Scotland's NHS needs more than political consensus on health
As the single biggest spend in the devolved Scottish budget, health has always dominated electioneering for the Scottish Parliament elections.
The 2016 election is proving to be no different, although the context and scale of the election itself is entering into uncharted territory. For the first time, the government elected in May will have considerable powers to raise additional funds, alongside a different funding arrangement with Westminster which will tie it less to a UK government’s spending priorities.
In only two weeks, health and social care will be formally integrated in what SNP ministers are calling “one of the biggest reforms since the creation of the NHS in 1948”.
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Behind the shouting, Scotland enjoys considerable cross-party consensus when it comes to health. All parties publicly endorse the Scottish Government’s 2020 Vision to shift care from the acute sector into the home or homely setting, and recognise integration as an important milestone on that journey.
The recently published National Clinical Strategy outlines those aspirations in more detail.
Even the Scottish Conservatives have committed themselves to a publicly-owned NHS, and at party conference, leader Ruth Davidson went as far as suggesting this bastion of socialism should get more public money, challenging the SNP to match increases in spending in England.
“The pressures in general practice, in recruitment, in capacity are only getting more intense and we must act.
“There is no way around this: if we want to maintain our NHS to the standards we rightly expect, then increased spending must be part of the solution,” she said.
The big solution, health and social care integration, needs councils and health boards to cooperate and drive change on the ground. Unfortunately, this doesn’t seem to be happening, and indeed, budgetary squabbles have intensified as the election approaches.
A report by the Accounts Commission and Audit Scotland in December suggested the two factions were not organised.
The latest budget by Finance Secretary John Swinney included an allocation in the health budget of £250m for social care, and this was used as a sweetener for councils upset at a £350m cut in their funding.
Local authorities are not comfortable with what is seen as a transfer of control to NHS managers.
“They’ve given it to the health boards. I don’t mind the health service getting more money, the health service needs more money, but don’t say they’re giving to us when they’re giving to the health service,” David O’Neill, president of COSLA, the local authorities’ umbrella body, told Holyrood last month.
The fallout has been significant, but at the centre is a battle for control of governance of the integrated health and social care boards (IJBs), to be comprised of NHS managers and elected councillors.
The partnerships have struggled to agree budgets, complex governance arrangements, and workforce planning, leaving them unable to make an impact, at least in their first year, Audit Scotland said.
This would leave uncertainty for partnerships and primary care hubs on the ground.
The reaction of councillors to the funding being diverted via NHS management suggests further rocky roads ahead.
And Audit Scotland wasn’t finished. Last week a second report was issued which advised the health service was being held back by “poor leadership”.
With the number of people aged 85 and over in Scotland expected to rise by two-thirds from 114,375 in 2014 to 187,219 in 2030, and double by 2034, the spending watchdog warned a lack of national leadership and clear planning is preventing the change needed if Scotland’s health and social care services are to adapt.
The Scottish Government, according to the report, needs to be clearer with health boards and councils about what it expects them to do to meet its 2020 vision.
Auditor General Caroline Gardner said: “The Scottish Government must produce comprehensive long-term plans for realising its 2020 Vision, and work to reduce the barriers that hold local bodies back from creating new ways of working that meet the changing needs of their communities.”
Government has also failed to shift spending from hospitals into community settings, the report warned.
Furthermore, despite the previous warning, the IJBs continue to focus on structures and governance and must shift to what needs to be done on the ground to make the necessary changes to services, according to the report.
“An ambitious vision can be a catalyst for change but, without a clear and detailed plan of action, there’s a risk that ambition is overtaken by circumstances,” said Gardner.
COSLA was strikingly dismissive of Audit Scotland’s findings. Councillor Peter Johnston, COSLA’s Health and Social Work spokesperson, said the latest report “adds little that is new” compared to the earlier audits.
“While we know that we need to deliver more sustainable and different models of care to meet the needs of the people we serve, this report – which does not evaluate or endorse any of the models – is in effect little more than an incomplete list of activity,” he said.
Johnston was more welcoming of the report’s recognition of the strain on budgets. Between 2011 and 2015, the health budget decreased by 0.6 per cent in real terms to £11.85bn, while overall funding for councils decreased by 5.9 per cent in real terms to £10.8bn.
