Scottish Government health programme

The Scottish Government has published its programme for government for the coming year. The health section provides the predictable long list of achievements. While this is expected, it unsurprisingly ignores the very real pressures that real term budget cuts are having on the service. Everything in the garden is apparently rosy, when self evidently it isn't.

The paper does helpfully reiterate the Scottish Government's approach to health service delivery by contrasting their approach with the shambles in England. 

"Scottish Ministers have categorically ruled out the disruptive type of reforms and upheaval being put in place in NHS England, and are committed to continuing to provide high quality health and social care to the people of Scotland that reflects the true values of the people delivering health and social care services in Scotland. The internationally recognised successes Scotland’s health services have achieved have been earned through working in partnership across the Scottish Government, the wider public sector and with staff. Looking ahead, Scotland’s approach remains one of integration, collaboration, innovation, and a focus on outcomes."

There is one new Bill. The Mental Health and Adults with Incapacity Amendment Bill aims to improve the operation and efficiency of mental health legislation for service users and practitioners alike. It will implement recommendations from the McManus Review Group, which reviewed specific aspects of the Mental Health (Care & Treatment) (Scotland) Act 2003. The Bill will also introduce new powers in relation to a Mental Disordered Offenders (MDO) Victims Notification Regime and will amend the Adults with Incapacity (Scotland) Act 2000 to remove the requirement for a single statutory ethics committee to consider all research-related applications involving incapacitated adults.

In addition to legislation, the programme includes other measures the government intends to implement in the coming year. These include:

providing a whole system response to improve the patient pathway in order to reduce pressure on Accident & Emergency (A&E) departments;

develop their strategy for engaging and empowering their workforce, providing a response in Scotland to addressing many of the issues raised by the Mid- Staffordshire/Francis Inquiry, and equipping them to work in an integrated way which reflects the different needs of different people and different places across Scotland;

achieve a sustainable performance on 4-hour A&E waits by the end of December 2013;

implement the world’s first national multiagency early years quality improvement programme across partner organisations to give Scotland’s children the best start in life;

achieve a measurable increase in early detection of cancer across Scotland, particularly in deprived areas, resulting in better outcomes.

Scottish Ministers regret the UK Government’s decision not to proceed with legislation to introduce plain packaging for cigarettes and other tobacco products. They will consult on the issue in the coming months, with the intention of introducing legislation in 2014-15. Similarly, the Scottish Government remains committed to introducing minimum pricing

per unit of alcohol, in order to reduce the terrible impacts of over-consumption. They will defend the legislation against any subsequent appeals in the courts. 

As with other sections of the programme there is nothing remarkable or unexpected in the programme. The Scottish Government's focus is on the independence referendum and little else.

Another go at health and care integration

Parliament will have another go at health and care integration next month with the Public Bodies (Joint Working) Bill. But will this be any more than moving the managerial deck chairs? 

Proposals for the integration of health and care services go back at least to the 1970‟s when the first joint finance arrangements were introduced. Since then we have had at least eight different initiatives and Acts, plus many reports. Staff who deliver these services could be forgiven for taking a somewhat cynical view of yet another reorganisation.

Almost everyone believes that health and care integration is a good idea in principle. However, the evidence from a range of studies indicates that structural integration in itself, and top down change in particular, does not deliver anticipated levels of service improvement. Petch (2011) states: “Differences in culture and in values and differentials in power tend to distort any blueprint and to undermine any projected model. Moreover major financial and time resources can be absorbed by attempts to implement such structural change without demonstrating effective outcomes”. These studies also show that local implementation is the key to effective service delivery across health and social care and that depends on culture, leadership, local history, context, time and vision.

 

If local implementation is the key, the apparent flexibility in the Bill for councils and health boards to agree a form of integration that meets local circumstances is to be welcomed. However, it may not be that clear. When you read the Bill, line by line, you are left with the impression that Scottish Ministers are granting themselves an extensive battery of powers to centrally direct their model of integration. Reserve powers of direction are reasonable, but this Bill goes much further and could result in a significant centralisation. 

Ministers can set outcomes that could be prescriptive - notably without any requirement to provide ‘inputs’ i.e. resources.  They must approve integration plans and have wide ranging powers to direct and set out requirements in regulations. Overall these powers reflect the NHS performance management approach that takes little account of local democratic accountability. Lets not forget that some £2.1bn of council spending is involved.

 

As these services are staff intensive you would have expected some detailed consideration to be given to the staffing aspects of integration. In which case you will be disappointed. The staffing provisions in the Bill are limited to contract protection aspects of TUPE only. There is no staffing framework as UNISON has proposed and this will, at best, lead to reinventing the wheel or at worse disruption. In addition there could be legal confusion over staffing decisions made by integration boards when they are not the employer.

