wants them to pay more when progress is being made and family budgets are already stretched.”

However, Clare Beeston, principal public health adviser at NHS Health Scotland, said the figures showed that setting the minimum cost of alcohol at 50p per unit could save lives by making alcohol less affordable. She said: “The analysis supports the well-established relationship between alcohol affordability and consumption, and some of these improvements are likely to be the result of the recession rather than permanent changes in consumption patterns, which history shows tend to reverse when the economy improves."

Dr Evelyn Gillan, chief executive of Alcohol Focus Scotland, put it more strongly, she said: “There is indisputable evidence that the price of alcohol matters. Quite simply, if the price of alcohol goes up, alcohol-related harm goes down.  It is disappointing, but not at all surprising, that the global alcohol producers have joined forces to mount a legal challenge. Like their colleagues in the tobacco industry, the global producers oppose any policies that are actually going to be effective in reducing consumption, despite their supposed commitment to tackling alcohol harm.”

 

NHS Scotland Annual report

The NHS Scotland Chief Executive's Annual Report has been published. The relentless spin in this type of report can be a bit hard going, but there are a few interesting points.

He highlights the significant challenges including Scotland's public health record, our changing demography and the economic environment. Over the next 10 years the number of over 75s in Scotland's population - who tend to be the highest users of NHS services - will increase by over 25 per cent. By 2033 the number of people over 75 is likely to have increased by almost 60 per cent. There will be a continuing shift in the pattern of disease towards long term conditions, particularly with growing numbers of older people with multiple conditions and complex needs such as dementia.

You can read all the achievements in the report but the highlights are lower waiting times, greater efficiency savings, reduction in hospital infection and reductions in deaths from cancer, stroke and heart disease. Healthcare in Scotland is also safer with the most recent Hospital Standardised Mortality Ratio (HSMR) statistics, showing a reduction of 10.6 per cent since December 2007. Patients are also generally happy with the treatment they receive with satisfaction ratings of around 90%.

The report also claims longer term progress:

"One of the most significant achievements is the fall in premature mortality in the past 20 years, which has decreased by over a third. This includes a 2 per cent decrease in the latest year alone. Premature mortality, a key indicator of the health of Scotland's population, measures the death rates of those aged under 75. In 1991, there were 540 deaths for every 100,000 people aged under 75. By 2011, the figure had fallen to 349."

Chart 1


What this doesn't say is that Scotland's relative position hasn't changed much, as the Sick Man of Europe report shows.

There are lots of numbers reflecting health promotion activity covering alcohol, smoking, drugs and physical activity. Somewhat lighter when explaining how all this is reducing health inequality.

The financial chapters paint a somewhat more rosy picture than the more objective Audit Scotland report. This chart shows how the £10,537 million is spent.

Chart 16


For the financial year 2011/12, NHS Boards delivered local Efficient Government savings of £313 million, representing 3.6 per cent of baseline funding against the 3 per cent efficiency target. So there is the cash to solve the pensions dispute?

While this is a glossy spin with the warts left out, it does none the less indicate that NHS Scotland and more importantly its staff, is generally performing well and delivering on the key targets. Solutions to Scotland's longer term health inequalities remain more challenging and needs more than NHS delivery..

Still the sick man of Europe?

 
This is the latest report from the Glasgow Centre for Population and Health. It provides a summary of Scotland’s mortality position relative to 19 other mainly Western European countries and highlights emerging trends.
 

Some of the key findings include:

 

·         Scotland’s relative ranking on infant mortality compared to other European countries has become progressively poorer for both sexes

 

·         Mortality rates among Scottish children (aged 1-14 years) have converged and rates for most of the selected European countries are now very similar to Scottish rates.

 

·         Scotland has had the highest mortality in Western Europe among working age men and women since the late 1970s.

 

·         Scotland’s relative ranking in relation to younger working age (aged 15-44 years) mortality compared to other European countries has become progressively worse for both sexes over the last 55 years. It is now the highest in Europe. 46% higher in Scotland for women and 54% higher for men than in England.

 

·         Mortality rates for elderly men (aged 75 years and over) has reduced but remains consistently above the Western European country mean. Elderly female mortality in Scotland has been the highest in Europe.

