Slow progress in improving care for older people

Reform of care for Scotland's older people needs to accelerate according to Audit Scotland.

As the Public Bodies (Joint Working) Bill moves towards the end of its legislative journey, Audit Scotland's report 'Reshaping care for older people' is a timely reminder of the challenges. Moving the managerial deck chairs around is only a small part of the solution.

The report reviews progress three years into the Scottish Government's ten-year plan to improve health and social services for people aged 65 or over. It is one of Scotland's biggest and most complex programmes and involves NHS, local government, voluntary and private bodies. The Government is supporting it with a four-year, £300 million Change Fund.

The report says:

• Improving care for older people and joining up services has been a policy focus for several years but progress has been slow, and monitoring of its implementation and impact needs to improve

• The Scottish Government needs to work with its partners to clearly plan how resources will move from institutions such as hospitals into the community. They also need to better understand why activity and spending on services for older people varies across Scotland

• The Change Fund has brought bodies from the different sectors together to develop and agree joint local plans to improve care, and a number of local initiatives are underway

• The information needed to make decisions and assess their impact on older people is not nationally available. Bodies need to improve and maintain data on costs, activity and outcomes for health and care services.

As usual with Audit Scotland reports, they are strong on analysis, bringing together the available data in a presentable format. This info graphic sets out the key data very helpfully.

The weakness is that the recommendations focus on getting public bodies to produce more data. Important though this is - it misses where the key focus needs to be.

For example, the funding of additional community care is almost entirely missing from the financial memorandum to the Bill. It has been assumed (Christie Commission) that the funding is coming from reducing unplanned admissions to hospital, calculated at £1.5bn. However, health boards are now arguing that far from reducing beds, they need more, and the Health Secretary has said he agrees.

The next problem is that care for older people in the community is little short of a national disgrace. The big numbers in this report do not reflect the problems facing home care staff in particular. Many are paid well below the living wage, employed on zero or nominal-hours contracts and given insufficient time to provide a quality service. The BBC File on 4 programme covered the cost of delivering care in England earlier this week. The same problems are all too evident in Scotland.

Numbers in this report are useful, but quality outcomes are more important.

For more on the social care crisis come to SHA Scotland's fringe meeting at the Scottish Labour Party conference on Friday 21st March 2014. 

Health inequality should be Labour's priority

Neil Findlay, Shadow Cabinet Secretary for Health led a discussion at tonight's AGM of SHA Scotland.

Neil's focus was the appalling levels of health inequality in Scotland. This reflects other socio economic factors in disadvantaged communities. The problem has been analysed to death, in effect reinventing the Black Report several times over. We now need to take action.

This is not just about the NHS. It's about jobs, income, housing, education, and community networks. Neil drew a comparison with investment in community services in the developing world. We need better integration and local initiatives, not just hospitals. Others pointed to the need for health impact assessments of every policy decision by health boards and councils. We also have to look at how resources are targeted on those areas most in need.

He also highlighted the pressures on NHS Scotland that he had heard from a wide range of staff, patients and healthcare organisations. These include budget pressures, staffing levels, vacancy rates, bullying and harassment, A&E waits, private sector payments and many others. In hospitals, crisis management is the norm with the target culture distorting priorities and putting unbearable pressures on many staff. Neil has called for a review of NHS Scotland, recognising the contribution staff make to the NHS that is Labour's finest achievement.

Community services are also under pressure. Neil used the example of Deep End GPs who use support staff to help patients with wider issues, but need more time with patients. One practice had not had a health visitor allocated for a year, others had limited contact with social work. Other members at the meeting were highly sceptical that the latest version of care integration is going to work. On local democracy, health workers made an unfavourable contrast between the NHS and the outsourcing initiated by many councils.

Home care quality is been driven to the bottom as council budgets are slashed. This was illustrated by the example of a 17yr old who was given four days training then allocated 30 visits in her first day, including patients with complex conditions. She was paid £5.13 per hour and worked from 8am to 10.30pm. Neil argued for good national standards and where services are contracted out they should compete on quality not wage levels. We should be raising the status of care workers so there is continuity of care, slowing the growing turnover rates.

There are similar problems in private care and nursing homes, where there is one scandal after another. In Edinburgh, 100 patients are bed blocking because of the number of nursing homes under investigation or being closed. A number of members referred to the size of new homes, creating new institutional environments.

Neil has established two reviews on social care and inequalities to feed into the SLP policy process that has just started. There was a detailed look at the remit for the health inequalities review and SHA Scotland is well represented on the group. Members made a range of contributions that will be fed into that process.

More bluster than solutions in health debate

NHS Scotland may not be a 'basket case', but it is under huge pressures that the Scottish Government would do well to recognise. Sadly, not much sign of that in yesterday's Scottish Parliament health debate.

