Home Health Policy

By Jennifer Dixon, London School of Hygiene & Tropical Medicine

Health and healthcare policy have been a matter for the separate administrations in Scotland, Wales and Northern Ireland since devolution in the late 1990s. While there have been many similarities in the policies the four UK countries since then, there have been some very high profile differences.

For example, developing competition between providers has been championed in England but rejected in Scotland, Wales and Northern Ireland. The split of purchasing from the provision of care was reversed in Scotland and Wales, but kept in England and Northern Ireland. And in Scotland and Wales prescription charges were scrapped, and free personal social care made more widely available in Scotland.

But what effect, if any, have these policy differences had on overall performance? To find out, we at the Health Foundation along with the Nuffield Trust commissioned researchers from the London School of Hygiene and Tropical Medicine and the London School of Economics to measure performance against 22 indicators, including mortality rates (avoidable deaths), life expectancy and ambulance response times. Drawing on largely publicly available data up to 2011-12, and in some instances 2012-13, the subsequent report revealed some interesting results.

Of the four nations, England performed marginally better in a number of areas including mortality rates, life expectancy and ambulance response times. However, nurse staffing levels were lower than in the other three countries. In Scotland, waiting times for planned surgery were down (similar to England) as were ambulance response times.

Wales on the other hand did not do as well when it came to waiting times, which have deteriorated since 2010, particularly for common procedures such as hip or knee operations. The difference between the typical waiting time for one of these procedures in Wales in 2012-13, for example, was 170 days compared to just 70 in England and Scotland.

Northern Ireland has improved on most indicators, but MRSA mortality rates still remain higher than in both England and Wales.

What this means and for whom

Four major messages come from what we found. The first is for the public. On the national indicators analysed, there were improvements across all four countries in investment, staffing levels, amount of activity provided and health outcomes. This is good news, although there is clearly a marked variation in performance within each country.

The second is for politicians. The main message here is that while the overall set of policies is producing results, no one policy cocktail consistently produces faster improvements over another, despite all the rhetoric.

This may be because there are many more similarities in policies than differences across all four nations. Or that where there are policy differences, they haven’t yet made enough of a difference to show up in the indicators. Some humility then is needed by politicians of all political stripes; how the health systems perform seems to be influenced far more by a bigger set of forces.

However, the data suggests that there may be two exceptions, both of which can be influenced by politicians. One of these is funding: the study period coincided with a large growth in public funding for healthcare, which can be associated with the improvements seen in performance. However, between 2010-11 and 2012-13, Wales saw a reduction in spending, potentially the reason for the lengthening of waiting times.

The second exception is targets and performance management. The data suggest that clear targets and strong performance management – as in the case of waiting times and rates of hospital acquired infection – produce results. This seems to be the case in Scotland, where waiting times on a range of indicators show marked improvement, particularly over the last five years. And part of the reason why, in Wales, performance against the less-stringent targets for waiting times has dipped since 2010, may not just be because of changes in funding, but because of less emphasis on the English-style tight performance management.

This isn’t a message for politicians to let rip with a vast number of targets and go for a heavy grip. Too many targets demoralise staff, cause collateral damage (other local priorities pushed aside) and can lead to stressed staff altering the figures.

The third major message in the report is for local staff: the managers, nurses and doctors. More than anything, it looks as though performance of the health system is down to you. Our study looked closely at the performance of one region in England (the north-east) relative to Scotland, Wales and Northern Ireland, because it was more similar on a number of characteristics than England as a whole. In the north east of England, a combination of faster funding growth, plus local conditions, seem to have produced the most marked reduction in mortality over the last two decades.

The fourth message is for the treasury. Probably due, in part, to devolution, it is becoming harder to compare data across the four countries over time, as all four countries decide to define data differently. If achieving value for money in public services is an objective of the treasury, isn’t it time to exert some leverage to expect all four countries to collect and count data in the same way, as well as do it their own way?

The issue that looms large is the impact of large scale reforms of the health system of the type we have seen in England, with the implantation of the Health & Social Care Act. Received wisdom is that the disruption it has caused will produce a dent in the trend for improvement in England relative to the other UK countries. But we’ll have to wait for the next instalment of the study to find out.

The Conversation

Jennifer Dixon is Chief Executive of the Healthcare Foundation charity. She is also She is also a trustee of NatCen Social Research and a member of the Care Quality Commission (CQC) board.

This article was originally published on The Conversation.
Read the original article.

Green space more essential to women

Women living in deprived areas with little green space are more likely to be stressed than men living in the same circumstances. Research published in an international journal on public health shows that there are significant gender differences in stress patterns by levels of green space. Women in lower green space areas show higher overall levels of stress, according to the research, led by OPENspace research centre at the Universities of Edinburgh and Heriot-Watt. The same does not appear to be true of men living in the same areas; an anomaly which the study suggests requires further investigation.

