OPTIONS FOR SCOTLAND
A STIMULUS FOR A NATIONAL DEBATE ON THE NHS
A DISCUSSION PAPER
Alex Neil, MSP for Airdrie and Shotts and former Cabinet Secretary for Health and Wellbeing
The three key measurements of success for the NHS are: how effective and efficient it is in preventing avoidable disease and ill-health; how effective and efficient it is in treating patients; and the quality of the “patient journey”.
Significant improvements have been made in achieving all these objectives since the SNP came to power in 2007. For example, the quality, scope and effectiveness of the Patient Safety Programme initiated by the Scottish NHS has rightly gained widespread international renown and has saved many patients’ lives, who otherwise would have died from conditions such as sepsis. The significant progress made in the last 10 years in reducing waiting times, especially for emergency and acute care, have been without parallel since the NHS was founded in 1948. Innovations such as the Family Nurse Partnerships, which provide a wide range of support services for teenage mums, are a recognition that improving the health of the nation isn’t just about what the NHS can do but requires a much broader strategy for dealing with the challenges faced by vulnerable groups in our society.
Patient outcomes for treating diseases such as cancer, stroke and heart conditions are much improved, albeit they have still some way to go to match average survival rates across Europe. Meanwhile the number of staff employed in the Scottish NHS is at a record level and compares favourably with the other nations of the UK when measured on a per capita basis. Staff pay, especially for nurses, is now significantly higher than it is south of the border.
The integration of health and social care services is now moving apace, although we still have a long way to go to get to where we need to be in every part of Scotland.
Whilst significant progress has been made in recent years there are still many areas of the NHS where further significant improvement in performance and outcomes are required, especially if the service is to keep pace with the rapidly changing levels and patterns of demand from patients.
To meet the challenges of the future there is now a need to develop a long-term, detailed strategy and business plan, covering the period to 2030.
Such a Plan needs to be much more specific, detailed and much broader in scope than the Delivery Plan recently published by the Scottish NHS. To be successful it must have at its core a realistic and comprehensive assessment of the key challenges the NHS in Scotland is facing.
The first of these challenges is the need to deal with health inequalities, which are a huge factor in determining the overall health of the nation.
As research published by the NHS has shown the policies which can have the greatest impact on reducing health inequalities aren’t actually those under the direct control of the NHS. Maximising employment levels, ensuring all those in work are paid at least the real Living Wage and enhancing the benefits of those who depend on them have much more rapid and wide-ranging impacts in reducing health inequalities than do improvements to the NHS. The provision of good quality housing and education are also prerequisites to improving the health of our people.
Any strategy or plan for improving the nation’s health which is worthy of the name must therefore relate to and be part of a much wider plan for economic and social progress which incorporates improvements in employment, wages, benefits, housing and education.
A plan for preventing avoidable ill-health and disease is a prerequisite to success in improving the nation’s health. That’s why, for example, the introduction of minimum unit pricing for alcohol, which has so disgracefully been held up by the actions of the Scotch Whisky Association, is so important. Tackling Scotland’s culture of binge drinking successfully would save the NHS and the wider economy billions of pounds every year.
Policies related to reducing the mis-use of drugs (including legal and illegal drugs); reducing the intake of potentially harmful products like sugar and caffeine; improving people’s diets; and, especially important, incentivising people of all ages to physically exercise on a regular basis are all key ingredients of a successful strategy for improving health.
As well as improved prevention, earlier detection of diseases such as cancer would lead to better outcomes for patients, both in terms of survival rates and their quality of life.
Based on the evidence that a child’s life chances, including their lifetime chances of good health, are determined by the time they reach 3 years of age, recently re-enforced by new research from a New Zealand University, priority must be given to improving the health and wellbeing (including financial wellbeing) of all infants from conception onwards as part of the long-term plan for improving health.
At the opposite end of the age spectrum, the number and percentage of the wider population represented by older people are increasing dramatically and are accompanied by an equally significant increase in the incidence of “co-morbidities”, i.e. older people these days typically suffer from a number of complex ailments.
As well as an aging population Scotland has got a rising population, which is welcome. An increasing population will require additional resources for the NHS to service it.
Another big challenge facing the NHS is the increasing cost of new medicines and technologies. Although Scotland has now got one of the most robust systems for evaluating the costs and benefits of new treatments, difficult choices can’t be avoided about which new medicines can be justifiably paid for and which can’t. Even when allowing a new medicine to be prescribed and paid for by the NHS doesn’t make sense in terms of making the best use of scarce resources, there will inevitably be a public clamour for it; sometimes through campaigns funded directly or indirectly by big pharma. It’s therefore important for politicians, ideally on a cross-party basis, to be able to explain to the public why such decisions are justified and necessary.
