Councils and health inequality

SHA Scotland has long argued that Local Government has a central role to play in reducing health inequality in Scotland. We therefore welcome COSLA and NHS Scotland’s new guide for councillors to support them in this role.

The Christie Review highlighted the importance of reforming public services to ensure that public sector bodies work together and focus more money on preventative spending rather than trying to fix what has already gone wrong. This will both save money in the long run and en-sure that money is spent effectively.

The guide’s key suggestions for action to address health inequalities:

·         Provide services universally but with scale and intensity that are proportionate to the level of disadvantage

·         Prioritise disadvantaged groups

·         Provide accessible services ( i.e. good transport links)

·         Offer intensive support

·         Do not only target geographical areas defined as deprived: you will miss the vulnerable who live elsewhere

·         Take into consideration that rural areas have people experiencing inequalities that may be harder to identify

·         Local policy should not be discriminatory

·         Ensure that local agencies work together with common aims and measures to reduce health inequalities

Trade unions will find the section on councillors’ responsibilities as employers in relation to healthy working lives useful. The most commonly reported reasons for workplace absence are musculoskeletal disorders and stress, depression or anxiety. The paper recommends the Healthy Working Lives Awards Programmes step by step guide to achieving a healthier workplace and highlights work done at Inverclyde council like smoking cessation classes, mental health support groups and even walking routes to work.

Overall a very useful resource.

Cost of demographic change

The Scottish Parliament Finance Committee has published a report that looks at the aging population in Scotland and the financial consequences. The inquiry remit was:

“To identify the impacts which demographic change and an ageing population will have primarily on the public finances in respect of the provision of health and social care, housing, and pensions and the labour force, and the planning being undertaken by the Scottish Government and key public bodies to mitigate such impacts.”

Scotland’s population increased to 5,295,000 in 2011 – the highest ever. Since the 2001 Census, the population has increased by 233,000 (5%). This represents the fastest growth rate between two census years in the last century. However, it is the most elderly age-groups of the population that are projected to increase most dramatically. Between 2010 and 2035 those aged 75 and over are projected to increase by 82%. The committee looked at the financial implications of this in three main areas: health and social care; housing; pensions and the labour force.

Evidence to the committee highlighted the importance of focusing on healthy life expectancy as well as life expectancy.  The ratio of healthy life expectancy to non-healthy life expectancy is not changing much in Scotland (for men it is widening), so the increase in life expectancy is also increasing the potential costs. ADSW estimates the difference between best and worst case scenarios is over £1 billion by 2030 - the difference between an 18.4% increase in costs (excluding inflation) or a 28.7% increase between 2010 and 2030. The committee recommends that the Scottish Government, councils and health boards do more long term planning to address this issue.

Council and health board budgets have not kept up with demographic change in the past ten years, let alone the future. For example, emergency admissions to hospitals have a targeted 10% reduction, but they are actually increasing, particularly for the o/75s. The committee found limited progress in preventative spending, joint planning or a shift in funding.

Current demographic projections would increase primary care spending for those aged 65 and older by 70 per cent by 2033 unless action is taken. The cost of a primary care consultation would need to be reduced by more than 38 per cent for spending on primary care for those above the age of 65 to remain constant in real terms by 2033.

The report also highlights significant pressure on resources arising from a likely increase in a number of health conditions as a consequence of an ageing society. These include: cognitive ability; hearing and sight loss; osteoporosis/fragility fractures.

Evidence on housing highlighted the need for new build and adaption of existing stock to accommodate an aging population. For example, the overall number of pensioner households requiring adaptations will rise from 66,300 in 2008 to over 106,000 in 2033. It is unclear if this rising demand has been costed in current plans.

Overall this report is a useful reminder of the financial implications of an aging population. If more than a little light on the positive elements.

Poverty in Scotland

The Joseph Rowntree Foundation has published ‘Monitoring poverty and social exclusion in Scotland 2013’, produced by the New Policy Institute. This is JRF’s sixth assessment of poverty in Scotland.

The report is an excellent overview of poverty in Scotland using the latest data. It covers child poverty and the impact of welfare cuts on those in work and those who are unemployed. Overall, they highlight that the number of working-age adults in poverty remained unchanged over the decade to 2010/11, but there were changes from workless families to working families and from those with dependent children to those without.

The health section highlights three main points:

§  Health inequalities in Scotland are not only stark but growing. A boy born in the poorest tenth of areas can expect to live 14 years less than one born in the least deprived tenth. For girls, the difference is eight years.

§  Rates of mortality for heart disease (100 per 100,000 people aged under 75) are twice as high in deprived areas as the Scottish average.

§  Cancer mortality rates in the poorest areas (200 per 100,000) are 50% higher than average, and have not fallen in the last decade, while the average has fallen by one-sixth.

The report may not be a surprise, but it does add to a growing body of work in recent months on health inequalities in Scotland.

Drug costs and free prescriptions

Audit Scotland has today published Prescribing in general practice in Scotland, its third report on the subject. It shows that NHS Scotland has improved how it manages prescribing in general practice during a period when it has faced considerable pressures.

GP prescribing accounts for 70% of all NHS spending on drugs in Scotland. This amounts to almost £1 billion a year. Spending fell by 11% in real terms between 2004 and 2011, despite the volume of prescriptions rising by a third during that time. The report says there is scope for further improvements and potential to save up to £26 million a year without affecting patient care. This could mostly be done through reducing waste and cutting the use of less suitable medicines.

While this is the headline from the study, I suspect many people will be interested in what the report has to say about the impact of free prescriptions. We already have ill informed comment from politicians who don't appear to have even read the report. Prescription charges in Scotland started to be phased out from April 2008 and were abolished in April 2011. The Scottish Government estimated that the total cost would be £73 million for the three years up to 2011/12, and £57 million in 2011/12 and in subsequent years. Critics argued that there is a risk that the abolition of prescription charges could lead to an increase in the overall quantity of prescribing beyond that anticipated.

The study says it is difficult to measure the impact of the abolition of prescription charges at present because:

·         the changes were brought in over a three-year period, making it difficult to identify a break point when trends changed;

·         the change took place against a background of increases in prescribing for many drugs;

·         over 90per cent of prescriptions were for people who were exempt from charges, making it difficult to distinguish any impact of the abolition of charges from overall trends;

·         changes to the community pharmacy contract make it difficult to assess the impact of drugs prescribed by community pharmacists under the Minor Ailment Scheme;

·         the total abolition of prescription charges took place in April 2011, too recently for our audit to identify emerging trends.

                 

They did look at prescribing trends for three common drugs available to buy that are also available on prescription: paracetamol, ibuprofen (both painkillers), and antihistamines. They compared changes in prescribing trends for three years before and after April 2008 when prescription charges started to be phased out. They found that paracetamol went down by almost a half, Ibuprofen went up slightly and antihistamines almost trebled. The study argues that no trends can be observed, but an obvious conclusion is that paracetamol is very cheap and antihistamines expensive, so more worthwhile to get a prescription.

SHA Scotland long argued for free prescriptions, not least because some of those just outside the exempt category had to prioritise which drugs to take.  There is no evidence in this study that indicates that the policy is not viable.

Healthier Scotland - Jan 2013

The January 2013 edition of our Bulletin, Healthier Scotland is now published.

The feature this quarter is on health inequalities, given the range of material published in recent months. But we also cover developments in mental health, NHS Scotland and public health.

NHS Scotland is rarely out of the news at present, so we hope this overview is helpful.

We hope to see members at the SHA Scotland AGM, this Thursday, 17 January at Glasgow City Chambers.

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.

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