Those in deprived areas suffer the most

Those in deprived areas suffer the most

Researchers looked specifically at the concentration of cortisol, the stress hormone, in men and women living in deprived urban areas in Scotland. They then looked at people’s perception of their stress levels and measured the relationship between gender and percentage of green space on mean cortisol concentrations. They found there was a positive effect of higher green space on women, but not in men.

The effects of contact with green space and a lowering of stress levels is thought to be associated with factors including increased physical activity which improves mood; increased social contact and better mental wellbeing. Contact with nature has also been shown to have positive effects on blood pressure and heart rate. However, most studies which have measured cortisol levels in relation to contact with nature have focused only on the levels immediately before and after contact with nature. This new study measured patterns in people’s daily lives

It concludes:

    in both men and women, perceived stress was higher in low green space areas, but women’s perceived stress was significantly higher in low green space areas than men’s
    perceived stress was higher for people with no garden, especially men

    both men and women living in deprived areas with higher levels of green space report less perceived stress and appear to be more resilient to the negative effects of urban deprivation

Dr Jenny Roe Heriot Watt University

Dr Jenny Roe
Heriot Watt University

Speaking on behalf of the research team, lead author Dr Jenny Roe from Heriot Watt University pointed out that the results were “important in understanding how neighbourhood green space might contribute to public health improvement. Stress is known to impact on cardiovascular health, alongside other risk factors such as genetics, age, diet and physical activity, but little is known about the contributions of environmental factors. We already know that higher levels of green space are associated with reduced cardio-vascular mortality. Our new study indicates that neighbourhood green space is associated with perceptions of stress as well as the levels of stress hormones in the body and this may be a pathway by which the environment can impact health. While we need more research to understand these mechanisms, our study represents a valuable step in establishing a biological pathway linking green space with stress levels in deprived urban environments.”

The research was carried out in collaboration with the Universities of Glasgow and Westminster, Biomathematics and Statistics Scotland and the James Hutton Institute.

By John Knox
It is one small step, when what is required is a giant leap. The SNP government’s Adult Health and Social Care Integration Bill does little more than set in moonstone what is already happening. Scotland’s 36 Community Health Partnerships are to be re-branded as Health and Social Care Partnerships when what is needed is a full integration of the NHS with local councils.

Community Health Partnerships were formed in 2004 in response to the bed-blocking crisis when elderly patients were stuck in hospital for up to six weeks because there were no places for them in nursing homes or care services in their own homes. The 14 local health boards were urged to work with the 32 local authorities to try to solve the problem -costing up to £50m a year – and bed-blocking has indeed become much less of an issue.

Since then, the CHPs have gone on to form permanent teams of doctors, community nurses, care workers, social workers and housing officials to try to integrate the care given to older people and prevent them landing up as emergency cases in hospital. In a report last year, Audit Scotland found that such partnerships now manage £3.2 billion of health and social care, over a quarter of the total health budget. They employ 28,500 health staff and 5,300 social care staff.

Audit Scotland did not question the overall strategy of local care but it did conclude that “there is now a cluttered partnership landscape” which has resulted in duplication and a lack of clarity about how the money is being spent and what the objectives really are.

The new bill will, no doubt, address these complaints. It will also “strengthen the role of clinicians and care professional, along with third and independent sectors, in the planning and delivery of services.” We await details of what exactly all this means.

But one thing it will undoubtedly mean is that there will be less work for local health boards to do. In fact, it seems to me, they will just get in the way and we would be better abolishing them altogether. The think-tank Reform Scotland has already proposed such a move, pointing out that a local authority health and social care system works well in Scandinavian countries.

Afterall, most other public services are provided by our local councils…schools, public health, social work, environmental services and, until the SNP came along, police and fire protection. It makes sense to me to integrate health and social care with this total package of services, so that we don’t have public agencies tripping over each other to solve problems and provide an efficient local infrastructure to our lives.

Integration would also mean that councils could get a grip of spiralling health costs and do so in a democratic fashion. We are facing a huge increase in the number of older people – a 12 per cent rise in the next five years to nearly one million, and an 18 per cent rise in the number of over-85s – all of them demanding increasingly expensive treatments. At some point, the politicians will have to say “No” and that rationing is best done at a local level where the trade-offs are more obvious and the politicians are more accountable.

Where would this leave our hospitals and other specialist services? It makes sense to have these remain in a small number of “hubs”. Councils immediately around them would need to co-operate in using their services. But each hospital or service could be run by its own manager or managing committee, without the superstructure of a health board. Councils, under this system, would contribute to their nearest hospital in proportion to how much they use them – an incentive to keep hospital stays down to a minimum, which is best for everyone concerned….. especially the patients and the taxpayers.

In many ways, this is to turn the NHS up-side down. But it is what many people are now calling for. The health service would be bottom-up rather than top-down, it would abolish one layer of administration, it would be centred on prevention rather than cure and it would be holistic not just clinical. It would do what the title of the government’s bill aspires to do….integrate health and social care.

– John Knox is a political writer and former BBC political journalist and Parliamentary commentator.