 

·         Mortality rates for oesophageal cancer are the highest in Europe although other cancers have improved. Lung cancer for women is very high and not improving at the same rate as men.

 

·         Male mortality rates for ischaemic heart disease (IHD), while still among the highest in Western Europe, have reduced and converged toward the Western European mean. Female IHD mortality in Scotland has reduced by over 80% since 1950, but has remained higher than in other Western European countries for the last 55 years.

 

·         Scottish mortality rates from chronic liver disease, including cirrhosis have risen steeply since the early 1990s among men and women. Female mortality is the highest in Western Europe.

 

In summary, mortality in the working age population remains comparatively high and mortality for circulatory diseases and many cancer related diseases is higher than in most other Western European countries. However, there have been notable improvements in Scottish mortality for a range of major conditions – both in terms of absolute trends and in relation to Scotland’s relative position in a Western European context. Growing concerns are evident, however, in relation to all-cause mortality among the younger working age population and elderly women, and for female lung cancer.

 

The report also concludes: “This prevailing economic context, which began with the financial crisis of 2008 and has led to rises in unemployment, job insecurity and widespread financial difficulties, makes it more likely than not that mental health problems, suicide incidence and poverty rates will increase.”

 

The report’s author Bruce Whyte said: "There has been no improvement in Scotland's mortality rates in the younger working age group at a time when other countries have improved. We know there are issues with alcohol, with alcoholic cirrhosis of the liver, accidental poisonings and suicides. There has also been a small contribution from things such as breast cancer and heart disease but we know the contribution of these chronic diseases is less."

 

Sadly, it would appear that the answer to the question "Still the sick man of Europe?" is 'yes'. But women are getting sicker too.

Bleak picture of NHS Scotland finances

Audit Scotland has published NHS financial performance 2011/12, an overview of the financial performance of the NHS in Scotland in the last financial year. It shows a picture of increasing financial pressure on health boards as the real term cuts bite.

 

 

Although the overall health budget has continued to increase in cash terms, it has been decreasing in real terms since 2009/10 and is projected to decrease further in real terms for the next three years.  The NHS continues to face significant pressures that will make it difficult to reduce costs while maintaining high-quality services. Demand for services continues to grow, particularly due to an ageing population; it is becoming more difficult to identify recurring savings as early opportunities have already been targeted. Building maintenance (£1bn backlog) and rising drug costs (+3.2%) are highlighted in the report. Spending on heating and lighting increased by 5.8 per cent on the previous year.

 

Three of the 14 territorial boards (Fife, Forth Valley and Orkney) would not have broken even without additional financial support from the government. As the three boards are using £6.2 million of capital to repay their revenue brokerage, these funds will not be available to the overall NHS capital budget. There is also a risk that the investment needed to maintain and develop the clinical estate, equipment and ICT will be unaffordable.

 

Nine territorial boards reported an underlying recurring deficit in 2011/12. Around 20 per cent of savings (£67 million) were non-recurring in 2011/12. This means that boards need to make further savings of £67 million immediately in 2012/13 just to be level with the 2011/12 position. These £67 million savings are included in the 2012/13 savings target of £272 million. Each year, it becomes more difficult for boards to find recurring savings.

 

Eight boards have categorised at least a quarter of their savings plans as high risk, with NHS Lothian stating that two-thirds of its savings plans are high risk. Overall, 20 per cent of the savings target is classified as high risk, raising concern about the achievability of the savings plans and boards’ ability to break even in 2012/13.

 

The NHS in Scotland employed 131,172 people (135,823 at 30 September 2009). Further reductions in staff numbers are expected reducing to 130,370 by March 2013. This represents a cumulative reduction of four per cent since 30 September 2009. While there have been increases in medical and dental staff over this period, nursing and midwifery numbers are forecast to reduce by four per cent. The largest decrease will be in administrative staff (8.1 per cent).

 

In 2011/12, total spending on PFI charges was £184.5 million (£154.1 million in 2010/11). This was due primarily to increases in charges of £15.7 million in NHS Forth Valley and £8.1 million at NHS Fife, as a result of the completion of the new PFI projects at the Forth Valley Royal Hospital in Larbert and Victoria Hospital in Kirkcaldy. PFI charges are a significant financial commitment for boards.