Shadow health minister Neil Findlay opened the Labour debate, he said: "The reality is that the NHS in Scotland, the staff who work in it are under pressure like never before". He drew attention to  budget pressures with "fewer staff being asked to do more for less" as some of the problems facing the NHS, along with bed blocking, waiting times increasing and a "skeleton weekend service" in hospitals.

The Cabinet Secretary for Health's response was combative rather than constructive. He dismissed a Labour demand for a review as the "laziest, most vacuous motion" he had encountered in 15 years of the Scottish Parliament. This is of course a classic lazy and vacuous response and a bit rich from a Government that has used reviews extensively, particularly when the alternative is a difficult decision!

Neil ­Findlay cited unions and professional bodies who believed the NHS in Scotland was close to breaking point. He said, "The Cabinet Secretary has a choice - he can either ignore those informed voices or he acts now and instructs a wide-ranging review of the health and social care system. As these voices have grown louder the Cabinet Secretary's response appears to be to stick his fingers deeper into his ears. This simply is not good enough."

Staff concerns are reflected in the latest NHS Scotland workforce survey. Three of the five lowest scoring statements related to how involved in decisions staff felt they were. The statement ‘Staff are always consulted about changes at work’ received the lowest percentage positive response of all (26%).  The second lowest percentage positive response was ‘There are enough staff for me to do my job properly’, with only 31% of respondents answering positively.

While the NHS has got off relatively lightly in the huge Scottish public sector workforce cuts, 6,000 posts have still gone. This is at a time when the demands on the NHS are increasing. It is therefore not surprising that NHS workers don't believe there are enough staff to do their job properly.

The Health Secretary yesterday referred to 'Everyone Matters: 2020 Workforce Vision'. This is an important document and reflects the constructive way NHS Scotland is seeking to address workforce change. However, this is largely a process document, it doesn't set out how change will be delivered in the current financial environment. Helen Puttick, makes a similar point in her entertaining but caustic analysis in today's Herald. Seeking practical measures she asks, "Why, then, do we have a plan that does little more than describe planning structures?"

NHS finances are also under pressure as the recent Audit Scotland report highlighted. They said "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". That's polite auditor language for putting a sticking plaster over the cuts. And real term cuts they are, when inflation and other cost pressures, not least drugs, are added to the balance sheet. For example, recent statistics revealed that there were 149,866 emergency admissions among people over 75 in 2012/13, compared to 116,128 in 2003/4. That's 410 a day.

The NHS in Scotland does an amazing job, but we do need to recognise that all is not well and staff are working under growing pressure that will impact on patient care. Political bluster is not the solution.

Neil Findlay MSP will be expanding on these themes at the the AGM of SHA Scotland on 30 January 2014.

Healthier Scotland - December 2013

The latest edition of our e-bulletin 'Healthier Scotland' is now on line.

http://www.shascotland.org/shanews%20dec13.pdf

Mick Jagger should make us plan for demographic change

We are told this week that Mick Jagger is delighted with the prospect of becoming a great-grandfather, according to his granddaughter Assisi who is expecting her first child in April. I highlight this news story in contrast to the regular media stories that forecast doom and gloom over our ageing population.

There is no doubt that demographic change will bring many policy challenges and I participated in a round table discussion hosted by The Herald on this very issue yesterday. However, the phrase 'demographic time bomb' ignores many of the benefits to individuals and communities. Older people remain significant economic contributors as well as important carers, of young and old, in their own right. Many of the voluntary organisations that make up the fabric of our society would collapse without the support of older people.

There is also some recent academic work that argues that we may be exaggerating the impact on health services because we are likely to be healthier into old age. 60 is the new 50, as Mick Jagger might illustrate. There is also a lot a focus on nursing home costs, but this only applies to a tiny proportion of older people.

Of course, none of this means that we shouldn't address the policy implications of an ageing population. The additional public spending impact is estimated at £2.5bn in Scotland by 2030. When I was working with the Christie Commission we were told that £1.5bn might be released from unplanned hospital admissions to help pay for this. With the increasing demand for beds that is now looking a remote prospect and I don't see any replacement plan in the current care integration proposals.

One aspect we do need to focus on is the workforce that cares for older people. We are seeing a race to the bottom in terms of pay and training, with care being viewed as the new retail in job terms. I was discussing this with a group of home care staff recently. Most of the younger staff told me that they would leave as soon as they could get a better job - little prospect of the essential continuity of care that many older people need. Others described minimal training before being expected to address complex care needs. Even more worrying, those on zero or nominal hour contracts said they wouldn't flag up safety or abuse issues for fear of losing hours.

Demographic change has positive implications for our society and we shouldn't over emphasise the negatives. What we should do is start serious planning. Respecting and developing the workforce is a good place to start.

Dave Watson

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.