An even bigger challenge relates to staffing levels. Although the number of doctors and nurses working in NHS Scotland are at record levels, the increasing lack of acuity of patients associated with the ageing of the population as well as Scotland’s (welcome) overall increase in population numbers and the rapidly rising percentage of the population who are elderly mean that the demand for medical staffing is proportionately much higher than hitherto.
The situation has been exacerbated by the pension policy changes made by the UK Government since 2010. Prior to then the maximum pension pot that could be saved tax-free was £1.5 million. This was reduced to £1.25 million then £1 million. Although such a big pension pot is much greater than the vast bulk of people in the UK could ever hope to enjoy, for most doctors (including GP’s and consultants) who have spent a lifetime working in medicine there was an expectation than when they came to retire they could achieve the full benefits of such a generous tax-free sum.
Since the maximum amount has been cut by one third, there is clear evidence that many more doctors are retiring early as they have accumulated the new maximum tax-free pension pot by the time they reach their middle to late fifties. Instead of working until they are in their sixties, as used to be the case, most of them now can retire and claim their pension from the age of 55, and then, if they are so motivated, work part-time on a locum basis. They are personally much better off financially doing that than they would be if they stay working full-time for the NHS.
This costs the NHS a small fortune. The permanent doctors are being lost to the system and being replaced by locums who cost up to 180% of the cost of permanent staff. Having too many locums can also put some aspects of patient safety at risk.
Another unintended consequence of the pension changes has been that there is less incentive for younger doctors to work longer hours, why is one of the reasons why fewer GP’s are willing to do out-of-hours work.
The “feminisation” of the workforce whereby young female doctors, who rightly make up a much larger number of doctors overall these days, are much less inclined to return to permanent, full-time work after having a family has also had a significant impact on the retention rate for young doctors.
The combination of the effects of pension policy changes and the feminisation of the working force along with the additional pressures doctors are working under these days from the increasing complexity of patients’ illnesses are all contributing factors to the increasing shortage of doctors in key areas of the NHS, including the number of GP’s and some consultant specialisms.
We therefore need to increase the supply of new doctors by a substantial amount on an ongoing basis to keep pace with the demand for more doctors.
We also need to relieve pressure on nurses and allied professionals who are equally under strain because of the increased level and complexity of demands being made upon them.
The single biggest challenge facing the NHS is the budgetary challenge. This arises from a combination of factors including the increased demand on services outlined above; the increasing complexity of medicine and medical care; costs for medicines and technologies rising significantly faster than the overall rate of inflation; the costs associated with meeting the ambitious targets set by the Scottish Government, for example on waiting times; cuts to the Scottish Government’s revenue and capital budgets; and the need for substantial new spending in recruiting and retaining staff as well as in capital investment.
Given the scale of the challenges facing the NHS in Scotland and the budgetary constraints under which it will inevitably be operating for the foreseeable future a comprehensive, long-term and radical action plan is needed to achieve the three objectives set out in the first paragraph of this paper.
The list of action items below highlights some of the main areas where I believe we need to take urgent action now. This is in addition to the wider policy initiatives required to make a serious dent on the levels of poverty and inequality in Scotland which are doing so much damage to the nation’s health.
- Introduce a ring-fenced, progressive National Health and Social Care Tax to fund increased investment needed for health and social care
The National Health Service already commands 40% of the Scottish Government’s current budget. As things stand that percentage cannot be significantly increased without a detrimental impact on all other budgets, including those which contribute towards the reduction in poverty and inequality levels in Scotland. The public spending constraints likely to be faced by the Scottish Government in the next few years mean there is little prospect of an increased level of real terms spending on the NHS prior to the next election. This is despite the reality that to come anywhere near meeting the aspirations for our health service highlighted in the opening section of this paper will require substantially more investment in both the NHS and social care over the next four years.
To persuade the public to pay higher taxes to pay for essential improvements to health and social care it is necessary to consider introducing a hypothecated tax to fund these services. That would allow the public to establish a direct correlation between the money they are investing in health and social care with the quality and level of services being provided; and hopefully thereby obtain their agreement to higher funding.
I don’t believe in hypothecated taxes as a general principle but the exponential growth in investment required for the foreseeable future to provide the level of health and social care spending being demanded by the public requires new thinking. A ring-fenced, hypothecated tax may provide the best means of obtaining the level of public accountability and acceptability needed to raise the funding needed to realise our aspirations for health and social care.