 

Auditor General for Scotland, Caroline Gardner, said:

“The NHS in Scotland continues to manage its finances within its total budget, and has achieved this for the fourth year in a row. The annual accounts show a picture of good financial performance, but this doesn’t reflect the pressure boards faced in achieving this. Money was moved between boards, several relied on non-recurring savings, and some needed extra help from the Scottish Government to break even in 2011/12. The requirement for boards to break even each year encourages a short-term view, and the NHS needs to increase its focus on longer-term financial planning.”

 

Health Inequalities

The latest Long-term Monitoring of Health Inequalities: Headline Indicators report has been published.

The gap in health outcomes between the most deprived and least deprived areas of Scotland is reported for a variety of indicators in both absolute and relative terms. The latest figures include data up to 2010 for most indicators.

The main findings are:

* The highest level of relative inequality continues to be seen in alcohol-related deaths among those aged 45-74. While there have been some improvements in recent years, death rates and levels of inequality were higher in 2010 than in 1998.

* Between 1997 and 2010 the death rate for coronary heart disease (CHD) among those aged 45-74 years fell 57%. The reduction was slower in the most deprived areas of Scotland than elsewhere, meaning that relative inequality has increased slightly over the long-term while the absolute inequality gap has narrowed. However there are signs that relative inequality has stabilised in recent years.

* There are also signs of recently improving trends (reducing or stabilising inequality in one or both measures) in Low Birthweight, Premature Mortality, and Alcohol Related Hospital Admissions.

* Over the longer term, inequalities have widened in one or both measures for All-cause Mortality (aged 15-44) and Cancer Mortality (aged 45-74).

THE extent of Scotland’s health inequalities is highlighted, showing that healthy life expectancy among men in the poorest areas of the country is just 47. Scotland’s health gap is now wider than anywhere else in Europe and that the poorest people can expect to die 20 years before the country’s wealthiest residents. Men in the most deprived areas have a life expectancy of 68. This is a year above the UK Government's proposed retirement age.

Scotland’s life expectancy and healthy life expectancy is going up with between two and three years more of healthy life than they did in 1999. However, the gap between rich and poor has failed to close and is now wider than 
in the rest of the United 
Kingdom.

David Walsh, of the Glasgow Centre for Population Health, added: “We are talking about extending working life, but we are seeing parts of Scotland where people are not going to get much time in retirement. These figures are shocking and they continue to be shocking.”

Dr Gerry McCartney, of the Public Health Observatory for Health Scotland, identified the key issues. He said:
"Inequalities in income are the most obvious point for action. Clearly, the economic recession and welfare reform are pushing in the wrong direction. Health policy is important, but it plays a 
minor part.”

Political action on mental health

It is very welcome that Ed Miliband is speaking in such a public way about mental health. One of the last taboo subjects is getting the political attention it deserves. He made it clear that as a nation we had both a moral obligation to support the most vulnerable in our society and importantly also made clear the economic case for tackling it.

The Scottish mental health charity SAMH calculates that three in every ten employees will have a mental health problem in any year, making mental health the dominant health problem among people of working age. The business case for tackling this is overwhelming with output losses of over £2bn last year or £950 per employee.

Following Miliband’s announcement in his speech of a new taskforce on mental health, there are some key areas Labour must address if we are to properly tackle the mental health crisis he describes.

It is widely accepted that work is good for mental health, providing a source of contact with others, structure, meaning to the day and providing a sense of self-worth. The problem is not work itself, but the support provided by employers. According to a recent CIPD survey only a quarter of respondents felt their employer and colleagues encouraged staff to talk openly about mental health problems and just 37% thought their employer supported employees with mental health problems well. So employers need more help and we need stronger, not Beecroft weaker, employment rights to protect workers suffering from this condition.

GPs and other frontline health workers need a better training to identify mental ill health, then provide the services and support needed as swiftly as possible.The Westminster All Party Parliamentary Group on Mental Health has warned:

“GPs may not possess enough knowledge of mental health problems to commission mental health services effectively [whilst] there is a need to ensure mental health features prominently in local health plans, so that people with mental health problems are encouraged to play a part in local decision making processes, and that public health professionals understand that mental health sits in their remit.”

