Category Archives: Scotland

Government austerity measures since 2010 have impacted healthcare across the UK.

Holyrood is the administrator for NHS funds in Scotland but the Scottish Government has struggled to mitigate the impact of Westminster cuts.

In the short-term they’ve had limited successes in keeping various healthcare plates spinning in the air — but with no clear end to cuts in sight, they might soon come crashing down.

So here are three ways austerity is impacting health in Scotland and an overview of the stakeholders combating cuts.

Economy

Prior to Scottish GDP figures being released in early July, the mainstream media was awash with warnings that the economy was on the brink of recession.

Yet organs like the BBC were forced to flip their doomsday scripts overnight when it was revealed that GDP had grown by 0.8 per cent — outperforming the UK as a whole.

But national statistics don’t reflect the challenges faced by those struggling regions where the economic picture isn’t so rosy.

The downturn in the oil and gas industry has led to a 50 per cent rise in unemployment in North-East Scotland — with a serious knock-on effect on mental health.

The Scottish Association of Mental Health’s Open Up campaign encourages residents in affected communities to openly discuss mental health problems — and helps them find sources of support.

In terms of the employment rate the high level picture is healthy in Scotland —but figures are partially propped up by part-time roles and zero hour contracts.

And workers in precarious employment are also facing rising rents — so it’s crucial to read between the lines with Scottish employment statistics.

Mental health

A report from the mental Welfare Commission in April revealed that even as austerity pressurised NHS mental health services, staff shortages in mixed psychiatric wards made female patients feel unsafe.

The Scottish Government pledged to spend £300 million recruiting 800 new mental health staff over the next five years to plug the gap.

This might present an opportunity for mental health nurses with diplomas to take online distance learning degrees that upgrade their skillsets for senior positions.

But the NHS across the UK is haemorrhaging skilled overseas staff because of Brexit.

Welfare reform

The Welfare reform Acts of 2012 and 2016 have had a huge impact on some of Britain’s poorest and most vulnerable citizens.

A UN report in late 2016 confirmed that these reforms show ‘grave or systematic violations of the rights of persons with disabilities’.

And the study also highlighted the cultural shift that means disabled Britons and other disadvantaged groups are cast as scapegoats for Britain’s economic woes.

Holyrood has spent £396 million over the past five years mitigating Westminster policies such as the bedroom tax — while their budget was slashed by £5 billion.

And Westminster Welfare cuts mean another £2 billion has disappeared from the Scottish economy as those affected save the little cash they have, rather than spending in shops.

Austerity has affected Scotland in similar ways to the rest of the nation. But it’s unclear whether the Scottish Government’s mitigation measures constitute a sticking plaster solution rather than a permanent cure.

Have you experienced the effects of austerity in Scotland? Share your stories in the comments section.

 

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Councils can make a huge contribution to tackling health inequalities across Scotland. The interaction and relationship with the Scottish Government is pivotal to making a difference.

National recommendations for action:

Funding: Reform the resource allocation to local authorities to ensure that it is based on socioeconomic circumstances of communities.

Income: Reform Council Tax and create fairer local taxation.

Structures: Further work to reform local authority structures -balance between local and regional services and integration with wider public services, particularly the NHS and public health services.

Local recommendations for action:

  1. Priorities: This is about priorities and decisions. Tackling health inequalities should be the top priority for councils. All other roles and actions of local government contribute to narrowing inequalities in health, wellbeing, and life expectancy inequalities in their populations.

  2. Education and Schools: Ensures schools develop social, emotional, health and wellbeing agendas as a foundation for learning. Schools can do more to promote physical activity and improve the nutritional value of school meals. Free school meals and the provision of breakfast has long been an important public health measure. Resolve the crisis in Additional Support Needs education.

  3. Physical Environment. How the environment can be improved including reducing air pollution, a major cause of death in Scotland. Councils and health boards also have a statutory duty to reduce carbon emissions as part of their climate change plans.

  4. Food policy. Further action to improve healthy food in schools and other local authority settings. Wider action to improve access, affordability of healthy food. In addition to the key environmental health role in better food safety.

  5. Active and Affordable Transport. An active transport plan not only reduces carbon emissions but also contributes to better health. Traffic management measures can reduce accidents that disproportionately impact on poorer areas.

  6. Early years provision: This requires universal provision delivered by qualified staff, not just child minding, and can be an important setting to deliver health improvement such as toothbrushing, hand hygiene, dietary habits, and also venue to engage parents and carers.