The NHS portrayed at the Olympic opening ceremony Picture: Shimelle Laine

Children’s literature and the NHS – Danny Boyle could hardly have come up with a better wheeze to capture my interest (unless he’d thrown in some greyhounds).

Westminster health secretary Andrew Lansley might not have much liked being represented by Voldemort (or possibly worse, a Voldemort puppet), but the message – hands off our NHS – came out pretty loud and clear.

The sequence annoyed many right-wing commentators – writing in the Daily Mail, Melanie Phillips said it seemed “a piece of gratuitous political propaganda”, while American talk show host Rush Limbaugh called it “honouring socialism and collectivism”. (He said this as though it was A Bad Thing, by the way.)

Limbaugh also suggested that Boyle (“a leftist”) had included the NHS to help Barack Obama in his quest to provide universal healthcare in the US. Loth as I am to admit to sharing an opinion with this particular shock jock, the same thought did cross my mind when watching the ceremony.

Because, in my view at least, the event was littered with messages to the rest of the world – couched in the self-deprecation for which Boyle’s vision has been rightly praised. Some of Britain’s most internationally recognisable symbols were celebrated, from the traditional (Shakespeare and Peter Pan) to Harry Potter and Mr Bean. Including the NHS in this celebration was a clear indication that Britain’s “socialised healthcare”, as the US would have it, is another thing we’d love to export.

But there were also messages for the home audience; surely it was no coincidence that the nurses and patients were beset on all sides by some of the scarier characters from children’s fiction. The Child Catcher from Chitty Chitty Bang Bang, Alice’s Adventures in Wonderland’s Queen of Hearts and Cruella De Vil – best known for being mean to dalmatians – were some that I recognised, although I couldn’t place the scary hairy creatures.

It really isn’t too much of a stretch to read into that a warning that the NHS as we know it – in England at least – is also under threat, in this case from increasing privatisation which was introduced by the previous Labour governments, then gleefully accelerated by the current Tory/Lib Dem coalition.

But what did Americans make of the NHS chapter? While researching this article (OK, I admit it, I didn’t know how to spell Limbaugh), I found an article written on the politics.co.uk site by American Cassie Cambers. She whimsically imagines how the scene would transpose itself “across the pond”, saying that insurance agents would pluck the children from their beds as they decided “to retroactively deny care” while a clock in the middle would show the highest healthcare costs in the world adding up as the scene unfolded.

Is this what we want? (I can’t believe it’s what America wants, but there you go.) Or do we want to keep – and, indeed, celebrate – a health service which is universal, free at the point of delivery and where high-quality care doesn’t, for the most part, depend on how much money you have?

Despite the horror in the Danny Boyle scene, there was a happy ending: Voldemort and his evil companions were defeated by Mary Poppins, who literally parachuted in to save the day. I wish I could be sure there will be similar salvation for the English NHS, let alone American healthcare. That really would deserve a gold medal.

Scalpel on a bloody hand

Who is wielding the scalpel? Picture: Jason Rogers

What’s in a name? Shakespeare might have it that a rose by any other name would smell as sweet, but the Royal College of Surgeons of England doesn’t quite agree.

At the weekend, the college issued a call for the job title “surgeon” to be protected so that only those who have qualified as a medical doctor and undertaken post-graduate surgical training can use the name. “Public support for this is clear, with 92 per cent of respondents agreeing that the job title should be restricted by law,” the college says.

I must say that when I heard this story, I thought that the surgeons were getting snippy about use of the word “surgeon” generally – and for me, it was “tree surgeons” who first came to mind. Frankly, I thought it was a bit off that doctor surgeons were being snippy about this particular branch (no pun intended) of practice, as it’s absolutely clear – or should be – that tree surgeons and human surgeons are dealing in completely different areas.

Then I thought about dental surgeons, and veterinary surgeons, neither of whom are obliged to be “qualified as a medical doctor”, but have surely been using the name for long enough. (The RCS itself first started giving a Licence in Dental Surgery in 1860 and veterinary practice became a profession distinguished by the title “veterinary surgeon” in 1844, according to the Royal College of Veterinary Surgeons.)

A bit further down in the RCS press release, however, and it’s clear who is actually getting the surgeons’ goats. They’re upset that the NHS and private sectors are employing people called surgeons – specifically “podiatric surgeons” and “aesthetic surgeons”. “Podiatric surgeons have not completed a medical degree but have instead trained only in the surgical and non-surgical treatment of the foot which leaves them unable to treat the patients as a whole,” the college says. “An aesthetic surgeon may not have a medical degree and may not have undertaken specialist surgical training.” College president Norman Williams adds: “It is extremely worrying that in the health sector clarity regarding job titles is lacking.”