The Scottish Government must be given the necessary powers to introduce such a tax and to make the consequential changes to other taxes. If it had any sense the UK Government would be looking at the case for a hypothecated tax too, to fund the NHS and social care in England.
- Making Better Use of Existing Resources
There is no doubt that the allocation of NHS resources will always require difficult decisions as demand will always far outstrip supply. To make that process easier we need to ensure that the resources which are already committed to the NHS are put to best use, by maximising effectiveness and efficiency in the delivery of services.
In addition to the financial savings which could result from the measures outlined in other sections of this paper, there are a number of areas where savings could be made to free up monies that would be better spent in funding the NHS’s priorities, including for example by:
- Improved monitoring of NHS spending, using the management information available to identify areas where the value for money and efficiency of delivery need to be improved
- Tackling the inefficiencies in the management of the drugs bill, which accounts for about 12% of all NHS spending. If all health boards were as efficient at managing the drugs bill as the best performing board the estimated savings could amount to well over £100 million per year; and still keep prescriptions free of charge.
- Reducing the avoidable use of the private health sector where the necessary resources and capacity exist within the NHS.
- Making savings in: administration costs and other non-clinical services, payments to outside contractors and management consultants, advertising, procurement, etc.
- Streamlining the NHS estate, with a more ambitious programme for disposing of surplus buildings, etc.
I believe that the proposals referred to in this and other sections of this paper, if implemented properly, could free up about £500 million a year of the NHS’s budget for redeployment and re-prioritisation within the service.
- Streamlining of Management Structures
There are now a total of 53 different organisations involved in the delivery of health and social care services in Scotland, excluding the 32 local councils. These include 31 local Integrated Health and Social Care Partnerships, 14 territorial health boards and 8 specialist health boards.
Most of these bodies have their own Chief Executive, Finance Director, HR Director, etc. as well as having too many layers of management.
Clearly it is absurd for a small nation of only 5.3 million people at a time of financial constraint to maintain this level of administrative overhead which is both unnecessarily costly and excessive. It needs to be radically streamlined as a matter of urgency, with the consequent cost savings being re-invested in frontline services.
4. Staffing Levels
NHS Scotland must do even more than it is doing to address the staff shortages relating to clinical, allied health and nursing/ midwifery staffing levels.
In addition to the welcome measures the Scottish Government has already taken I would suggest:
- An end to the revolving door created by the “locum industry” that operates within the NHS.
Employing locum doctors and agency nurses can cost up to 180% of the costs of a permanent member of staff. The locum doctor/nurse receives up to 130% of the wage they would get as a permanent member of staff, whilst the other 50% or so goes to the agency which arranges the shifts.
We are now in a situation where the differential in remuneration between locum/agency staff and permanent staff, etc. is actively incentivising an increasing number of doctors and nurses not to enrol as permanent staff within the NHS and instead to operate on a locum/agency basis. Whilst there will always be a need for some locums and agency staff, the balance between them and the number of permanent staff is getting out of hand, at great expense to the NHS and the patients.
We need to eliminate the differential in wages and terms and conditions between permanent and locum/staff staff. There should be additional payments for loyalty/length of service as a permanent employee and increased rewards for good performance. Also the non-financial benefits of being a locum/temporary worker should be either extended to or compensated for with permanent staff.
The organisation of the locum/agency staff should be taken over by the NHS itself rather than allowing outside agencies to profiteer at the taxpayers’ expense.
I believe that this approach will bring huge benefits to patients and will provide better value for money for the NHS; although it will require a revision of the Scottish Government’s Pay Policy.
- Other measures which could help address the staffing situation in the short-term would include employing many more Modern Apprentices in both primary and secondary care, recruiting doctors and nurses who have retired early to come back into the NHS on at least a part-time basis, taking measures to compensate for the impact of the pension reforms mentioned above to encourage doctors not to retire early and making far greater use of tele-health technology which allows medical staff to manage patients’ health from remote locations.
- The staffing situation in social care merits more urgent attention. In addition to the extra investment already being put into social care by the Scottish Government there is a need to implement a comprehensive plan to enhance the rewards and career prospects for all social care workers.
- In the medium to longer-term many more doctors and nurses have to be trained in Scotland. Whilst the recent increase in the number of doctor trainees by 100 is welcome, it is nowhere near enough to satisfy the future demands of the NHS in Scotland.
As well as significantly increasing the number of students admitted to medical college every year there has to be a focussed approach to get many more Scottish domiciled students to study medicine in Scotland as well as targeting more students from a rural background.
