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.

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