On this point, I couldn’t agree more. Trying to keep up with job titles in the NHS is a minefield, and doctors are among the worst offenders. Titles of junior doctors, or doctors in training (as some prefer to be called) are particularly confusing. A few years ago the terms “junior house officer” and “senior house officer”, usually shortened to JHO and SHO, were replaced when training was changed under the Modernising Medical Careers (MMC) initiative. The most junior of junior doctors are now called Foundation (Year) One or Two (FY1/FY2, or sometimes F1 and F2). Further up the scale, the doctors previously known as specialist registrars (SpRs) are now STs (Specialty Trainees) – although, even more confusingly, there are still some SpRs around who were on the old training scheme. Add to the mix various other titles (staff grade, associate specialist, specialty doctor, trust doctor and so on) and it’s easy to see where people can get muddled.

And health service staff themselves don’t help. A couple of years ago an otherwise very nice young lad (I know, I’m getting old) introduced himself to me (wearing my patient’s relative hat) as “I’m Tom, I’m the FY2”. As it happened, I did know what that meant, but I do write about these things a lot, so am a bit more exposed to it than most. On the other hand, a friend of mine (attending a rather stressful day of tests) was brusquely asked if she’d “seen the registrar”. She was nonplussed: as far as she knew a registrar was someone who worked in a registry office.

Surgeons too (the medical variety, the ones the college is trying to protect) arguably don’t help themselves. Once they pass their college membership exams (usually a few years after graduating with a medical degree), they stop calling themselves Dr and instead revert to Mr, Mrs, Miss etc. This dates back to the days when surgeons completed an apprenticeship, rather than medical training, before taking on the role – using the title is a sort of inverted snobbery which is often seen as a way of expressing superiority over mere physicians. Even more discombobulating, obstetricians and gynaecologists in England also go with Mrs/Mr/Miss, while those in Scotland stick with Dr.

If anything, surely this is even more confusing to patients. Some surgeons, particularly younger ones, actually call themselves Dr for that very reason, and there have been moves (notably in Australia) to get rid of the titular discrepancy in its entirety.

So what of podiatric and aesthetic surgeons (so-called); are they entitled to use the title? Etymology doesn’t help – “surgeon” (via old French, Latin and Greek) basically means someone who works with their hands. So that’s pretty much everyone then. Even in the narrower, more modern understanding of the word, yes, they do perform surgery, in that they are cutting into skin, flesh and even sometimes bone to try to improve the health, wellbeing or appearance of the patient. Certainly the Society of Chiropodists and Podiatrists is coming out fighting, pointing out that podiatric surgeons undergo some 11 years of “rigorous training”. “The issue of titles lies more with the understanding within the general public of roles within healthcare in general,” a spokesman adds.

Perhaps if medical surgeons want to help ease the confusion they could take steps themselves: first, stop calling themselves Mr/Mrs/Miss (okay, not usually all three at the same time) and stick with Dr (bearing in mind that it’s an honorary title anyway, unless they’ve actually gained a doctorate such as an MD or PhD on top of their MBChB, but that’s a whole other issue); second, lobby government and various other accreditation bodies to ask for a more simplified way of describing medics in their different stages of training; and third, if other professions insist on adopting the job title which was traditionally theirs, they could go for a new one of their own – one with just as venerable overtones, with an equally colourful history.

Yes, perhaps they should jettison “surgeon” and replace it with “sawbones”. Then we’d all know where we were. And the RCS wouldn’t even have to change its initials.

It's a date: do we still love the NHS now it's 64?

Last month I was at an absolutely fantastic wedding where one of the readings – along with The Owl and the Pussycat – was The Beatles’ When I’m Sixty-Four. It was the first time I’d properly listened to the words, possibly because the chap reading it sounded so plaintive when he asked “Will you still need me, will you still feed me?” with particular stress on the “feed”.

At that point I hadn’t clocked the significance for the NHS (why would I?). But it came to mind again on Sunday when I turned my desk calendar (courtesy of RCN Scotland) over to July. There was a picture of the Fab Four and a quotation from the song, and a bit of cheery copy pointing out that the NHS celebrates its 64th birthday this year, on 5 July.

The Paul McCartney song has often been invoked by campaigners questioning whether older people get a good or a raw deal from various institutions, including the NHS. Parodies abound – including this recent version which questions whether free healthcare will survive the English NHS health reforms.

But now that the NHS is 64 – or will be tomorrow – should we be looking at how the lyrics apply to the health service itself? Are we still sending it a Valentine? Birthday greetings? Bottle of wine? (OK, maybe not the wine.) Or are we about to lock the door against it?

To take the Valentine question first, it’s actually quite hard to say. When you speak to people about the NHS, it’s almost fashionable to knock it (unless you’re talking to Americans in which case it’s nationally obligatory to say how marvellous it is). People will often say how awful the NHS is, and how so-and-so had a dreadfully long wait for an operation, although if you ask the same people about their own GP practice, or about their own local hospital, it’s generally a far more positive story. But enough of anecdote, what do the statistics indicate?

Last month the King’s Fund published data from the British Social Attitudes Survey, which has tracked public attitudes about key areas of public policy since 1983. The figures show that satisfaction with the NHS fell significantly from 70 per cent in 2010 to 58 per cent in 2011. This drop was all the more startling because it followed years of almost continuous annual improvements in public satisfaction since 2001.