While that comment refers to the position in England, the same applies in Scotland. It is also unacceptable that waiting list targets rarely include mental health services. According to research by Mind, a partner is four times more likely to leave someone because they have a mental health difficulty as compared to a physical disability; and 27% of sufferers report facing discrimination.

Political action on mental health may not provide the kind of publicity opening a new hospital does. However, if we as a society are to be judged by how we treat our most vulnerable, we have a responsibility to provide the best possible care and support to those facing difficult times. Ed Miliband’s speech is a welcome start, but it must lead to something bigger and better for those who find themselves suffering in silence.

Occupational health and safety

As early as 2009, David Cameron called for an end to the ‘over-the-top’ health and safety culture in Great Britain. In January 2012, he pledged that, ‘one of the coalition’s new year resolutions is this: 'kill off the health and safety culture for good.’

In Scotland, the lethal combination of weak regulation and heavy industry caused endemic levels of occupational illness and disability. Through images, film and oral testimony this event highlights the lived experiences of Scots whose health has been affected by their occupation and illustrates both the risks of trivialising occupational health and safety and the complexities surrounding responsibility.

Understanding Occupational Health and Safety in Scotland since 1800
Saturday 10 November 2012
Summerlee Museum of Scottish Industrial life, Coatbridge
1.00pm to 4.00pm

Homeopathy on the NHS?

A recent rant on Labour List attacked the UK Social Health Association for its position on Homeopathy on the NHS. The author concluded:

"It’s bad enough to have a Conservative Secretary of State for Health that supports an utterly farcical and unsubstantiated form of treatment for patients but we are in no position to hold him to account unless our own Labour family is united. To have our own affiliated organisations support this position requires an immediate and decisive response, so that this issue does not distract us from our fight to ensure that we have a world class National Health Service."

The UK SHA response was “Homeopathy does no harm and its cheap. NHS wastes money in much worse ways”.

A number of SHA Scotland members asked what our position was in light of this debate. The last time this issue was debated was in our submission to the 2005 Scottish Labour policy review when we said:

"SHA Scotland believes that alternative and complimentary therapies have a significant role to play in NHS treatment. The success of the Glasgow Homeopathic Hospital is a good example of provision that should be supported including the retention of in-patient beds."

The debate on Homeopathy in Scotland has widened in recent weeks. As budget cuts impact health boards are beginning to question this provision. NHS Lothian is currently consulting on the issue and NHS Highland have come out firmly against. The debate is covered well in this BBC piece.

To sum up each side of the debate.

Against

The British Medical Association, believes there should be no further NHS funding for homeopathy, They argue that scarce resources are being spent on a treatment with "no scientific evidence base to support its use". The 2010 report by the cross-party House of Commons Science and Technology Committee, found there was no evidence beyond a placebo effect - where a patient gets better because of their belief that the treatment works.

For

The Faculty of Homeopathy says it is "not accurate" to say there is no evidence for homeopathy. They claim that the conclusions drawn from studies have been "cherry-picked" by opponents and that there is evidence for the effectiveness of its treatments. They also claim that homeopathy is a safe, cost-effective alternative which can actually save the NHS money.
 

What do you think?

Why Inequality Matters

The Centre for Labour and Social Studies have produced a booklet 'Why Inequality Matters". This builds on the pioneering work of Wilkinson and Pickett in The Spirit Level.

As the booklet points out the case against inequality is not an abstract, moral argument. With an abundance of evidence, The Spirit Level dramatically revealed that it actually has an impact on people’s everyday lives. And as the Nobel Prize-winning economist Paul Krugman has shown, there is a link between inequality and financial crises. As he pointed out, it is no accident that both major modern crises – the first beginning in 1929, the second in 2008 – coincided with historic levels of inequality.

The chapter on health highlights that there are now over 200 studies of income inequality and health. Life expectancy, infant death rates, low birth weight, the number of people badly overweight, the number of people with poor mental health have repeatedly been shown to be worse in more unequal societies. The UK has the fourth lowest life expectancy out of the 23 most developed countries. The three countries that have even lower life expectancy are those with even greater income inequality – Portugal, the USA and Singapore.

Put simply, and that is this booklets strong point, inequality kills. That is why it should be central to our thinking on health policy in Scotland in the coming years.

Reform Scotland and GP services

Dave Watson on Reform Scotland's report on GP services.


