Healthier Scotland - December 2013

The latest edition of our e-bulletin 'Healthier Scotland' is now on line.

http://www.shascotland.org/shanews%20dec13.pdf

Mick Jagger should make us plan for demographic change

We are told this week that Mick Jagger is delighted with the prospect of becoming a great-grandfather, according to his granddaughter Assisi who is expecting her first child in April. I highlight this news story in contrast to the regular media stories that forecast doom and gloom over our ageing population.

There is no doubt that demographic change will bring many policy challenges and I participated in a round table discussion hosted by The Herald on this very issue yesterday. However, the phrase 'demographic time bomb' ignores many of the benefits to individuals and communities. Older people remain significant economic contributors as well as important carers, of young and old, in their own right. Many of the voluntary organisations that make up the fabric of our society would collapse without the support of older people.

There is also some recent academic work that argues that we may be exaggerating the impact on health services because we are likely to be healthier into old age. 60 is the new 50, as Mick Jagger might illustrate. There is also a lot a focus on nursing home costs, but this only applies to a tiny proportion of older people.

Of course, none of this means that we shouldn't address the policy implications of an ageing population. The additional public spending impact is estimated at £2.5bn in Scotland by 2030. When I was working with the Christie Commission we were told that £1.5bn might be released from unplanned hospital admissions to help pay for this. With the increasing demand for beds that is now looking a remote prospect and I don't see any replacement plan in the current care integration proposals.

One aspect we do need to focus on is the workforce that cares for older people. We are seeing a race to the bottom in terms of pay and training, with care being viewed as the new retail in job terms. I was discussing this with a group of home care staff recently. Most of the younger staff told me that they would leave as soon as they could get a better job - little prospect of the essential continuity of care that many older people need. Others described minimal training before being expected to address complex care needs. Even more worrying, those on zero or nominal hour contracts said they wouldn't flag up safety or abuse issues for fear of losing hours.

Demographic change has positive implications for our society and we shouldn't over emphasise the negatives. What we should do is start serious planning. Respecting and developing the workforce is a good place to start.

Dave Watson

Minister capitulates to establishment over health board democracy

The Scottish Government has announced that it is to abandon the idea of directly elected health boards in favour of a return to appointees who can be removed my ministers. A bold attempt at introducing a small element of local democracy has been strangled by government that is increasingly prone to centralise services and undermine local democracy.

In the 2007 election, the SNP pledged to introduce elected health boards, citing concern that health authorities had not always properly listened to local views when considering changes to services. Scottish Labour also agreed to support the pilot elections held in Fife and Dumfries and Galloway in 2010, in which 16 and 17-year-olds were allowed to vote for the first time.

The turnout was low, with fewer than one in five voting in Dumfries and Galloway, and one in ten in Fife. However, this was the first time people were asked to vote and there was only limited promotion. An independent assessment of the pilots found 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. It also buried myths about politicisation, although it also found that elected members were more willing to challenge officials. No wonder the health establishment was so opposed!

Now Health Secretary Alex Neil has capitulated to those interests, he said: "This pilot project was designed to ensure that the views of local people about their NHS are heard effectively, and to encourage them to be more involved in how the health service is run. These pilots have demonstrated that the most effective approach was a pro-active approach from boards to advertising and recruiting to posts. I am confident that these new measures will help to increase public engagement and improve local accountability. I am confident that these measures will help to increase public engagement and improve local accountability more effectively than when we tested direct elections as part of the pilot."

Sadly, there is little evidence to support this view. Officials and the health establishment’s patronising top down approach to public engagement has eventually worn the new health minister down.

Of course directly elected health boards are not the only way of extending local democracy into NHS Scotland. Other options include greater local authority involvement up to and including the creation of unitary authorities. Reform Scotland has recently argued for the merging of councils and health boards. However, they also argued for fewer and more remote councils. A point well argued by Lesley Riddoch in the Scotsman, who points out that we have the most remote local democracy in Europe. Its not apathy, wrong size governance is to blame.

Taskforces are no substitute for action on health inequality

The latest statistical bulletin monitoring long-term health inequalities shows some stabilisation in relative and absolute terms. However, huge inequalities remain that requires a comprehensive strategy to tackle inequality.

The amount of their life that people could expect to be in poor health was much higher in the most deprived communities, where men and women can expect to spend 22.7 years and 26.1 years respectively in “not good” health. That compares to just 11.9 years and 12 years for men and women in the most affluent parts of Scotland.

The main findings in the report include:

·       Healthy life expectancy at birth: There continue to be inequalities in relative and absolute terms. Between 2009-2010 and 2011-2012.

·       Premature Mortality (under 75 years): Following a long-term increase, relative inequalities have stabilised since 2006. Inequalities have declined in absolute terms over the last decade.

·       Mental Wellbeing: Inequalities are increasing in absolute terms but remain stable in relative terms.

·       Birth weight: Inequalities are now stabilising in both absolute and relative terms.

·       Hospital admissions for heart attack (under 75 years): Over time, inequalities have fluctuated in both absolute and relative terms, with a general upward trend since 2008.