In a blog on the King’s Fund website, chief economist John Appleby points out that the survey was taken at a time when there was a polarised and heated debate taking place on the Westminster government’s proposed health reforms. “Reports of opposition to the reforms were high profile,” he writes, “and, regardless of the merits of arguments on both sides, will have no doubt contributed, at a minimum, to a climate of uncertainty in the public’s minds about the NHS and its future.”

He adds that cost-cutting is probably adding to public discontent about the future of the NHS, not necessarily how it’s performing now – “which sees its expression in lower levels of satisfaction”.

The British Social Attitudes Survey, of a necessity, has an English bias in terms of population size – and, of course, the health reforms promoted by Andrew Lansley will not be implemented in Scotland (although whether they will affect health services north of the border is another question). So what are satisfaction levels like at a more local, Scottish level?

Patients in Scotland are increasingly being asked their opinions about health services and the results tend to be pretty good. For example, the 2011/12 Scottish Patient Experience Survey of GP and Local NHS Services (completed by 145,569 respondents) shows that at least 90 per cent of patients responded positively about their experience of consultation with doctors or nurses, although they were slightly less positive about access to GP services.

Lest we get too smug, however, and think the results show things are much better in Scotland, it should be remembered that English practices also score highly in patient experience surveys, again with around 90 per cent of those in England, Wales and Northern Ireland being positive about the care provided. Even more salutary are the findings from the Scottish Attitudes Survey, which in 2011 found that just 56 per cent (2 per cent below the British figure) were “very, or quite satisfied with the way the NHS runs nowadays”.

That’s still more than half – so, on balance, I reckon we are still sending the NHS a Valentine, although maybe a last-minute one bought from a garage, as we’re not quite as much in love with it as we were a couple of years ago. But what about the central question – now that the NHS is older (whether or not it’s losing its hair) do we still need it? Or should we be replacing it with a younger model – perhaps a model which makes more use of private providers?

I’m very certain in my own mind about the answer to this, but actually it’s probably fair to say that we don’t yet have the evidence to show which healthcare system is best. Yes, there are numerous UK and international reports which seek to compare health systems, but all have their flaws, not least because getting data which compares like with like is nigh on impossible, at least at the moment. And there’s the issue about what we actually value in a health service – broadly the UK system tends to perform well on measures such as universal access, but less well on survival rates from cancer.

There’s also the question about whether there is, in fact, a UK health service. I’m inclined to think there isn’t. Yes, all four countries have a broadly similar publicly funded service, generally free at the point of delivery, but they are diverging, and it’s getting to the point where comparing England with the rest of the UK is a bit like comparing biscuits and apples: they’re both foodstuffs, but that’s about it.

These growing differences should mean that objective judgement on how well each type of system performs ought to be easier to come by. Last week’s report from the National Audit Office comparing healthcare systems across the UK should be a good start – although, again, it was hampered by a lack of comparable data.

Then there’s the question of whether we’re still prepared to “feed” the NHS – that is, give it enough resource – as it turns 64. All UK governments say they’re protecting health spending, but that’s in relative terms; at a time when all public budgets are tightening, the ever-hungry health service certainly has no need to loosen its belt.

I really hope that we will answer the NHS in the affirmative, should it ask us The Beatles’ question. At the weekend I once again had reason to feel pleased that the health service is there, doing its bit to keep one of my loved ones on the road. Yes, it’s not perfect and – like most others its age, has its creaky bits – but I hope we recognise that we do need this particular 64-year-old. And I sincerely hope we continue to feed it, too.

'Be upfront' about money issues in the NHS, warns Theresa Fyffe

By Theresa Fyffe

We all know that money is one of the main causes of relationship breakdown and I’m sure the same level of disagreement happens in the Scottish Cabinet each year when the draft budget is discussed.

Yet funding for health has emerged relatively unscathed, while the overall budget for Scotland has shrunk. This is partly thanks to Nicola Sturgeon and partly realpolitik. What politician, after all, would wish to go against the public which holds our NHS so dear?

But as this week’s report by the Scottish Parliament’s Health and Sport Committee makes clear, there are concerns as to how the health budget of £11bn is actually spent.

And when politicians use phrases such as “may conceal underlying financial problems”, “glacially slow” and “the committee reserves the right to be sceptical”, then you know there are issues which need to be addressed. In relationship terms, it would be time for counselling; some thorough check-ups are needed for our health budget – and that’s just what the health committee will be delivering in a year’s time as it builds on this week’s report.

Among the biggest issues identified by the committee in its current report, problem number one is how do we take account of the impact of financial decisions on the quality of patient care? When demand is growing and the budget is at a standstill, this is something that must be tackled. Targets may be met by health boards, but that doesn’t mean patient needs are being met.