 

Part 2 of the Bill includes shared services powers for the CSA and the establishment of Joint Ventures. These are enabling provisions, except that in Part 1 of the Bill ministers have powers to approve plans and direct contracts and services.  There is scope here for further privatisation and the Financial Memorandum indicates that regulations could direct third sector involvement. All too often on this issue there is a confusion between community engagement and ‘commercial’ voluntary sector delivery interests. £150k has also been provided to the private sector to support their engagement.

 

On costs, the Financial Memorandum is somewhat speculative and vague. The big financial gain from integration is supposed to be NHS bed costs from unplanned admissions. This has been estimated at around £1.5bn. However, these savings are only realised if the beds are closed and the Health Minister has put a big question mark over that. Glasgow and Lothian health boards have also recently called for more beds not less. I would also question if VAT will be recoverable by integration boards under the s33 exemption - remember the police and fire debacle on this point. £32m to the Treasury, rather than care services, would be an outrageous waste.

Overall, the powers in the Bill don't  match the rhetoric of local solutions.  There is a real concern that the centralising tendency of government, overrides the strong evidence that top down direction doesn't work. 

Dave Watson

Austerity Kills

Dave Watson argues austerity kills and offers some reading to prove it.

I was out for a drink in Glasgow recently (I know, not a good start for a health blog!) and bumped into a group of psychiatric nurses I used to represent in Glasgow hospitals. We got chatting about work and the impact of the recession on their job. They could all give examples of patients who had been admitted to hospital with a range of mental health conditions linked to their changed economic circumstances. A CPN told me of a patient in the community who lost his volunteering role and other support and is now back in an acute ward.

There has been plenty of analysis of the economic and social impacts of austerity economics, but much less on the disastrous effects on human health. Cutting key public services at a time when people need them most. As a result many countries, including the UK, have turned their recessions into veritable epidemics, ruining or extinguishing thousands of lives in a misguided attempt to balance budgets and shore up financial markets. Yet sound alternative policies could instead help improve economies and protect public health at the same time.

This is charted by public health experts David Stuckler and SanjayBasu in their provocative book, ‘The Body Economic, Why Austerity Kills’. Through extensive data and case studies they show how government policy becomes a matter of life and death during financial crises. Clive Cookson’s review in the Financial Times sums this up well:

“Austerity kills – and on a grand scale. So argue David Stuckler and Sanjay Basu in The Body Economic, a powerful attack on efforts to curb public spending since the financial crisis, which holds belt-tightening politicians responsible for a health catastrophe.... [B]y telling the stories of individual victims of austerity as well as analyzing its impact at the population level,Stuckler and Basu provide a wealth of evidence that it is bad for our health. That is a valuable contribution to the current debate.”

The charts below illustrate just one example of their analysis. You might think this is a heavy data read and not for me. But the case studies help to break up the data and make this a very readable book. Try it.

Happy Birthday NHS Scotland

Happy Birthday to the NHS, 65 years young today. Probably Labour's greatest political achievement and as essential today as it was after the Second World War. There is no question of retirement, at least not in Scotland. We can be grateful for a broad political consensus that recognises the value of public service delivery.

Not so in England. As Polly Toynbee highlights in the Guardian today, health competition is hugely inefficient and comes at a cost. Queues of ambulances stack up outside bursting A&Es, with emergency admissions up by 35%. 4,000 nurses gone and patients waiting over six weeks for diagnostic tests that are up by 88%. GPs are seeing 40 patients a day with their appointments systems gridlocked.

Almost everything can be tendered out to Any Qualified Provider. NHS Direct is broken up among 46 bidders for local services, paid only 30% of the old cost per call, so already many contracts are going bust. The result is unqualified call-centre operators pouring extra patients into A&E with trivial complaints. The London ambulance service is using 10 times more private ambulances, at a cost of £4m a year. Between a quarter and a half of all community services are now run by VirginCare.

The most outrageous example quoted by Toynbee, is two hospitals trying to merge in Poole and Bournemouth have spent £1.67m on legal advice from costly competition lawyers. It reminds me of when Scottish hospitals were structured into trusts, employing marketing managers before doctors.

Of course all is not well with NHS Scotland. Despite some protection from the cuts, around 6000 staff have been lost since the financial crash. This has resulted in real pressures on the service.  Emergency beds made available to help the NHS cope with a flood of patients last winter are still being used because regular wards are overflowing. The average number of available staffed beds in Scotland's acute hospitals have fallen by 1400 since 2003, with a big increase in private bed spending as a consequence. A&E waiting times have trebled in some boards and MSPs are calling for patient records to be checked for waiting time manipulation. These are largely the consequences of financial cuts, but at least we are not wasting resources on an ideological drive to competition.

Financial and demographic pressures have started a debate on what should be provided by the NHS. The latest is Hugh McLachlan in today's Scotsman. He argues: "If we tried to provide on the NHS all that might reasonably be thought of as appropriate medical treatment, it is likely that we would be unable to pay for services such as pensions or free primary, secondary and higher education without raising significantly more money in taxation."

