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