What happened with waiting times in NHS Lothian is one – albeit extreme – example, but how can we be assured that the health budget is delivering high-quality services that meet the needs of patients and our wider society? One answer is the government’s quality strategy, but with almost a third of the total Scottish budget being spent on our health services, the members of the health committee need to find meaningful ways of reassuring themselves – and the public – that the government and health boards have got the right balance between money and quality services.

Problem number two identified by the health committee concerns every politician’s favourite subject – preventative spend.  While universally acknowledged as good for patients and the public, preventative spend might not actually save money for the public purse. And even if there are savings to be made, these may well appear in another budget, not the one which funded them in the first place. So claims for savings from preventative spend programmes certainly need to be looked at more widely to make sure that plans to invest now to prevent health or social issues arising in the future is money well spent.

Next up, problem number three. While much of the rest of the public sector can only dream of the “protection” of its budget in these tough economic times, the committee asks the question “are the levels of health spending adequate?”. Or, to put it another way, is it enough to pay for the services that people need? This may raise some eyebrows, but given increasing demand, due to Scotland’s growing – and ageing – population, it is a very legitimate point. And as new services – for example, the Scotland-wide abdominal aortic aneurism programme – are introduced, which boards are expected to fund, how can the wider financial implications be assessed?

And so to problem four. Are efficiency savings, for example, just cuts by another name? Indeed, are non-recurring savings actually concealing “underlying financial problems”? This is something we have consistently highlighted, so we’re pleased the health committee is going to look into this in more detail the next time the budget is in its in-tray. We are concerned that health boards have been cutting their workforce to make short-term savings, badged as efficiencies, but which may impact patient care. Is this really what the public wants of its NHS?

The fifth problem raises questions about successive Scottish governments’ attempts to treat people at, or as close to, home as possible. Progress on this long-standing priority to shift funds and services from hospitals to communities has been, in the words of the committee “glacially slow”.

In our own work on NHS funding, we have found that getting up-to-date financial information from health boards can be challenging and have been arguing for greater transparency for some time. As demand grows and budgets, at best, stand still, it is clear some difficult decisions about the future provision of services will have to be made if financial and political harmony are to be maintained.

In any relationship, choices have to be made. And the only way that the NHS can avoid a breakdown and have a long and successful future is by bringing the public, patients, staff and indeed, politicians, with it when it makes those tough choices.

So three cheers for the parliament’s health committee for starting the debate on these crucial issues now about what the future holds for Scotland’s NHS. For as we all know, it’s much better to discuss money issues up front, rather than put it off until later.

Theresa Fyffe is director of RCN Scotland.

Nicola Sturgeon (right): Blanket coverage for 'disastrous week'

Trying to catch up with press releases and emails after a week away has suddenly become a lot easier, thanks to Scottish Labour. Handily on Sunday (perhaps a name for a weekly DIY mag?) the party’s press machine whirred into action with a summary of all that had been “disastrous” in health the previous week.

The charge sheet was impressive: a failure to get a handle on “blanket-gate”, with the shortage apparently now having hit kids’ covers; critical staffing levels at Scotland’s specialist paediatric cardiac unit; a care homes drugs scandal; norovirus outbreaks closing 20 hospital wards – and, as Labour puts it, “continuing questions over the SNP’s hidden waiting lists”.

It’s almost too much for the brain to take in – a bit like being told there’s a choice of 10 puddings, most of which you really, really like, and only being allowed to sample one.

But, from the sweet spread on offer, I’m plumping for the “continuing questions” over hidden waiting times. To be fair, the main reason that the subject was raised last week was a debate led by Labour’s own health spokeswoman Jackie Baillie in the Scottish Parliament on Thursday morning – which rather begs the question of whether you can legitimately refer to the questioning continuing when you are, in fact, the questioner. But leaving that to one side, does Ms Baillie have a point? And, assuming she does, and questions are continuing, will any of this stick to the health secretary?

To recap, NHS Lothian has been manipulating waiting lists and has been found out. Health secretary Nicola Sturgeon says the problem is confined to Lothian (whose chief executive coincidentally resigned, ahead of a report which found the board bowed by a bullying management culture); Labour says it’s more widespread than that.

Specifically, Ms Baillie says that numbers of patients removed from the waiting time guarantee are up three-fold in NHS Ayrshire & Arran and NHS Fife; four-fold in NHS Greater Glasgow and Clyde and NHS Lanarkshire; and a stonking five-fold in NHS Grampian. That sounds like quite a lot, really, and would seem to back Audit Scotland’s point that “there is evidence pointing to an inappropriate use of this code”.

We’ll have to wait until the autumn for Audit Scotland’s own report into the management of waiting times to find out if the practices at NHS Lothian were more widespread. But even if they are, is it fair for Labour to label it the “SNP’s hidden waiting lists”?

Health boards – and trusts previously – have long been creative, shall we say, about meeting centrally set targets; this was the case before devolution, was the case under successive Labour/Lib Dem administrations, and is likely still the case under the current regime. The golden rule is generally that if one lot is doing something, others may be too.