I was intrigued by the Sunday media warm up to today's launch of Reform Scotland's latest report on GP services. GP's should have better web sites, well that's probably true, even if perhaps not the greatest challenge facing primary care at present. Even a suggestion that all GPs should be salaried. Dangerous socialist thinking here, straight from the SHA policy manual. Certainly not what we expect from the right wing marketeers at Reform Scotland.

However, I needn't have worried. The report itself is full of the predictable market led solutions that you would expect from Reform Scotland. An organisation whose objectives are the apparently,  “traditional Scottish principles of limited government, diversity and personal responsibility". Translated this means- small state, privatisation and blame the poor!

The report's recommendations focus on extending GP catchment areas and allowing new GP practices to open. This will apparently create competition with better opening times and websites. And here was me thinking that patient care was the first concern of service users!

The wicked Scottish Government ban on commercial GP providers must of course be ended. After all are not GPs themselves private providers? Well yes they are, a hangover from the 1948 compromise, but that doesn't mean we make the position worse by importing rapacious privateers with profit as their only motive. I just wonder if Serco has made a donation to Reform? Not of course that Reform Scotland needs any encouragement to promote the influence of privatisation companies.

We can of course agree that GP practices should have a decent website and opening times could be more flexible. I don't in principle have a problem with a Scottish GP contract and I agree that health boards should be more democratically accountable. The SHA have strongly supported direct elections for this reason.

However, this report is very clearly focused on introducing a market approach to NHS Scotland on the Tory, English model. Planned services are the best approach to primary care provision, rather than wasteful competition that would lead to marketing managers replacing practice nurses. The relationship with a GP and their staff can be a very personal one and we dont want that compromised, any more than it already is, with the current commercial element. We have seen with privatised occupational health services the role commercial pressures can play.

SHA Scotland has long argued that we should indeed go in the opposite direction, through the introduction of salaried GPs. Many doctors working in primary care would welcome this as their focus, unlike Reform Scotland,  is on the patient not running a business.

Healthier Scotland - August 2012

The August 2012 edition of our E-Bulletin Healthier Scotland has been published.

Link here.

Shifting the Culture

The Socialist Health Association Scotland has published its response to ‘Shifting the Culture’ a Member’s Bill consultation on measures to help change culture in relation to alcohol in Scotland.

SHA Scotland welcomes this consultation by Dr Richard Simpson MSP and Graeme Pearson MSP. While SHA Scotland broadly supported minimum alcohol pricing, we also recognise that this is only one measure of many that needs to be taken to tackle the scourge of alcohol on Scotland’s health and wellbeing.

The consultation gives a clear statement of the policy context for the Bill and in particular the ongoing health and other challenges alcohol abuse causes in Scotland, although we believe a greater emphasis (and understanding) on the socioeconomic context and impacts of alcohol is necessary. 

We believe that this context should have a greater focus on the deep seated health inequalities in Scotland. The impact of heavy drinking is greater in our poorer communities (e.g. alcohol-related facial injuries are up to seven times greater than in our most prosperous areas). This is also reflected in teenage drinking and alcohol-related cancer rates. Moreover, the true risks associated with alcohol consumption are when in combination with other risk factors (e.g. smoking, poor diet, obesity, and lack of physical exercise), and these “multiple risks” are more than three times greater among those from poorer circumstances. So focusing on alcohol in isolation of other risks and out with the context of socioeconomic circumstances may not be the best approach. In many ways alcohol is the fuel that fires health inequalities. We are not convinced that the issue of health inequalities has been fully considered throughout the document.

The paper states that the objective of the legislation is to shift the culture of drinking in Scotland. However, the measures are almost entirely about control and inhibition. While we agree this is needed, we question if this will be fully effective in changing the culture. A greater focus on the inequality that is at the root of the problem would be a better approach.

We believe that to truly tackle Scotland’s alcohol culture and its impact on societal and health / wellbeing would be through addressing the causes of the causes – i.e. by tackling the underlying social and economic inequalities in society.

