Wednesday, April 16, 2014

How Scotland rejected NHS marketisation

Given the downward spiral of the NHS in England, we should give full credit to the Scottish Labour administrations who ensured that Scotland exited the road to health marketisation.

A few recent events made me think about the recent history of the NHS in Scotland. Firstly, the announcement that Malcolm Chisholm MSP is to retire at the next election. He was the Labour health minister who abolished NHS trusts in Scotland.

Secondly, an answer Nicola Sturgeon MSP gave at a recent UNISON referendum hustings comparing the NHS in Scotland and England. She didn't quite say that this was entirely down to the SNP, but those not aware of the history might have interpreted it that way. That's not to say that she wasn't a very good health minister herself and strongly opposed to marketisation. However, she was continuing the work of others. It also reflects the fact that there is not an ideological divide between Scottish Labour and the SNP on health.

Thirdly, a trip to our UK health conference reminded me just how bad NHS England is!

Following the 1997 general election Labour came into government and quickly initiated the devolution referendum that resulted in the first devolved administration in 1999. In April 1999 they set the path to reform by halving the number of NHS trusts in Scotland from 47 to 28. Susan Deacon was the first health minister and everyone was left in no doubt that the market was not the future for health care in Scotland. I spent some eighteen months on secondment to the health department during this period and then served on her advisory board. I'll be circumspect, as I am probably still covered by the Official Secrets Act and the key players are still alive, but let's just say there was some institutional resistance to the direction of travel!

None the less important steps were taken to build cooperation in the NHS rather than competition. Market testing was dropped and services started to come back in house. This included a new HR strategy (the primary reason for my secondment) that introduced partnership working into the NHS. A model that survives to this day and has been rated as probably the best of its type in the world.

At the end of 2001, Malcolm Chisholm took over as health minister and he took over the reform process that resulted in the NHS Reform Act of 2004. This Act formally abolished trusts and established a duty of cooperation. We had Community Health Partnerships for primary care and staff governance was given a statutory footing.

It is often said that Scottish Labour is dictated to by 'London Labour' - largely a myth in my extensive experience of the policy making process. However, it is certainly the case that when New Labour in England reintroduced elements of NHS marketisation there was pressure to follow the same model in Scotland. What is less well known is that Scottish Labour ministers resisted that pressure. I remember one Blairite special advisor in the run up to the UK general election complaining, that the Tories said if their reforms were so good why didn't the Scots adopt them - could we not just sound a bit like them? He was firmly told that the answer was, 'it's devolution stupid!'. However, part of the problem was that ministers were told not to highlight differences and as a consequence they have never got the credit they deserve.

The last Labour health minister, Andy Kerr, went against Gordon Brown's decision to defer a PRB award (topical again this month) and bought, what is now the Golden Jubilee Hospital, into public ownership. Even if he didn't appreciate our press release welcoming the hospital's 'nationalisation'!

The one issue that didn't get resolved was stopping the big PFI hospital projects that had been started and some smaller ones that joined the programme. Ministers like Malcolm Chisholm didn't like PFI, but they were told it was 'the only game in town', due to off balance sheet funding. Wrong in principle and practice and sadly a lesson not learnt to this day, as the present Scottish Government has one of the biggest PFI programmes in Europe.

The first two post devolution administrations didn't get everything right and certainly not over PFI. However, they made crucial decisions over a partnership approach to health through cooperation rather than competition. Health ministers like Susan Deacon, Malcolm Chisholm and Andy Kerr, supported by the wider cabinet, made these decisions and kept to this approach despite political pressure from elsewhere. When we see what's happening to the NHS in England, we should remember to say, thanks very much comrades!

Dave Watson

Health and Care integration

Health and care integration is right in principle but it will take more than moving the managerial deck chairs around to deliver quality care.

I took a day away from the STUC in Dundee to make a day trip to Brighton to speak in panel discussion on health and care integration at the UNISON UK health conference. I was giving the Scottish perspective on what is a similar challenge across the UK.

The context for integration is pretty similar across the UK. Demographic change is even more acute in Scotland with 25% of the population over 65 by 2035 and an 80% increase in the over 80s. Today's FT had an interesting UK Statistic reporting that centenarians will grow from 14,000 in 2013 to 111,000 in 2037. It will at least keep the Queen busy. Their overall message was let's embrace longevity, it's a good thing. That said, we can't ignore the financial pressures that have resulted, in social care at least, in a race to the bottom as UNISON Scotland's Time to Care report highlights.