The evidence available clearly demonstrates that medical students, once they graduate, are much more likely to return to their country/local area of origin to practice. There is therefore real benefit in getting more students from Scotland overall and from rural areas in particular, where there is a particular problem in relation to recruitment, to help ensure the Scottish NHS is adequately staffed in future.
Some of the £500 million of annual savings referred to earlier should be used to fund medical scholarships to incentivise more students to enrol in medical school provided they are prepared to commit to work for the NHS in Scotland for an agreed period once they graduate.
5. Expansion and Reform of the Primary Care Sector
There is universal agreement throughout the NHS that massively expanding the role and resources of primary care services is essential if we are to achieve our objectives of treating many more patients at home rather than in hospital, reducing the number of avoidable admissions into acute care and accident and emergency departments, and improving the overall quality of and access to healthcare in Scotland. Such an expansion should also help reduce some of the stresses and strains in the acute sector, especially in unscheduled care and emergency medicine.
The additional monies promised for primary care by the Scottish Government for the next 4 years are both welcome and very necessary. The commitment to significant additional investment in the so-called “deep end” GP practices is especially welcome as these are covering some of the most deprived parts of Scotland, which desperately need enhanced health and social care.
The development of local hubs, based on the Alaskan model of community healthcare, is also very welcome and is a prerequisite to transforming the provision of NHS services in Scotland.
Although much progress is being made there is still a need to up the scale and pace of primary care expansion.
More work needs to be done to more timeously and effectively to roll out new ideas and proven best practices throughout the NHS in Scotland. Examples include the “digital pen” invented in the Western Isles, the COPD programme initiated and administered by the South West Glasgow GP’s Forum, the use of new technology such as tele-health and social care and the use of apps, and the use of “data mining” to make maximum use of this technique to help drive short-term and strategic improvements throughout NHS To help achieve this the NHS should also establish a “Test and Spread” Unit to identify proven good practise within the NHS and from elsewhere in the UK and internationally to ensure there is consistency in the application of good practise throughout Scotland.
Such a programme could bring significant medical and financial benefits to the NHS in Scotland.
Summary of Recommendations
- To meet the challenges of the future there is now a need to develop a long-term, detailed strategy and business plan, covering the period to 2030.
Such a plan must relate to and be part of a much wider plan for economic and social progress which incorporates improvements in employment, wages, benefits, housing and education.
- A plan for preventing avoidable ill-health and disease is also essential to success in improving the nation’s health.
- As well as improved prevention, earlier detection of diseases such as cancer would lead to better outcomes for patients, both in terms of survival rates and their quality of life.
- Given that a child’s life chances, including their lifetime chances of good health, are determined by the time they reach 3 years of age, priority must be given to improving the health and wellbeing (including financial wellbeing) of all infants from conception onwards as part of the long-term plan for improving health.
- We need to increase the supply of new doctors and nurses by a substantial number on an ongoing basis to keep pace with the demand from patients.
- To fund the increased investment needed for health and social care in future, consideration needs to be given to introducing a ring-fenced, progressive National Health and Social Care Tax. The Scottish Government needs to be given the necessary powers to introduce such a tax and to make the consequential changes to other taxes.
- In the short-term there is scope to re-direct at least £500 million of annual savings from low priority spending in the NHS to free up monies that would be better spent on higher priorities. For example, tackling the inefficiencies in the management of the drugs bill, which accounts for about 12% of all NHS spending could save upwards of £100 million per year and still keep prescriptions free of charge.
- There is a vital need to radically streamline the number of different organisations involved in the delivery of health and social care services in Scotland, with the consequent cost savings being re-invested in frontline services. These include 31 local Integrated Health and Social Care Partnerships, 14 territorial health boards and 8 specialist health boards.
- Urgent measures are required to address the staff shortages in the NHS and social care, as detailed above in Section 5.
- There is an urgent need to up the scale and pace of primary care expansion and reform.
This paper is by no means an exhaustive narrative on the future of the NHS and social care services in Scotland. It isn’t meant to be but rather to provide some stimulus for a national debate on how we meet the huge challenges which we all face in how we should organise, staff and fund these services in future.
Despite some of the more hysterical coverage sometimes in certain sections of the media the truth is that the National Health Service’s performance in Scotland compares favourably on most measurements with the rest of the UK and other European countries.
But the rapidly developing challenges described briefly in this paper merit a fundamental assessment of what we need to do differently and better to be able to meet these challenges.
I hope this paper helps inform that debate and that at least some of the ideas it contains will be seriously considered and implemented by those in a positon of authority to do so.
Alex Neil MSP