A balanced breakfast: Holyrood's pre-election Q&A with the party health spokespeople
Scotland’s health service faces the challenge of an ageing and more sedentary population, increasingly with more complex long-term conditions.
Long-term strategies to tackle this include an increased focus on prevention and radical change in the future model of the health service itself. This will require more than the usual short-term, snap policy announcements associated with election campaigns.
Before the election mudslinging began in earnest, Holyrood held three separate breakfast question and answer sessions with the Health Secretary and the health spokespeople of the two parties vying to be her main challenger next term.
Targeting prevention- a roundtable discussion on public health
Scotland's NHS needs more than political consensus on health
John McTernan: when health is a personal responsibility
In partnership with the British Heart Foundation in Scotland, the events were designed as “a nice gentle opener to what will become a more adversarial election campaign,” according to the chair, Holyrood editor Mandy Rhodes.
The audience was made up of some of the most prominent voices in the health landscape, who asked some insightful and searching questions of our political representatives.
There was a sense across all three events that some form of political consensus has built up around health, with all three agreeing on the need for some bold decisions on public health and for health and social care integration to be successful in shifting the model of how care is delivered in Scotland.
Scottish Conservative deputy leader Jackson Carlaw said the various lobbying organisations – many of whom were present – had made it clear a non-partisan approach was needed.
“In terms of trying to agree how we go forward, this ‘ya-boo – we promised more than you did, we said we’d have shorter this than you did, we said we’d have more of them than you have, we said we’d invest more of that than you did, you said you would and didn’t’ – type politics, I mean, it has achieved absolutely nothing, actually,” he said.
While the approach may have once been successful in winning votes, he said, the public has since become aware of the pressures on health services.
“They can see the hugely ageing population; they understand the pressures that exist now. I think the public have come to be a bit less influenced by politicians who say ‘I’m the only person who knows what to do with health and everybody else is going to betray the health service’.
“I just don’t think they’re as receptive to that kind of rhetoric as they once were.”
Scottish Labour’s equality spokesperson, Jenny Marra, agreed there was a consensus on long-term strategy, but a balance had to be struck when a third of Scotland’s budget goes to the NHS.
“There has to be democratic accountability for that, which is our job and the role of parliament,” she said.
As well as being a service, the NHS is also “a huge bureaucracy”, said Marra, which constantly evolves.
“To do that is a constant process of change, and to achieve that politically, there has to be an element of consensus, and I think there is.”
The work on access to new medicines and development of the senior charge nurse programme were examples of where the parties had worked well together, according to Carlaw.
Surprisingly, Carlaw also paid tribute to former health secretary Alex Neil for having taken a collaborative approach.
“Alex did, unbeknown to most people, bring the political parties together privately with civil servants to seek to begin a discussion. I think he was a confident politician in his own mind and he was therefore able to do that. There’s been less of that since,” he said.
Neil’s successor, the current cabinet secretary, Shona Robison, said appointment to the role had been “a great honour”, having previously worked under Nicola Sturgeon when she had been health secretary.
On being appointed, Robison said she had felt a need to “accelerate the changes” after “quite a horrendous winter” which had led to long waiting times at A&E departments and delayed discharge.
“I just felt there was a lack of resilience. You could see two winters ago the NHS took longer than it should have to recover. Working with the Royal College of Emergency Medicine (RCEM), we worked out there were six things that needed to happen in every hospital to make a difference, so we really got stuck into that,” she said.
However, with the pressures on A&E comes pressure on government, with targets on waiting times failing to be met. Targets, by their very nature, are something the government is held to account over.
Robison said she was happy to discuss what targets were appropriate going forward.
“We want to measure the right things. There is more of a focus on outcomes. If the RCEM was sitting in the room they would tell you the four-hour A&E target isn’t just about what happens at the front door of the hospital, it’s a bit of a measure about how the whole hospital is working. To meet the four-hour target at the front door of the hospital, the back door of the hospital needs to be working efficiently,” she said.
Performance and outcome indicators aside, Carlaw said the Scottish Conservatives have resisted reacting to journalists who seek quotes on negative health stories.
“Increasingly, we’ve started to go back and say ‘no comment’. Go and have a look. You’ll actually see in what some call Tory-titled papers, where you might expect to see me quoted, I’m not, but somebody else has been,” he said, indicating other opposition parties.
However, Marra, too, said she had been more selective. “I tend to try and be quite picky about what we comment on and don’t, because there are legitimate stories and families, people in our communities who have had bad experiences.
“That can happen in any system, it can happen in the education system, but people need to be represented, they need us as their elected representatives to stand shoulder to shoulder with them when these things happen and speak this truth to power. That is our job.”
However, already this year hospital closures and other health board decisions have drawn the public eye, as the reshaping of the NHS takes place.
April 1 is the deadline for the new integrated health and social care boards to go live. Robison said it was “one of the biggest reforms” of the NHS since 1948. Some of the partnerships are further ahead than others in freeing up acute beds, she conceded.
Robison said she could name “the five areas of Scotland” which account for 65 per cent of delayed discharge.
“Take Glasgow. The relationship between Glasgow City Council and Greater Glasgow and Clyde Health Board was never one made in heaven, it’s not one I would have put up there as would have been one of the successes of integration, but my goodness, what a revelation now.
“They have managed to massively reduce the delayed discharge to over-75s to the extent they can name the people to me who were waiting to go home, because they were in single figures. Now, that’s an amazing thing in the city of Glasgow.
