Postcode lottery: tackling variation in health outcomes and the NHS

Written by Tom Freeman on 12 September 2018 in Inside Politics

As new figures show the amount of bed blocking varies widely by health board, Holyrood looks at how the delivery of care can depend on where we live and which health board looks after us

Postcode lottery - Holyrood magazine

If you live in one of Scotland’s most deprived areas, you are twice as likely to die early or live with a life-limiting condition as those in the most well-off places, the country’s Public Health Observatory has found.

Looking at overall disease burden, researchers found it was 14.1 per cent in the poorest areas compared to 6.7 per cent in the least deprived. And the burden itself is different by area too.

The leading causes of ill health in the poorest areas are drug-use disorders at 8.1 per cent and heart disease at 7.9 per cent, while in the wealthiest areas it is neck and lower back pain at 6.4 per cent followed by sense organ diseases at 5.6 per cent.

The biggest difference is for the rate of chronic liver disease, where the rate in the most deprived areas was 7.3 times higher than in the least deprived areas.

The link between lifestyle, environment and outcomes is clear to see, with illnesses associated with mental wellbeing, diet, drug use, tobacco and alcohol dependency far more common in poorer areas.

While rates of smoking, obesity and alcohol dependency tend to be higher amongst those who live in the more deprived areas there is evidence too that those in poverty also suffer disproportionate harm from the effects.

A University of Glasgow study last year found the harmful impacts of alcohol are higher in socio-economically disadvantaged communities, even after accounting for different drinking patterns and rates of obesity and smoking.

Lead author Dr Vittal Katikireddi said it revealed how poverty may reduce resilience to disease.

“Our study finds that the poorest in society are at greater risk of alcohol’s harmful impacts on health, but this is not because they are drinking more or more often binge drinking,” he said.

“Experiencing poverty may impact on health, not only through leading an unhealthy lifestyle but also as a direct consequence of poor material circumstances and psychosocial stresses.

“Poverty may therefore reduce resilience to disease, predisposing people to greater health harms of alcohol.”

The NHS, then, is asked to take up a burden caused by wider inequality and lifestyle choices. A burden that is felt more keenly in some areas than others.

Advances in healthcare and technology have been successful at tackling Scotland’s biggest killers, but that in itself has led to another burden on the NHS – a population that is getting older and presenting with multiple illnesses.

While the number of people who need key diagnostic tests such as endoscopy or radiology scans has increased from 60,762 to 87,482 in two years, the number of people waiting more than four weeks for those tests has trebled from 10,857 to 31,175. Those waiting more than six weeks for a test has soared from 4,750 to 18,644.

And like health outcomes, services also suffer from regional variations, as evidenced by today's figures on delayed discharge which show you are far more likely to be stuck in a hospital bed despite being well enough to leave in Lothian than you are in Glasgow.

Furthermore, on a target to get 90 per cent of patient journeys from referral to treatment within 18 weeks, the most recent figures show NHS Scotland managing 82.8 per cent overall, but only 66.9 per cent of patient journeys were within that timescale in NHS Grampian.

In NHS Lothian, 75 per cent of journeys were completed in 18 weeks, but the health board said only 85.8 per cent could be fully measured.

With varying acute local needs, having vastly different levels of service and practice has been a source of frustration for ministers. 

Former health secretary Shona Robison introduced a ‘once for Scotland’ approach in an attempt to consolidate good practice.

“It basically says ‘if it’s happening there and working well, you’ll have to have a damn good reason for not making it happen in your patch,’” she told Holyrood at the time.

And early indications are that her replacement, Jeane Freeman, has a similar perspective. “We need to get much better in health and social care at taking evidenced good practice and spreading it at pace in this country,” she told Holyrood.

However, variation can be hard to detect too, as revealed in the latest investigation by BBC Scotland’s Dispatches last week into the horrific case of a Tayside surgeon who had apparently caused injuries to patients over a number of years.

Dr Sam Eljamel retired in 2014 after being suspended when an internal audit found he had repeatedly made mistakes in operations leading to dozens of patients suing NHS Tayside.

In one case, a woman’s tear gland was removed instead of a tumour.

The BBC investigation found NHS Tayside did not have systems in place to pick up on the fact that so many mistakes were happening in operations conducted by the former head of neurosurgery at the board.

NHS Tayside said it has since taken the series of complaints on board, changed its practices and made improvements to how it holds records.

“There has been much learning by the organisation immediately following these events and many improvements have been made over the past five years,” said Professor Andrew Russell, NHS Tayside’s medical director.

Because the particular doctor in question has retired he will not face further investigation, but the revelations do reveal the level of harm that can be caused by local circumstances without even being noticed. If it takes a number of people suing a health board to flag up an abnormal set of outcomes, what other variations are going unnoticed?

Awareness of the extent of the differences between services is expected to be boosted by the publication of a new Atlas of Variation, commissioned by the Chief Medical Officer Catherine Calderwood.