“Reductions in council budgets will present a risk to our ability to deliver on integration, implement new models of care, and importantly, shift care into community-based settings and social care provision,” he said. “We also welcome the recognition that the Scottish Government approach to hospital-based performance targets acts against our shared ambition to shift the balance of care. If we are going to have targets for the NHS then at a minimum, they should drive the change we want to see and not act as a barrier to it.
“It is also worth taking this opportunity to say that what IJBs are being asked to do is incredibly difficult and, we hope, transformative, however we, and Audit Scotland, need to let them get on with it now.”
Leaving the IJBs to their own devices is not likely to be a tactic welcomed by health professionals and third sector organisations, who strongly lobbied to be included in decision-making from the onset of the integration legislation.
From large-scale charities like Marie Curie to small, local voluntary services like community transport and support groups, representatives of the third sector have been keen to stress they can be actively involved in the agenda.
The Health and Social Care Alliance Scotland (the ALLIANCE) pointed to examples of good practice raised by Audit Scotland. These included the National Links Worker Programme, which installs a worker in ‘deep end’ GP practices to point patients to a range of local services, and House of Care, an initiative to empower people with long-term conditions to manage their own care.
Chief executive Ian Welsh said these showed where the third sector is already leading change. “Audit Scotland’s new report describes a need for greater strategic leadership and planning to drive new models of care but, in our view, this must be complemented by supporting changes driven by people who use support and services themselves – an area where the third sector excels,” he said.
Audit Scotland approached intermediary group Voluntary Health Scotland (VHS) to hold two events at the start of the year in an attempt to engage the third sector in the results of their first report and with shaping future services. VHS’s chief officer Claire Stevens told Holyrood the events revealed a need for a shift in mindset and culture from the public sector towards recognising the third sector as an equal partner.
“There’s a real appetite from the third sector to be actively involved in the integration agenda and a sense that if there is going to be a true shift from acute to community-based care, then they are an essential partner in this happening,” she said.
The responsibilities of the IJBs also need to be clearer, argued Stevens.
“At this early stage in integration authorities’ (IAs) development, there’s a need for more clarity on what the role of IAs will be in helping tackle health inequalities and related causal factors such as housing, homelessness, social isolation and loneliness. IAs should embed addressing health inequalities in all strategy and planning and the third sector is very well placed to assist in this process.
“Come Audit Scotland’s next report on integration, we hope to read of IAs that have taken steps to proactively engage with the third sector – it’s a sector that is ready to have discussions on what it can bring to the integration table and one that is driven by improving outcomes for service users, the key ambition of this whole process.”
In practice, with care being delivered in communities around a primary care hub, it is thought the GP will be at the centre, supported by a multidisciplinary team and services provided by the third sector.
However, a crisis in GP recruitment, which has been frequently raised by the Royal College of General Practitioners (RCGP) and the British Medical Association (BMA) over the last few years, was recognised by Audit Scotland.
In its election manifesto, RCGP Scotland has called for an incentivised strategy to provide an extra 740 GPs by 2020 to meet demand, as family doctors retire or relocate, and practices struggle to recruit.
A BMA survey revealed 26 per cent of practices in Scotland had at least one GP vacancy, and of those, 41 per cent indicated that the post had been vacant for six months or longer.
The chair of BMA Scotland’s GP Committee, Dr Alan McDevitt, said: “It is not enough to talk about record numbers of GPs in Scotland when the vacancy rate shows that there are simply not enough doctors to meet the demands being put upon general practice.
“Every unfilled vacancy puts more and more strain on remaining GPs who must struggle to cover the gaps in their practice while also coping with rapidly increasing demands on GP services.”
The scale of change also needs to be adequately resourced, he added.
At the BMA’s recent Scottish conference of local medical committees, Health Secretary Shona Robison announced a £20m boost to general practice, including £11m to raise GP pay by one per cent, expenses by 1.5 per cent and money towards training.
Dr Miles Mack, chair of RCGP Scotland, said it represented “the beginnings of some positive action”.
He added: “It is a small but hopefully significant step in the right direction.”
McDevitt welcomed the measures for “immediate relief”, which also included IT systems, occupational health for GPs and support for backfill for maternity and paternity cover, but said it would not provide long-term answers.
The new GP contract, he said, would need to be properly resourced. “Ultimately, increased funding and staff are essential to secure the future of general practice.”