Money for health - moving to the root of the problem

There has been some debate recently about personal financial incentives to achieve healthy behaviour. The Harvard philosopher Michael Sandel has been brilliantly exploring the issue from many angles [ listen to radio 4 debate here: http://www.bbc.co.uk/podcasts/series/r4sandel ]

The argument against payment incentives is characterised as bribing people to be healthy and wasting money. Needless to say The Sun, The TaxPayers’ Alliance, and The Tories are not the biggest fans [ http://bit.ly/JLmcZB ]

However, the debate to-date largely misses a crucial link. Health and wellbeing are determined largely by behaviours / lifestyles (e.g. smoking, alcohol, diet, physical activity); and also directly by socioeconomic factors (e.g. income, education, occupation, housing, family, networks, culture). These behaviours / lifestyles are also determined by the same socioeconomic factors - "the causes of the causes” if you like. The pattern almost always follows that lower socioeconomic circumstances increases adverse behaviours and so impacts on health. There is plenty of evidence to support these pathways and also that shows that because of the adverse social and economic circumstances the "choice" of the adverse behaviour is not one necessarily freely taken (e.g. healthy foods are not so affordable or available; smoking and drinking often arise out of the chronic stress of poverty and unemployment).

We cannot, therefore, try to really improve lifestyles and behaviours without improving the underlying social and economic circumstances. To change this may be considered as "up stream" or requiring major political change and beyond the remit of health (or other) services. And obviously progressive taxation and / or better distribution of wages are the major solutions. However, incentivising with monetary / payment is an attempt in a relatively small, local, and direct way to address these socioeconomic causes of the causes.

A Dundee programme – called quit4u – offering payment of £12.50 a week (in supermarket food vouchers) to encourage people living in deprived circumstances to quit smoking has been shown to work. The two year evaluation, just published, demonstrates improved quit rates at 3 months and even 12 months [ full evaluation here www.healthscotland.com/documents/5827.aspx ]. At its launch the Dundee initiative was met with much the same aversion, which has dominated the debate on this area. But, at its heart has been an ethos of understanding this socioeconomic link and trying to do something, albeit in a small way, about it. So praise must go to NHS Tayside for taking this bold and groundbreaking action in the face of much hostility. We urge other health boards and Scottish Government to follow suit and take more positive action with the powers they have to make a difference to the lives of those most in need if we are going to tackle inequalities in health and wellbeing.

Hospital Acquired Infections

The closure of eight wards at Royal Alexandra Hospital in Paisley because of an increase in people showing symptoms of the Norovirus bug has thrown the spotlight back on HAI's. Two people suffering from diarrhoea and vomiting died in the hospital. NHS Highland also reported an increase in the number of cases of diarrhoea and vomiting with Raigmore Hospital in Inverness closing two wards to new admissions and a ward at Caithness General is also shut.

Scotland's Chief Medical Officer, Sir Harry Burns has stressed that Norovirus cases were decreasing in number, saying: "The number of cases of norovirus, the number of outbreaks, has fallen over the past few years. So things are stable and probably going in the right direction. It's something we are seeing less of, a 16% reduction in the figures over the past two or three years."

Sir Harry also highlighted the importance of hygiene in tackling the virus: "Hand-washing is probably one of the most important things we can do. It is dealt with by soap and water; conventional clean hands. Hand hygiene among NHS staff in Scotland at an all-time high".

More generally on HAIs, the Health Protection Scotland Point Prevalence Survey, which involved 13,558 patients, 844 wards and 75 hospitals, records a snap shot of all types of infections on the day of the survey. The April 2012 report highlights that prevalence of healthcare associated infections was 4.9 per cent in acute hospitals and 2.5 per cent in non-acute hospitals – a significant reduction on 2006 levels.

Health Secretary, Nocola Sturgeon commented,  "the overall level of infections has reduced by one third since 2006 and cases of some types of infection which cause particular concern, such as C.diff and MRSA blood stream infections, have fallen by over 75 per cent. This is good news but I am in no doubt that there is still more that can be done as we strive to embed quality in all aspects of patient care in Scotland. This is a substantial report and so I have asked the HAI Task Force National Advisory Group to consider the report’s findings and to provide advice on its implications for future HAI policy and priorities.”

So good progress, however, HAI's are a long way from being eradicated. On average at least one patient in every 20 on a ward in acute care at any one time has an HAI.  Scottish Labour's Shadow Health Secretary, Jackie Baillie, said: "The fact six people have died in recent days, 20 wards have been closed and more than 100 people across Scotland are suffering from norovirus symptoms should be a stark reminder the battle against hospital superbugs is far from over."