He follows and supports Professor Frazer's view that we should consider discrimination on the basis of age in the allocation of NHS health care. He argued that: “We have to be realistic and say if you spend the resources on treating an 85-year-old with pneumonia, then you won’t be able to treat a 35-year-old who’s had a car crash. It is as simple as that.”

While there is a valid debate to be had about what NHS Scotland should do, we must remember that the NHS is primarily a treatment service. The biggest challenge for health in Scotland is not the NHS, but health inequality. In Glasgow alone we can still see differences in life expectancy as extreme as 54 years in the poorest communities and 82 years in the most affluent, a near 30 year difference. David Conway's post on this site outlines what we need to do, recognising that this is not a matter for NHS Scotland alone and requires a comprehensive policy response across all government departments.

A new drive to tackle health inequality would be a fitting way to celebrate the NHS in Scotland's birthday.

Big setback for homeopathy in Scotland

NHS Lothian has decided to withdraw funding for homeopathic remedies, following a public consultation. The current service provides more than 1,000 appointments for patients each year, including more than 100 people referred by other health boards.

The health board said the decision reflected the results of a public consultation, which showed most people were against spending nearly £250,000 a year on homeopathy because of a lack of scientific evidence that it works. This view is challenged by British Homeopathic Association who said said, “The health board has been predisposed to withdrawing the service from the outset of its farcical consultation process, with many patients unaware it was taking place. It was a consultation which failed to listen to actual patient feedback in the form of general correspondence and feedback at public meetings, instead concentrating only on the flawed online survey, which was hijacked by people outside Lothian who campaign against homeopathy. Consequently, the survey’s results are skewed and unrepresentative of the local population.”

SHA Scotland gave space to both sides of the argument in the latest edition of our policy journal.

Healthier Scotland - June 2013

The latest edition of our E.Bulletin 'Healthier Scotland' is now on line.

The focus is on our recent work and future projects on health inequality. But there is much else besides,  covering all the news on health in Scotland.

NHS Scotland workforce

ISD has published their statistical survey of the NHS Scotland workforce as at 31 March 2013. Here are some of the key points:

·         The total number of staff in post (excluding GPs & GDs) is 133,205.3, compared with 132,541.5 (WTE) as at 31st December 2012. This is an increase of 0.5% (663.8). This includes 1100 (WTE) Highland council staff that transferred to the NHS.

·         However, there are 4,471 fewer staff (headcount) employed by NHS Scotland since 2009. Nearer 6000 if you take into account the Highland transfers.

·         Nursing & Midwifery accounts for 42.8% of all staff. Administrative Services 18.3%, Support Services 10.3%, and Medical (Hospitals not GPs) 8.4% (all WTE).

·         The number of nursing and midwifery staff in post is 57,036.6 (WTE), compared to 56,608.5 as at 31st December 2012. This is an increase of 0.8% (428.2). However, this is still a reduction of 1392(WTE) since 2009.

·         The use (in hours) of agency nursing and midwifery staff has increased in the year 2012/13 by 14.0% costing an extra £2.5m. The use of Bank staff has increased by 13.1% at a cost of £13.7m.

·         The number of Allied Health Professionals is 9,583.4 (WTE) compared to 9,511.8 as at 31st December 2012. This is an increase of 0.8% (71.5 WTE). OT’s up by 24 (1.2%)

·         The number of administrative staff is 24,381 (WTE) compared to 24,222 as at 31 December 2012. An increase of 0.7% (159.6WTE). Mostly due to a significant increase in NHS24 Call Handlers.

·         The number of support services staff in post as at 31st March 2013 is 13,755.9 (WTE) compared to 13,708.1 as at 31st December 2012. This is an increase of 0.3% (47.7 WTE). Sterile services being the main component of the increase.

·         The number of emergency services staff is 3,670.1 (WTE) compared to 3,661.8 as at 31st December 2012. This is an increase of 0.2% (8.3 WTE). Mostly drivers and technicians. 

·         Across all specialties, the number of Hospital, Community and Public Health Services (HCHS) medical and dental staff is 11,925.9 (WTE), compared to 12,003.3 as at 31st December 2012. This is a decrease of 0.6% (77.4). The number of Consultant posts is up by 37.

For April 2012 to March 2013 the sickness absence rate for Scotland is 4.80% which is an increase from 4.63% in the previous year. 

Equality and diversity data is limited because it is only available for two-thirds of the workforce.  Of those declaring there are: Asian 3039 (2.7%); Black 774 (0.7%); White 106,238 (96.5%). Less than 1000 disabled persons are employed by NHS Scotland.

There are now 1250 (WTE) NHS staff over the state retirement age of 65. A further 6587 staff over 60. Proportionately higher in administrative and support services but still over 2500 nurses.

Staff turnover increased by 40% last year with 9757 leaving their post. This is back to 2009 levels.