Friday, December 21, 2012

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.

Thursday, December 13, 2012

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

Tuesday, December 4, 2012

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.”