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.

US Government shutdown shows why we should reject private health

The US government shutdown should remind us of the power of the US private health care lobby and why we don't want it here.

I was listening to an American political analyst on the radio this morning commenting on the US Government shutdown. This astonishing mess is caused by the Republicans wanting to shut down Obama's modest health care reforms, before they even start. He starkly described the USA political system as being as dysfunctional as Italy.

That may well be true, but for me it demonstrated something else about the US political system - the lobby power of the private health care lobby. A few years ago we sponsored a showing of Michael Moore's film 'Sicko' at the Glasgow Film Theatre, followed by a debate on healthcare. We had politicians from all the political parties on the panel, but they all agreed on one thing - thank god for the NHS!

This film shows just how powerful the lobby is in protecting their massive profits that results in the most expensive health care system in the world. Billions spent on administration rather than care - a system that excludes millions from health care and bankrupts even more. Health bills are the major cause of bankruptcy in the USA. My favourite clip is Moore taking public service workers, including firefighters who survived 9/11, to Cuba to get free health care that they couldn't get at home.

So why does this matter in the UK. Well in England the NHS is moving rapidly in the same direction. Under the guise of competition, the English NHS is allowing the very same health care corporations to get a very big foot in the door. Once there, they will defend their profits in same way as they do in America. The Tories will be bought and paid for, just as the Republicans are in the USA.

In Scotland, we should be very grateful for devolution and the political consensus on the NHS. We resisted the New Labour reforms  and scrapped the Tory trust model that placed marketing managers before nurses. The political consensus has largely held, to the level that commercialisation is actually unlawful in some circumstances. Private contractors have largely been banished and services brought back in house, reuniting the health care team. Only the CBI is left arguing for privatisation, an issue I was sparring with them over at the Health Committee last week. Even they are largely going through the motions at the behest of English member companies. The only significant blemish is the PPP hospitals and community facilities that waste scarce £millions every year. Sadly, they are likely to do so for years to come as the SNP introduce new PPP schemes through the hub Initiative and so called NPD model.

Of course we are not entirely exempt from the consequences of Tory NHS privatisation in England. The aim is to cut spending and that has a knock on effect on Scottish budget allocations. That's why Scots joined their colleagues in Manchester on Sunday in the largest demonstration Manchester police had seen for a generation.

So when we look in astonishment as the richest country on the planet closes down its government. Remember that the cause is private health care corporations and their lobbying muscle. Then vow to redouble our efforts to campaign against it happening here.

Scottish Health Budget

The Scottish Government has published its draft budget today for the next two years. The health budget continues to receive a  degree of protection from UK Government cuts. However, in real terms, inflation and other demand costs  are likely to keep up the financial pressure on services.



No such protection for local government that takes another big revenue hit.

The power of big business to undermine public health

Two recent health stories highlight the challenge for public health when sensible measures to tackle tobacco and alcohol abuse run up against the commercial interests of big business

A recent study by Cancer Research shows that almost 20,000 children in Scotland start smoking every year. They have called on the Scottish Government to act quickly on its pledge to introduce legislation on plain packaging for cigarettes. A similar move by the UK Government was put on hold earlier this year with a strong suspicion (subsequently denied) that Tory strategist Lynton Crosby influenced the decision on behalf of his commercial clients. 

The Scottish Government's recently published programme for government confirms that they are still committed to introducing this measure. However, for now, they are promising a consultation and legislation is not likely before 2014/15.

The public health benefits of this measure are clear. The research shows that packaging without branding is less appealing to children and would support other action to discourage young people from starting to smoke. Vicky Crichton said: “Smoking is a serious problem in Scotland with almost 20,000 children, tempted by glitzy, slickly designed packs, being lured into starting smoking every year. It is an addiction that is often life-long and kills more than 4,000 Scots annually. If the Scottish Government is serious about curbing the death toll caused by this lethal habit and meeting its goal for Scotland to become a nation free from tobacco by 2034, then swift action needs to be taken.”

The importance of tackling smoking amongst the young is highlighted by the statistic that  eight out of ten adult smokers start the habit by the age of 19. If the tobacco industry can catch them young, they are likely to have a customer for life. While the rest of us pick up the public health tab.

The second story covered the latest alcohol consumption statistics. Adults in Scotland are continuing to drink more heavily than those south of the Border. Beer, wine and cider sales are similar to England and Wales. However, Scots drink far more spirits, almost three litres per adult per year, compared to less than two litres in England and Wales. Vodka, not whisky is the tipple of preference. It should be said that the good news is that alcohol consumption overall is reducing. However, it remains to be seen if this is more about the economy than a long term shift in consumption. 

NHS Health Scotland also found two-thirds of alcohol sold in 2012 was below the proposed minimum price of 50p per unit. The Scottish Government has taken steps to reduce harmful drinking, with measures such as banning multi-buy discounts, and it wants to create a minimum price to eliminate cheap alcohol from the market. They believe the fact that a quarter of alcohol bought from off-sales in 2012 was below 40p per unit, and two-thirds below 50p, adds weight to its legislation to introduce a minimum price.

Public health minister Michael Matheson said: “We still drink around a fifth more than England and Wales. That is fuelling much higher levels of harm, which results in 100 alcohol-related hospital admissions a day and costs Scotland £3.6 billion each year – £900 for every adult in Scotland.”

And that brings us back to big business because the Scottish Government’s plans have been delayed by a legal challenge from the drinks industry. Even at EU level objections have come in from cheap wine producers. Campbell Evans of the Scotch Whisky Association said: “Minimum unit pricing is not the way to tackle misuse – it does not target the heaviest drinkers, it would be illegal and it would damage the Scotch whisky industry.”

You see it's not about profit, the measure just wouldn't be effective. A familiar refrain from big business to justify their actions over the years. In the case of tobacco and alcohol, a combination of lobbying and legal action is certainly delaying important public health measures.