I’m reminded of financial troubles in Tayside over a decade ago, where it turned out that NHS bodies had been using various strategies, including spending non-recurring money (eg one-off cash from selling off assets) to meet financial break-even which, at the time, was the priority national target. There were other problems too – including a lack of effective oversight and communication from the (Labour-led) centre, but it was the use of non-recurring funding, or the criticism thereof, which caused consternation elsewhere in Scotland. At the time, I remember receiving regular calls on behalf of more than one NHS senior manager clearly concerned lest the net would spread wider and more heads would roll.

The use of non-recurring funding to mask deficits has virtually faded now as an issue, but for years was a major point in Audit Scotland’s valuable annual overviews of the NHS in Scotland – and, believe me, it wasn’t confined to one health board area. Nonetheless, I don’t recall its being called “Labour’s selling off hospitals to pay the wages bill” scandal and I’m not sure it would have been fair if it had.

So will Labour’s current accusations stick? Can we legitimately blame Ms Sturgeon for what’s been going on in Lothian, certainly, and possibly elsewhere too? The answer is probably a bit of yes and a bit of no. Financial matters and accountability have rightly been tightened up massively since 2001, partially due to the Tayside troubles. Also, since the abolition of trusts (again under Labour), there is less mud-slinging between contractors and commissioners, basically because they are all part of the same bodies – NHS boards – now.

In the last dozen or so years, however, we’ve also seen nationally set targets for the health service proliferate and strengthen. Successive administrations have set successively tougher goals in a variety of areas from healthcare-associated infections to, erm, waiting times. The current target – that nobody with a waiting time guarantee should wait more than 18 weeks from referral to treatment – is particularly stretching; it essentially means that patients have to be seen and treated in a fraction of the time than just 10 years ago.

Lest we forget, former health minister Susan Deacon’s Our National Health, published in 2000, set a maximum waiting time of nine months for treatment by 2003 (down from 12 months previously), but that only kicked in once you’d had your first outpatient appointment; 18 weeks referral to treatment is a huge, huge improvement.

It’s also a huge undertaking, particularly when budgets are tight. Financial constraint may well be an incentive to do things differently, as Ms Sturgeon and others have said, but it can also prompt creative thinking of the type sadly seen at NHS Lothian. Presumably none of the staff wanted to make patients wait longer than necessary, but manipulating lists to meet targets became the Lothian way.

Arguably, then, by setting ever-tougher targets, at the same time as squeezing budgets, Ms Sturgeon has some responsibility for managers’ unfortunate inventiveness – but does that really mean that it’s the “SNP’s hidden waiting list”? Probably no more than the old Tayside troubles, or, indeed, previous waiting times problems (deferred list, anyone?) were “Labour’s NHS scandals”.

Let’s just pop back to 2002 for a moment and hear from John Swinney: “A culture has been created that forces hospitals to use every dodge in the book to get their waiting lists figures down and responsibility for this lies squarely at Labour’s door.” None of this would have come to light if the SNP had not ceaselessly pursued Labour over waiting lists,” added the then SNP leader.

Perhaps, then, Ms Baillie and Labour are only getting their own back with today’s inflammatory words. But wouldn’t it be grand if political parties, instead of name-calling and blaming, actually worked together to create a culture which puts patients first? Now that would be a pud worth having.

Dr Lewis Morrison Picture: BMA Scotland

By Lewis Morrison

This is a historic week for the medical profession as the British Medical Association (BMA) ballots doctors on industrial action. We are taking this unprecedented step in protest against planned UK Government reforms to the NHS pension scheme, which will result in NHS staff working longer and paying more into their pensions.

These reforms have not been negotiated, nor have they been agreed. They are being imposed upon NHS workers and, despite our best efforts, the Government will not enter into negotiations.

In its efforts to convince the public that what the Government is doing is correct, the Treasury says that all public sector pensions are now unaffordable and in need of significant reform. But not all public sector pensions are the same and these arguments cannot be levelled at the NHS pension scheme – which has recently undergone significant reform and which has been shown to be affordable and sustainable for the future. These changes are unnecessary and unfair.

Unnecessary because the NHS pension scheme was extensively reformed in 2008, and far from being in deficit provides a positive cashflow to the Treasury of around £2 billion a year. In 2008, the BMA agreed to a tiered contribution scheme where those who earned more paid more in contributions. We also agreed to an increase in the normal retirement age to 65 – and, perhaps most importantly, we agreed a cost-sharing arrangement where any future cost increases in the scheme would be met by pension scheme members, not by the NHS or the taxpayer.

On any reasonable test, the current coalition Government proposals are blatantly unfair. The reforms mean that all public sector employee contributions could rise by 6 per cent over the next three years regardless of where each employee group started. So, senior civil servants paying as little as 1.5 per cent will see contributions rise to about 7.5 per cent of salary, while senior NHS workers on the same income will have to pay 14.5 per cent. This is totally unreasonable.

These increases are nothing to do with the “improvement” of the NHS pension, but are a tax on public sector workers to fund the deficit of the Treasury, caused by mismanagement of the banking industry.