Hand washing disciplines and infection control staff will probably help mitigate the worst aspect of the problem, but it will not alter the underlying reasons for the development of HAIs. This is beacuse they are an unintended consequence of the factory style hospital care we have developed in recent years. Occupancy and bed turnover rates are at an unheard of level. This together with waiting time targets put constant pressure on hospitals to move ever increasing numbers of sick people through the hospital, together with a similar increase in different vistors.

We also have non-NHS reasons for the increase including farmers using antibiotics. Again, something that is unlikely to change quickly. The overall proportion of bloodstream and urinary infections has risen, with E.coli a growing problem in both. Health Protection Scotland has reported that the prevalence of E.coli was higher (20.8% versus 6.7%) than that reported in the previous Scottish PPS (survey). It confirmed the growing resistance to antibiotics although even this could not account for the rising prevalence of E.coli in Scottish hospitals.

So while an army of protocols, staff and lotions are mitigating the problem of HAIs, we should remember that the underlying cause is in our factory approach to modern acute care. That isn't going to change quickly, if at all.

Healthier Scotland - April 2012

The April edition of the SHA Scotland E-Bulletin - Healthier Scotland is now out!

The Alcohol (Public Health & Criminal Justice) (Scotland) Bill

New consultation from Scottish Labour MSP's Richard Simpson and Graham Pearson on their proposed Alcohol (Public Health & Criminal Justice) (Scotland) Bill.

While SHA Scotland supports minimum alcohol pricing we also recognise that this is only one measure of many that needs to be taken to tackle alcohol abuse in Scotland. 

 The Bill contains a total of 14 measures, spanning public health and criminal justice policy including:

• Stop retailers flaunting the new ban on bulk-buy promotions by closing down a loophole in the law
• Require government to report on progress on public health and child protection licensing objectives
• Clamp down on alcohol marketing in public places, especially where children may be exposed
• Introduce a legal limit of 150 mg per litre of caffeine of pre-mixed alcoholic drinks
• Evaluate and improve alcohol education and public information campaigns
• Tighten the law to prevent unfair discrimination against 18-21 year olds in off-sales
• Give local communities a greater say in licensing decisions
• Establish a National Licensing Forum to drive forward improvements in licensing laws and devise solutions to emerging problems
• Give local authorities powers to roll out ‘bottle-tagging’ to help the authorities crack-down on retailers selling to those under age and proxy purchasing
• More targeted disposals for those convicted of alcohol-related offences
• Fast track treatment for individuals taken into custody who are perceived to have an alcohol problem
• Give courts powers to ban individuals from drinking in specified places to help curb alcohol-related criminal or disorderly behaviour and to protect others from such behaviour
• Extend the successful Drug Treatment and Testing Orders (DTTO) to cover offences where alcohol has been a factor
• Require GPs to be notified of any new conviction by patients where alcohol was a factor to ensure patient receives appropriate treatment and support

This is a comprehensive paper that sets out a cogent case for the measures described. The consultation paper can be downloaded here. The SHA Scotland will be considering this at our May meeting and we would encourage members to read the paper and let us have your views.

Why We Support the Alcohol Minimum Pricing Bill

The Socialist Health Association Scotland supports the Alcohol Minimum Pricing (Scotland) Bill being debated at Holyrood today.

The price of alcohol misuse paid by Scottish society is well over 2 billion pounds, with the cost to the NHS estimated at over 400 million.

But, the true price of alcohol is borne by our communities and families.

Alcohol has an important place in our cultural and social lives and in our economy. But our relationship with alcohol has gone in wrong direction down the wrong road. In fact we have driven off the road and into a lamp post – drunk and disgraced.

The harmful effects of alcohol misuse are also widely known in terms of its impact on health and wellbeing and on health inequalities – where alcohol contributes much to the shameful inequality in life expectancy that blights the people of Scotland.  

Sadly, alcohol misuse hits the poorest hardest. But, as Ed Miliband said “the gap between rich and poor doesn’t just harm the poor. It harms us all”. And So problem drinking is not confined to certain groups, it affects us all. Recent data from the Scottish Health Survey show that we are all drinking too much.