This was a point Holyrood put to First Minister Nicola Sturgeon as she visited Queen Margaret University to announce funding for medical school places for poorer students and £3m to train an additional 500 advanced nurse practitioners.
When the new recruits graduate, don’t they need a properly resourced primary care system to move into? With so much money pouring into firefighting in the acute sector, it is difficult to shift the primacy of funding, Sturgeon conceded.
“This is always something in any country that is easier to say than to do,” she told Holyrood. “But what we’re doing with social care right now, taking money from health to social care recognises that. We need to shift resources from acute care to primary and community care. That has to be done in a managed way that doesn’t destabilise acute care. That’s important.
“But is it more expensive to have community care? Arguably, no. The most expensive way you can provide healthcare is in hospital. You can deliver healthcare more cost-effectively and in a way that’s better for patients by doing more in the community.”
Presumably, though, primary care still needs more investment? “Absolutely,” Sturgeon agreed.
“This is one of the complexities of the health budget, and it’s reflected in the budget, it’s reflected in the workforce. Numbers and quantum is important but it’s also how you’re spending that money, and in terms of workforce, the mix of people who work in the health service.
“All of that is changing, radically, and we’ve got to make sure we’re in front of that change and trying to shape it rather than getting into a position where we’re responding to it and trying to catch up.”
Other seismic shifts in budgetary prevalence have gained political traction in recent years. Mental health has moved up the agenda, as well as a rising recognition of prevention as a way of focusing on health rather than disease.
A report by English think tank the King’s Fund this month suggested the separation between physical and mental health has had a high human cost, with the life expectancy for people with severe mental illness (such as bipolar disorder or schizophrenia) 15 to 20 years below that of the general population, largely as a result of physical health conditions.
Politicians have argued for ‘parity of esteem’ between mental and physical health, but Chris Naylor, Senior Fellow at the King’s Fund, said the report showed that was not enough.
“The [UK] government has set the goal of parity of esteem, meaning that mental healthcare should be ‘as good as’ physical healthcare. We argue that there is an even greater prize at stake – that mental healthcare should be delivered ‘as part of’ an integrated approach to health.”
Prevention was recognised by the Christie Commission in 2011 as the lynchpin of service reform and sustainability, but to say progress has been slow is an understatement.
The Scottish Parliament’s Finance Committee has been investigating why this might be the case, and responses to its call for evidence have been telling.
“Historically, the structure of the public sector has been more effective at reacting to social problems rather than by seeking to tackle their root causes,” said Aberdeenshire Community Planning Partnership.
Resource management rather than prevention has remained the key driver for change, the partnership told MSPs.
“It is recognised that there is widespread political support for prevention, however, political support for withdrawing or reducing vital acute services does not always exist, as these decisions are viewed as unpalatable.”
Cultural change “can take years”, the submission said. The next government will have five.
Indeed, taking money from acute care is not a narrative we’re likely to hear in the lead-up to the election. Not from the politicians, anyway.
Part of the shift into communities is supposed to be about consolidating highly specialist services into large centres of excellence, following the model of the Golden Jubilee Hospital in Clydebank. Centralising specialist services is not new in Scotland, but closures often tend to lead to political conflict, especially near to elections.
Before the official campaign had even begun, politicians clashed over leaked proposals to close Lightburn Hospital in Glasgow and consolidate or downgrade the children’s ward at St John’s hospital in Livingston.
NHS Lothian faced accusations of delaying the findings of the St John’s review being carried out by the Royal College of Paediatrics and Child Health until after the election because the findings were ‘politically sensitive’.
Documents released through a Freedom of Information request by Labour MSP Neil Findlay included a health board memo to senior managers which said: “The neutral stance could arguably be to have it available before purdah, it being seen as a political advantage to the SG [Scottish Government] to delay the publication.
“That said, if we stick to publishing post-election it will remain an attractive campaign issue for Neil in particular rather than AC and FH [Angela Constance and Fiona Hyslop, both SNP ministers with surrounding constituencies] – us in cahoots with SG. If we publish sooner, they are all drawn in and it also probably becomes a major local and media campaign.”
Closing hospitals is one thing, but the National Clinical Strategy suggests balancing the centralisation with an increase in smaller and rural hospitals and modern primary care hubs. Is anyone budgeting for those?
How much the future of health and care will be helped or hindered by the political debate leading up to the election remains to be seen.