The atlas was due in spring but now Holyrood understands it will now appear before the end of the year.

This tool will reveal variations in health outcomes across Scotland and will highlight where innovations have worked or where things are done differently.

In her last annual report, ‘Practicing Realistic Medicine’, Calderwood said: “The aim of the Atlas is not to provide answers but to provoke questions and dialogue. 

“These questions will not only lead to a better understanding of the reasons for variation, but will help to identify variation that is unwarranted and potentially harmful.”

But while Calderwood hopes the atlas will provide “insightful knowledge for clinicians”, many NHS staff feel they are preoccupied with firefighting.

It is often said the NHS is characterised by its staff, but these staff are stumbling through a working environment of mounting pressures and strict unrelenting targets. 

Staffing levels in each area are being linked with the outcomes, especially in places which struggle to recruit for particular roles.

The rise in people waiting for diagnostic tests was linked with staffing levels by Cancer Research UK’s Scottish head of public affairs, Gregor McNie.

“It’s crucial there are enough imaging, endoscopy and pathology staff working to deliver tests,” he said.

The last Scottish Government’s iMatter survey of health and social care staff revealed that 46 per cent of NHS staff didn’t think there was enough staff for them do their job properly.

Legislation was introduced in May which will mandate that boards have to maintain safe staffing levels, but despite the fact there are more staff working in NHS Scotland than ever before, it has not kept up with demand, while the pressure has contributed in turn to problems in retention and recruitment. 

As Scotland’s population ages and presents to services with more complicated combinations of multiple conditions, so the lists of vacancies and unfilled training places have lengthened.

The NHS Scotland workforce report in June showed there were 418 unfilled consultant posts and 850 nursing and midwifery posts vacant for three months or more across the country.

What could be significant is the new pay deal, which will see NHS Scotland staff noticeably better paid than their counterparts anywhere else in the UK.

NHS staff in England earning under £80,000 have been offered a 6.5 per cent pay rise over three years, while their Scottish counterparts have been offered nine per cent.

This is a regional variation far more palatable to the Scottish Government. 

The new deal in Scotland means that by 2021 an NHS porter at the top of the Band 2 pay scale would be paid £1,200 more than a counterpart in England, while an advanced nurse practitioner at the top of Band 7 would be paid £1,500 more. 

Will this attract more people to work for the NHS in Scotland, and in turn alleviate some of the pressure on Scotland’s health and care system?

Thomas Waterson, chair of the UNISON Health Committee, said: “Eighteen months ago, some people said that we couldn’t negotiate a separate pay deal for NHS workers in Scotland. Then they said that we couldn’t negotiate a better deal for Scotland. The Scottish Government should commit now to develop negotiating structures in Scotland and allow us to self-determine on pay.”

The Scottish Government has confirmed salaried doctors and dentists earning less than £80,000 will get their three per cent this year, backdated to April. The pay rise will be capped at £1,600 for those earning more than that.

“By offering fair pay increases we can help to support recruitment and retention of staff, encouraging health professionals to build their careers in Scotland’s NHS,” Freeman said.

Doctors’ union the British Medical Association (BMA) welcomed the move but said it was not enough to reverse the long-term downward trend in doctors’ real-terms pay amid a recruitment and retention crisis.

Pay levels will not be the only factor, however. 

Record numbers of nurses and midwives from European Union countries quit Britain last year ahead of Brexit.

A total of 3,962 left the UK Nursing and Midwifery Council register between 2017 and 2018, and with the immigration status of those who remain still unclear only six months before the UK leaves, the figure can only rise.

Outgoing BMA Scotland chair Dr Peter Bennie aired his concerns over Brexit with MEPs in Brussels.

“At a time when our workforce is already stretched to its limits, it is unthinkable that we could simply stand by and lose this important supply line of doctors for our hospitals and communities,” he said.

“But it is not just a numbers game. The free exchange of ideas and experiences that doctors pick up from working in different health systems, and that European doctors bring to Scotland, benefits them as professionals, their colleagues and the patients they care for.”

Last month Bennie cited frustrations with staff levels as a reason behind his own decision to retire early.

The consultant psychiatrist is retiring from clinical practice at just 55 because of “the lack of sufficient colleagues to feel you can do the best job that you can”.

If Bennie’s situation is being replicated, it suggests poor staff numbers and retention creates a downward spiral which itself encourages more to leave.

New ways of attracting people into the NHS may be needed. The Royal College of Nursing is looking at ways to attract more men into a profession which is traditionally dominated by women.

Theresa Fyffe, RCN Scotland director, said: “The growing demands on health services mean that more nurses with the right level of complex decision-making and technical skills are urgently needed. The shortage of men applying means we are losing out on many talented future nurses Stereotypes, low pay and the perception that nursing is not a ‘male’ profession may be some of the reasons why men have steered clear but we need to break down these barriers.”

Diversity itself, perhaps, could break down variation of the unwanted kind.

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