“Actually, they said one of the biggest things that made a difference was the empowerment of the frontline and operational staff to get on with the job and work with each other to solve the problems.”
Asked if health and social care regulation – currently done by the Care Inspectorate and the Healthcare Improvement Scotland – should also be merged, Robison said she had been “mulling it over”.
Audit Scotland has reported that the integration authorities are behind with their strategy and governance arrangements, but our opposition politicians were supportive.
“I don’t think it’s going as badly as some of us thought it might,” said Carlaw, remembering how many different voices had an interest in being represented in the decision-making process. Marra said the agenda was “definitely moving” and urged recognition of the complexity of the commissioning process.
“There’s two people in my family, my grandfather and my great aunt, both at home and receiving carers going in three or four times a day, and it is a highly complex and burdensome operation. Not just for them, but for the family a generation down. A lot of the burden falls on my mum, the stress that brings her,” she said.
She welcomed the Scottish Government’s move to bring the living wage agenda into social care. “Terms and conditions and training of care workers is paramount,” she said.
Robison said the shift of care into the community would be led by a new model of primary care, with funding following the new GP contract, which is being tested in Inverclyde.
“Every GP practice there, bar two, I think, signed up to this new model, so it’s not just about one practice there, it’s the whole area testing this new model which will inform [contract] negotiations.”
A multidisciplinary approach will be central, with the third sector “also critical”, she said.
“It’s about building that into the normal delivery of primary care community services. If we don’t do it as a mainstream way of delivering services, it’s always going to be an add-on initiative and we’ve got to try and move away from that.”
Health service delivery isn’t the only thing that must change, suggested Carlaw, who talked about the “responsibility agenda” around people’s sense of responsibility to the NHS and to their own health.
“My mother thinks the GP should visit her twice a week with a bouquet of flowers just to see if the house is clean. She is of a generation who has an unrealistic expectation,” he said.
People end up in A&E because they don’t think they will get a doctor’s appointment, he suggested.
“In Glasgow it’s becoming self-defeating, because we’ve told the public we’ve built the most magnificent hospital on the planet, that it has this fantastic concentration and degree of specialisation, so what does the average person sit and think if they don’t feel good? ‘That’s where I’d better go’.”
If people are to be aware and responsible for their own health, then more concentration needs to be put on the prevention agenda, the spokespeople agreed. Marra pointed out it has been five years since the Christie Commission recommended such a shift, but the spending hadn’t followed.
The next parliament session, she argued, could see a “real and radical” preventative agenda.
“There are advantages and disadvantages to a five-year parliament. It’s quite a long one. One of the key advantages is at the start of a five-year parliament, you’re far enough out from an election to explore some bolder ideas around an agenda,” she said.
Public health messages and campaigns don’t hit more deprived communities as effectively, argued Marra, and so government needs to intervene in the market in a similar way as Jack McConnell’s government did with the smoking ban.
“Jack didn’t tell people you can’t smoke. He said in this shared space, this public arena, the rules are smoking will not be allowed. There’s an opportunity to take that kind of approach,” she said.
Carlaw said he was resistant to falling into an era of more “socially driven health legislation” if it was seen as the “only golf club in the bag”.
“My late colleague David McLetchie famously once said if we’re not careful we’ll come to a point in Scotland where something is either compulsory or it’s banned, and there will be nothing in between. At times, it does begin to feel like that,” he said.
However, Carlaw did say he recognised the effectiveness of the smoking ban, even when some in his party had been against it.
“I can be conflicted by the knowledge not intervening or seeking to change attitudes simply means the NHS ends up picking up a huge otherwise avoidable bill, and a heck of a lot of people’s lives are fatally undermined as a consequence.”
He pointed to the Scottish Conservative policy of universal national health visiting up until the age of seven, and the fact they supported minimum unit pricing on alcohol, albeit with a ‘sunset clause’ to test its effectiveness.
In fact, Carlaw pointed out, apart from a member’s bill by Labour’s Richard Simpson, the Scottish Parliament hasn’t debated alcohol since.
“We haven’t reached the tipping point on alcohol,” said Marra. “It certainly has a massive impact on families. Alcohol misuse has had an impact on my family, I’m sure it’s had an impact on every one of your families, on every family in Scotland. We need to get to a public conversation, a tipping point on that.”
Sugar looks to be the next big challenge, with obesity and diabetes seen as major challenges for the health service. The British Heart Foundation has suggested the parties sign up to World Health Organisation guidelines on levels of sugar, fat and salt as a preventive measure for all non-communicable diseases.
Robison said the Government had learned from its experience with minimum unit pricing, which has been challenged in the courts by the drinks industry.
“Clearly we need a strong evidence base if we take strong action because we’re in the courts with minimum unit pricing and defending that from a position of a very strong evidence base, so we have to have the evidence,” she said.
The effectiveness of a sugar tax was questioned by all three of our political representatives, but it was clearly on the agenda.
Marra said she had tweeted a reaction to Public Health England’s recommendations for a sugar tax in November, and “that night I had Coca Cola asking to meet me. I took the meeting because they know the more this debate is in the public domain, the closer the tipping point on this, where legislators like me, Shona and Jackson will feel more emboldened.”
Marra also challenged the third sector to move their own focus and resources into prevention. She told the representatives in the room: “You think there should be a shift in resource at government level, and you’re absolutely right I do too, but I think the third sector need to make that case as well, and actually see the shift in your budgets, if I may be so bold.”