There have been efforts to promote care integration since the 'joint finance' initiative in the 1970s, with admittedly limited success. An Audit Scotland report found few examples of effective joint planning. The long waits for patient discharge have largely gone, but 837 patients are still in Scottish hospitals who should not be. That's the equivalent of the Southern General Hospital. The Scottish public service model, based on collaboration not marketisation, should enable joint working, but as the Christie Commission found this hasn't always been achieved.

The new integration model is outlined in the Public Bodies (Joint Working) Act, to be implemented in April next year. This permits two broad models. Lead agency and body corporate bring in councils and health boards together in Health & Social Care Partnerships. Everywhere other than Highland are likely to go for the body corporate model. They will be run by an Integration Joint Board with at least 3 council and 3 Health board members plus non-voting members from the voluntary sector, trade unions and patient groups. Each Board has to develop integration plan (services, budgets) and a three year Strategic Plan. There will also be Locality Planning Groups below council level. All of these plans have to approved by minister who has extensive powers and will set national outcomes and lead an accountability process. No staff will transfer to the new bodies, they will remain employed by councils and health boards.

UNISON Scotland welcomes the less prescriptive model than first envisaged, but remains concerned about the extensive ministerial powers that could be another force for centralisation. International studies show that local implementation is the key to successful integration. The staffing provisions are minimal, but after our Bill lobby a partnership group has been established to address workforce issues.

Outsourcing remains a concern as home care is the most outsourced public service Scotland and we don't want to see that extended any further - certainly not into NHS provision. The financial provisions in the Act are weak with little indication of how growing care needs are to be funded. The savings identified in the Christie report on unplanned admissions have already been absorbed into rising, not reducing NHS bed requirements. I would also argue that GPs are weakly integrated into new system and they can be a big driver for admissions to hospital.

Finally, for the future more work is needed on the detailed secondary legislation and local plans. UNISON's short term focus is on effective joint branch working and developing skills. The industrial relations cultures in health and local government are also very different.

In the longer term, I argued that we need to address three key care issues. Improve the social care workforce as set out in UNISON's Ethical Care Charter. Find a way of funding care at the level we are going to need. And develop a new social contract that sets out the responsibilities of the state and the citizen. Vague concepts like co-production and asset based approaches need more definition.

Dave Watson


Tuesday, April 1, 2014

Self-directed care - rhetoric and reality

Self-directed care is right in principle, but does not always match with the reality of care provision in Scotland today. The rhetoric of choice and control is often used as cover for a deteriorating service.

The Self-Directed Care (Scotland) Act comes into force today and requires local authorities to offer personal payments if requested. I was interviewed by the BBC today on the impact this legislation will have on care in Scotland.

This approach works well for some service users, but can be an unnecessary burden for others. We should therefore be careful not to turn this into another one-size fits all approach to social care. UNISON signed a joint statement as far back as 2006 with the Scottish Personal Assistant Employer Network supporting direct payments while recognising that this approach should not be used a cover for cuts. However, by 2012 it was becoming clearer that assessments were focused on making savings rather than delivering better care. We illustrated these concerns with case studies in our report, ‘Personalisation in Scotland – The Facts’.

Today, cuts in budget provision means that the individual service user often has a smaller budget to buy equivalent services. This has contributed to the ‘race to the bottom’ in home care as highlighted in UNISON Scotland’s recent ‘Time to Care’ report. Staff, often paid little more than the minimum wage, on zero-hours contracts, with little training, are literally running about trying to provide the same service.

Many service users don’t understand or want the responsibilities of being an employer. As a consequence the service is being privatised with agencies providing the staff rather than the envisaged genuine personalised service. With budget cuts service users are being forced to choose a cut price ‘personalised’ service that is short on quality.

Self-directed support is leading to cuts in collective provision, such as day centres. This leads to greater social isolation that we know has a damaging impact on health. Social isolation is associated with a higher risk of death in older people regardless of whether they consider themselves lonely. A study of 6,500 UK men and women aged over 52 found that being isolated from family and friends was linked with a 26% higher death risk over seven years. Our home care members report that they are often the only living person some elderly people see in days. All the more reason to allow more time to care.

There is also no legislative requirement that a personal employer checks for Protection of Vulnerable Groups Scheme membership. Our discussions with home care staff indicated that many would be reluctant to raise care abuse concerns, particularly when they are employed on zero-hour contracts. Given the disparate nature of this service it is difficult for councils and regulators to check on the quality of care in the same way as they do in residential settings.

Overall, self-directed care is still right in principle and works well for some groups of service user. However, it isn’t suitable for everyone and has some big downsides, particularly when budgets are under financial strain.