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.

Socialist Health Association Scotland – the case for making health inequalities a top priority

To our national shame - the World Health Organisation repeatedly uses this example of health inequalities from Scotland:

“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”.

Giving parts of Glasgow – lower life expectancy for men than the national average in Yemen, India, or North Korea. While other parts of Glasgow – have among the highest life expectancy across the whole of the UK and the world. Thus, depending, literally, on which side of the railway tracks you are born will predict how long a life you will live. But, we know - it is not about luck. And it is not a Glasgow effect either. A substantial body of international evidence shows that poor health is a direct consequence of wider social and economic inequalities. Inequalities in income. Inequalities in health. Thatcher’s real lasting legacy…

We - in SHA Scotland - believe that inequality remains the greatest challenge we face.

Health inequalities need to be at the top of our policy agenda – not a matter for NHS Scotland alone.

Inequalities in health can be defined as:

(i)         Inequalities in access and uptake of health services – for example GPs

working in the most deprived communities – also described as working in the “Deep End” – have less time and capacity than GPs working in other areas.

(ii)        Inequalities in health behaviours - which themselves are more socially

determined rather than merely lifestyle choices; and despite our successful ban of smoking in public places – smoking still plays a big part in health inequalities   

(iii)       Inequalities in health and disease outcomes – the big killers and almost any

disease you care to investigate.

These challenges almost seem too great, too intractable. But to quote George Orwell “Economic injustice will stop the moment we want it to stop and no sooner, and if we genuinely want it to stop the method adopted hardly matters”.

So, the first and most important requirement therefore is to find and harness this will.

There are four arguments that make the case for tackling health inequalities, which we believe would carry opinion.

1. Inequalities are unfair – with poor health the consequence of the unjust distribution of social determinants such as income, jobs and education

2. Health inequalities affect everyone across the socioeconomic gradient – this is described as the “spill over” effects associated with factors such as alcohol, drugs, violence. Just because you are at the top – does not make you immune.

3. Health inequalities are avoidable – they are created – they can be tackled - policy options such as tax policy, regulation of business and labour, and welfare benefits are the key. And in this regard - we welcome the proposed Labour Party Commission to review devolution of income tax powers.

4. The means to reduce inequalities are available and affordable and save in the long run. Preventative spending can work.

These means would provide outcomes which would benefit all in health, social and economic terms. But in addition to macro-economic solutions we also believe 3 broad policy areas are worthy of our attention:

Firstly -           we need to re-engage with community development work – move

away from silo individual behaviour lifestyle change interventions that were damned in the recent Audit Scotland report as having limited success and cost no small fortune. Community Development can build on the recent enthusiasm for “asset based approaches” – but will need the targeted financial commitment.

Good examples of Community Development work which aims to develop local solutions for local issues – include fresh food cooperatives, credit unions, local energy saving initiatives, environmental enhancing schemes, and community support workers.

Secondly -       we do need the democratisation of NHS and reform of local

organisational structures – grasping the Christie Commission recommendation for local government and health agencies to work together. But more radically - the creation of common public service authorities should be in our sites: bringing public health and primary care together within new local public service authorities.

Finally -           we need to resolve the thorny issue of targeted vs universal services. It needn’t be either or. Focusing solely on the most disadvantaged - a purely targeted approach - will not reduce inequalities sufficiently. To reduce the gradient of inequalities actions must be universal. But – and here is the caveat – with a scale and intensity that is proportionate to the level of disadvantage. Proportionate universalism if you like.

There is no doubt we will have to make tough decisions – but a government that genuinely cares about improving the health of the population and reducing health inequalities ought therefore to incorporate health inequality impact in its policy setting processes.

The SNP’s Ministerial Taskforce on Health Inequalities is inadequate and sidelines the issue.

SNP policy does not have tackling health inequalities at its heart. Even the Coalition government in England have a more explicit health inequalities outcome target.

We call on the Labour Party Scottish Policy Forum:

to grasp the thistle of health inequalities – which so burdens us in Scotland.

to ensure that measures to address health inequality are a major element of Scottish Labour’s next policy programme

and to recognise that this is not a matter for NHS Scotland alone and requires a comprehensive policy response across all government departments.

Healthier Scotland - The Journal: April 2013

Healthier Scotland: the Journal is part of our attempt to take the health debate in Scotland forward. We welcome the level of political consensus in Scotland around health that means we avoid the ideological dogma that is undermining the NHS in England. However, we have huge health challenges to address and that requires new thinking on how to address them. 
In this edition we start with Iain Gray’s challenge to the health consensus. He argues the status quo is no longer an option for NHS Scotland. Dr Margaret McCartney author of ‘The Patient Paradox’ argues for a different type of reform by concentrating resources on those who are ill. Dave Watson then provides an overview of health inequality in Scotland and asks if structural change can be part of the solution.

Shelia Duffy outlines the role tobacco use plays in health inequality and Richard Simpson follows that up with his proposed private members bill on measures to address alcohol misuse.

The debate over homeopathy in the NHS has resurfaced with the NHS Lothian consultation and a vigorous internal debate within the SHA. So we invited a doctor and a scientist to give us their contrasting views on the subject.

Gordon McKay rails against the media portrayal of mental health and Matt Mclaughlin highlights the role of nurses in NHS Scotland as their numbers fall yet again.

As always we welcome views on any of the issues raised in this edition and are grateful to the contributors for their time and effort.

Scottish Labour Party Conference 2013

The SHA Scotland fringe meeting at this year's Scottish Labour Party Conference will be held on Friday 19 April 2013 at the Palace Hotel, Inverness, starting at 5:30pm.

The subject is 'Tackling Health Inequality'.

Chair: Gordon McKay - Chair UNISON Labour Link Scotland

Speakers:
Jackie Baillie MSP - Shadow Cabinet Secretary for Health
Dr David Conway - Chair SHA Scotland

SHA Scotland has also submitted a contemporary motion on the same topic.

"This conference recognises that Scotland's major health challenge is health inequality. The Joseph Rowntree Foundation’s, ‘Monitoring poverty and social exclusion in Scotland 2013’, is one of a number of reports that draw attention to this issue. The health section of that report 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 Joseph Rowntree report also concludes that the “Labour Government has taken poverty and social exclusion very seriously, marking a clear distinction from recent previous administrations”. Labour's actions are in stark contrast to the actions of the ConDem coalition who through welfare cuts and reductions in public spending are creating even greater health inequality. 

Conference also recognises that the SNP's Ministerial Taskforce on Health Inequalities is an inadequate response to the scale of the challenge facing Scotland. 

Conference welcomes the recent recognition of the role of local government in tackling health inequalities in the form of a new guide for councillors published by CoSLA and NHS Scotland. The guide’s key suggestions for action to address health inequalities include providing services universally, but with scale and intensity that are proportionate to the level of disadvantage. While offering intensive support, it cautions against targeting geographical areas defined as deprived because this means missing the vulnerable who live elsewhere. Particularly rural areas that have people experiencing inequalities that may be harder to identify. The guide also reinforces the Christie Commission recommendation that local agencies work together with common aims and measures to reduce health inequalities. 

Conference therefore calls on the Scottish Policy Forum to ensure that measures to address health inequality are a major element of Scottish Labour's next policy programme. Recognising that this is not a matter for NHS Scotland alone and requires a comprehensive  policy response across all government departments."