·       Coronary Heart Disease – deaths (45-74 years): Following a long-term increase, inequalities have stabilised in relative terms. In absolute terms, despite a slight increase in the latest year reported, inequalities have been narrowing. Hospital admissions rate for heart attacks was approximately 2.5 times higher in the most deprived areas than the least deprived communities.

·       Cancer Incidence and deaths: Over the long term, inequalities are more stable sine 2004. Patterns of inequality vary by cancer type. People aged between 45 and 75 in the poorest communities were more than twice as likely to die from cancer than those in the least deprived areas.

·       Alcohol – The level of absolute inequality has fallen since 1997, while relative inequality has remained stable over the same period. These types of admissions are more common in deprived areas – 493 per 100,000 population compared to 89 per 100,000 population in areas of low deprivation.

·       All-cause mortality aged 15-44 years: The level of relative inequality has increased since 1997 but in recent years has been more stable. Absolute inequality shows no clear trend over time.

Following this report the BMA joined calls for action to tackle health problems in deprived areas as because the gap between rich and poor has “never been more apparent”. In particular they called for all policies to be assessed to examine what impact they would have on health inequality.

Public health minister Michael Matheson said that reducing the health gap between rich and poor was “one of our greatest challenges”. He blamed welfare reform as a barrier to improving incomes. Predictably, all would be well if we vote for independence.

However, the BMA's Dr Keighley said, people were “living healthier and longer lives”. But he added: “For those people living in the most deprived communities the inequalities in health have never been more apparent. We cannot simply continue to argue that public health policies are working to improve the lives of Scots when the differences between rich and poor are so apparent. No matter how many taskforces and inquiries politicians establish they are no substitute for action."

It’s hard to disagree with that analysis.

Tackle inequality not just disease

A new study by NHS Health Scotland has examined 30 years of health trends in Scotland and found large differences in preventable causes of death across social groups. In simple terms the gap between rich and poor is leading to thousands of unnecessary deaths in Scotland.

Increasing inequality in morbidity and mortality from the poorest and to the wealthiest, is described as 'a gross injustice'. The report positively highlights periods of decreasing inequality in the UK and elsewhere, showing that this trend is not inevitable and further action can make a difference.

International research (Phelan and Link) indicates that approaches which focus on reducing immediately visible causes (such as tobacco and alcohol) and targeting professional support to those living in deprived areas, will ultimately fail to eliminate health inequalities. This research hypothesises that socioeconomic inequality is a fundamental cause of health inequality.

The report describes trends in absolute and relative inequalities for 47 to 50 causes of death for men and women across Carstairs deprivation deciles between 1983 and 1999 and men aged 20‐64 years across occupational social classes between 1976 and 1999 to determine whether new socioeconomic inequalities in mortality emerged for certain causes of death whilst declining for others in Scotland during this time. In addition, they tested Phelan and Link’s theory by comparing socioeconomic gradients for avoidable and non‐avoidable mortality and assessing whether inequalities in mortality increase with increasing preventability of cause of death.

They found that absolute and relative socioeconomic gradients for specific causes of mortality decreased whilst others emerged. There was a clear socioeconomic gradient for avoidable causes of mortality, but not for non‐avoidable causes of death. Where causes of death became more preventable, it is clear that relative inequalities in mortality increased.

The results have important policy implications for any efforts to reduce health inequalities in Scotland. Evidence that all‐cause socioeconomic inequalities in mortality persist despite reductions for some specific causes, and that inequalities are greater with increasing preventability, suggests that focussing on reducing individual risk and increasing individual assets will ultimately be fruitless in reducing inequalities and may even increase them. Elimination and prevention of inequalities in all‐cause mortality will only be achieved if the underlying differences in income, wealth and power across society are reduced.

This report is further and detailed evidence to support the view, advanced by SHA and others, that behavioural change programmes have limited impact. Seriously tackling health inequalities requires a comprehensive and cross cutting policy response that is not limited to the NHS.

NHS Scotland puts a sticking plaster on cash shortfall

Audit Scotland has published its annual report into the finances of NHS Scotland.

The key message is:

“The NHS in Scotland managed its finances well in 2012/13 but needs to focus more on long-term financial planning and sustainability to make the changes needed to meet increasing demands. In 2012/13, pressures on the NHS’ capacity became more apparent and the health service spent more on short-term measures to deal with them.”

Put another way, the NHS is putting sticking plasters on long term funding problems.

The report also indicates that demands on healthcare are rising and signs of pressure on the NHS were apparent. In particular, some boards missed waiting times targets; staff vacancies increased; and spending on bank and agency staff and private health care rose.

Agency staff and private care spending is a good example of short term spending that is hugely wasteful. The report calls for stronger long-term financial planning to address this.

The report also highlights spending of over £115 million on the top ten high-cost, low-volume (HCLV) drugs in hospitals in 2012/13. These can be a pressure on
NHS boards as spending increases at a higher rate than other costs and it can be less predictable. The top ten drugs are generally a specialist type of drug used to treat rheumatology conditions and irritable bowel conditions (anti-TNFs) and cancer drugs. Spending on HCLV drugs increased more than spending on overall hospital drugs and drugs prescribed in general practice over the past two years.

This again highlights the importance of addressing drug costs in NHS Scotland.