Our efforts to tackle Scotland’s increasing alcohol culture have thus far been pretty hopeless. You may not be surprised that health education and awareness campaigns are the main alternative proposal from the drinks lobby. Such campaigns don’t work – are usually expensive and largely ineffective.

Many of the arguments against alcohol minimum pricing echo those we heard when the Labour-Liberal administration were legislating to ban smoking in public places. Landmark public health legislation which we can be proud in Scotland to have led the way on and which thre rest of the UK followed. Legislation, which in a short time has delivered dramatic reductions in heart disease and deaths with none of the adverse effects muted at the time.

The thrust of this Bill is to increase the cost of alcohol. Simple. Alcohol is too cheap – fact! It is over half as affordable now than it was in the ‘80s. And it’s not surprising then that consumption has doubled in the same period.

There is now a large body of evidence from around the world that links the price of alcohol to the level of consumption and in turn to the level of alcohol-related harm.

And, yes we recognise that taxation could achieve the same benefits, with the added advantage that revenue would go to the state rather than the retailers. However, excise duty is a reserved power and there is no way George Osborne and David Cameron will act. A compensatory levy, similar to the recent 'Tesco Tax', could cover this point. But it needn’t be an absolute condition for support.

The only other major argument against this legislation is that it will disproportionately affect low income groups.  Alcohol, at present, already disproportionately effects low income groups. The way supermarkets target and sell alcohol as a loss leader, row upon row of cheap cider and booze is a disgrace and no different to and arguably more harmful than a drug dealer up a close.

A robust evaluation of the policy, as it is introduced, should be undertaken which explores any adverse impacts – particularly, in relation to ensuring the most vulnerable communities are not harmed and inequalities widened. And the promised sunset clause to fully mitigate.

There is wide support for this, and the NHS, the police, the media, children’s charities, wide sections of civil society including religious groups, and public opinion. Up against who? The alcohol lobby and some licensing boards.

Like the smoking ban, this legislation is not perfect, nor is it going to be a panacea to all our alcohol problems. And of course it needs to be part of a wide range of initiatives, which need to be brought forward. But, there is no doubt it is part of the solution. 

Abstaining in parliament on such an important issue does not feel right and will not look right.

The right thing to do is to support the Bill.

Scottish Labour Fringe Meeting

SHA Scotland was on the fringe at last weekend's Scottish Labour Party conference in Dundee. 'Health policy - where next?' was sponsored by UNISON Scotland.

UNISON's Gordon McKay chaired the well attended meeting and opened by referring to the Progress journal's implied support for the English health reforms and marketisation of the NHS. Some 'comrades' clearly have lost the plot! He contrasted this with SHA Scotland's new policy journal Healthier Scotland.

Dr David Conway kicked off the debate with SHA Scotland's principles and his analysis of where we needed to take the debate.  He welcomed the level of political consensus in Scotland around health inequalities but recognised that we have huge health challenges to address and that requires new thinking on how to address them.

Shadow Health Secretary Jackie Baillie MSP debunked the myth that NHS Scotland was somehow protected from cuts - £319m was being cut. But her main message was that the agenda for Scottish Labour is wider than simply healthcare. We need to relentlessly focus on life chances for the youngest children. 

There were many excellent contributions from the floor. In particular a lot of debate around social care integration in Scotland.  Including concerns that the Change Fund is being used to privatise not integrate care services. The Highland pilot in particular is heading for disaster according to more than one contribution.

Good debate as ever from a knowledgeable audience. 

Healthier Scotland - The Journal

The first edition of our new policy journal - Healthier Scotland has been published.

The March 2012 edition was launched at our fringe meeting at the Scottish Labour Party Conference in Dundee.

This edition includes:

 

Future health policy	Jackie Baillie MSP
Minimum price for alcohol?	Dave Watson
Low pay is bad for your health	Eddie Follan
Health impact of climate change	Dr David Conway
NHS Scotland ‘leading edge’ of industrial relations	John Gallacher
Housing and health	Murdo Mathison
Local healthcare in Norway	Eberhard ‘Paddy’ Bort
Scotland in the midst of an obesity epidemic	Richard Simpson MSP
English health reforms	Stephen Adshead
NHS Scotland – the real challenges	Matt McLaughlin
Coronary heart disease	Janet McKay