That doctors are considering industrial action is a reflection of just how angry they are at these reforms – but we want to be clear that our argument is with the Government, not with our patients. To that end, the form of industrial action we are proposing is based on an overriding commitment to patient safety. All emergency care or other care urgently needed would be provided, with doctors attending their place of work as usual. If someone urgently needed care, it would be provided.

However, services that could safely be postponed would not be undertaken on the day. In hospitals, this would mean that some non-urgent procedures and outpatient appointments are postponed. GP surgeries would not offer advance-booked appointments, but would be open and fully staffed so that they could see patients in need of urgent attention who turn up on the day.

The BMA hopes to work with NHS managers at a local level to plan for the industrial action, to ensure that patients are aware of the reduced services on the day and have as much notice as possible of any inconvenience or cancellation of appointments.

There is, of course a Scottish dimension – and while devolution has offered us opportunities to do things differently in Scotland, this is not necessarily the case when it comes to NHS pensions. The Scottish Government runs the NHS pension scheme north of the border and has told its NHS staff that while accepting the need for public sector pension reform, it has followed the Treasury lead of increasing employee contributions under the cosh of a pound-for-pound deduction from the Scottish block grant if it deviates.

Ultimately there is little scope for deviation from the UK proposals, particularly as the UK Government intends to legislate on its pension reforms and these will apply in Scotland.

Industrial action by doctors has always been a last resort. This Government, however, has left us no option other than to proceed with the first ballot of the profession since the 1970s. The solution is in their hands.

Dr Lewis Morrison is a member of the BMA Scottish Council and chairman of the BMA’s Scottish Consultants Committee.

Burning cigarette

Picture: Super Fantastic

By Sheila Duffy
Chief Executive of ASH Scotland

Scotland has long suffered jokes about the health record of its citizens, and laboured under the “sick man of Europe” tag. Tobacco is the single largest contributor to that problem, with smoking implicated in one in four deaths in this country and with a greater impact on mortality than social class.

Yet Scotland is fighting back, and successive Scottish administrations have tackled the issue head-on, implementing world-leading public health policies to address the problem of tobacco. Perhaps the high-point in this work so far came with the introduction of smoke-free public places in advance of the rest of the UK. Smoking rates have halved from 47 per cent in 1972 to 24 per cent now, and the success of tobacco control efforts was highlighted recently with the publication of figures showing the lowest rates of youth smoking since records began in the mid 1980s.

Sadly not everyone welcomes this progress. The powerful tobacco industry has fought these public health measures every inch of the way – and their lies, trickery and legal challenges risk turning Scotland from leader to laggard in tobacco control.

This week, on Wednesday 16 May, tobacco industry lawyers will once again appear in the Scottish courts to oppose public health legislation. This time it is the ban on cigarette vending machines, passed overwhelmingly by the Scottish Parliament back in 2010. Such vending machines, implicated in young people accessing cigarettes, have already disappeared in England. Large, bright tobacco displays have now been removed from English supermarkets. The laws to do the same in Scotland have twice been upheld by the courts, but a quirk in the Scottish legal system allows a final appeal to the UK Supreme Court and of course the industry lawyers are fighting it to the last.

Most recently, a joint UK and Scottish Government consultation on requiring tobacco to be sold in plain packaging has been met with a furious industry response, and many of their familiar tactics. The industry has funded “grassroots” opposition, saturated retail sector media with scare-mongering stories and threatened further legal action.

Tobacco industry opposition to public health measures is a global problem, with legal challenges to public health measures underway from Australia to Uruguay. Yet there is also a global mechanism to respond. The Framework Convention on Tobacco Control (FCTC) is the first international public health treaty. Brokered by the World Health Organisation 174 governments are parties to the FCTC, representing 90 per cent of the world’s population.

As a signatory to the FCTC the UK, and hence the Scottish Government, is required to protect public health from the vested interests of the tobacco industry. Article 5.3 of the Framework Convention recognises the “irreconcilable conflict” between public health and tobacco industry interests and requires governments to engage with the industry only so far as is absolutely necessary to organise effective regulation.

Here is an ideal opportunity for the Scottish Government to regain the initiative. Scottish ministers already keep tobacco industry representatives at some distance, but committing to fully implement Article 5.3 means agreeing to full transparency in all contacts with the industry, and also with those such as lawyers, PR firms and lobby groups working on their behalf. It would involve encouraging a policy of disinvestment of public money from tobacco shares. It should require a special declaration of any tobacco connections or interests from any individuals and organisations engaging in public health policy discussions.

The tobacco industry is a public pariah. In a recent YouGov poll only 7 per cent of Scots agreed that “the tobacco industry can be trusted to tell the truth”, and for good reason. They have a long history of lying and manipulating to place their profits above the interests of public health. The Scottish Government committing to fully comply with Article 5.3 would send a clear message that the tobacco industry has no role to play in determining the public health policies of our nation.