  7. Housing: Council should be building and refurbishing more social housing and supporting a fuel poverty strategy through energy efficiency standards and measures. A warm, dry house is an essential element on any health strategy.

  8. Licensing: Using planning and licensing powers to address number and distribution of alcohol, gambling, and unhealthy fast food outlets.

  9. Economic powers: Using economic powers support regeneration of disadvantaged communities and help people to find and stay in good quality jobs. Procurement powers should promote fair work practices, including the Scottish Living Wage.

  10. Voluntary groups: Supporting community groups that help develop strong resilient communities.

  11. Community development and participation: Invest in community development and build better systems to ensure genuine community participation in local policy development.

  12. Leisure and culture facilities: Maintaining and developing cultural and leisure facilities that promote good health, ensuring access for all. Improve affordability and access.

  13. Exemplar Employers: As employers, develop fair work practices with well designed and paid jobs. Promote healthy workplaces with first class occupational health services.

  14. Care services. Social care services should be developed focusing on improving care workers pay, training, working conditions, as well as improving standards and regulations. This also means supporting collective services like day care, which tackle social isolation, particularly for older population.

Life expectancy in Scotland

No serious plan to tackle health inequalities in Scotland can ignore the pivotal role of local government.

Through their planning powers, management of transport and traffic systems, open public spaces, and leisure and cultural services, they can contribute to the quality of the built and social environment. They have powers to promote equality and wellbeing. They work in partnership with the NHS and other agencies such as the police, and voluntary & community organisations to support public health by leading community planning. In short, they make a vital contribution to weaving the social fabric of their areas and seeking to create and sustain healthy places for people to be born, grow, live, work and age.

Rising demand on the NHS and a growing funding gap means that our current health and care system is creaking at the seams. Addressing this requires a shift from the treatment of ill-health to preventing it. Above all health inequalities remain Scotland’s most urgent health issue.

As our National Commission on Health Inequalitiesi highlighted, too often solutions are focused solely around the NHS. In practice many of the policy levers rest with local government and they are well placed to influence the wider determinants of health. Not least because of there close connection to communities and their role in coordinating how best to use all the available assets to promote well-being.

In this paper we make the case for health and well being to be central to the purpose of our councils – recognising that they have to be fairly funded to make meaningful interventions.

How councils contribute to a healthier Scotland

Services like refuse collection, street cleaning, dealing with fly-tipping, and environmental health directly ensure that we avoid ill health by removing the sources of disease from our communities. Living in pleasant surroundings rather than litter-strewn streets and accessing cultural facilities are also good for mental health. Sports centres, parks, and allotments offer free or inexpensive routes for people to keep fit, active and healthy no matter their age or ability. These are essential health services.

Local government also delivers direct health and care services: free personal care for the elderly, care homes support and adaption’s for people living with disabilities and chronic health conditions. These services save lives and are essential to the quality of life of many Scots. Without those lots of people would still be in hospitals, unhappy and costing a great deal more money. Housing is also a key health service. A decent safe secure affordable home is vital to both mental and physical health.

Education and the tackling the educational attainment gap is essential to addressing health inequalities. As well as teaching the subjects children need to pass exams and get jobs, schools deliver a range of health and relationships education. Schools are important settings for implementing healthy food and physical activity policies. Schools are also the gateway to a range of other agencies that can support families like educational psychologists and social workers. Ensuring that children have the best possible start and make good choices about their own lives and health will not only mean they have better lives but that we can look forward to long term savings. What the Christie Commissionii called preventative spending. The Childsmile – national supervised toothbrusing programme in nurseries is a case study in preventative spendiii. There is also a crisis in the inclusion and support for Additional Support Needs children in Scottish schools with a postcode lottery in how this is delivered.

The role of the councillor is recognised by NHS Health Scotland in their elected member guidanceiv. They describe the role of the councillor “as very important in terms of influencing the positive health of communities and ensuring the gap between our more affluent communities and individuals and those not so well off, isn’t widened.. Councillors are the key advocates for their communities and for ensuring tackling health inequalities is central to the purpose and work of the local authority.

Some councillors also have a direct responsibility for the delivery of health services. Every council is represented on their health board, providing the only local democratic accountability health boards have since the decision to abandon direct elections. Others serve on Integrated Joint Boards tasked with coordinating the provision of community health services and social care. Councils also lead community-planning partnerships.

Councils also invest in community development to build local capacity to respond to local needs. Single Outcome Agreements should include clear outcome measures for reducing inequality and health inequalities, together with the commensurate resources targeted on greatest need. This should lead to the development of greater resilience enabling individuals and communities to withstand challenges such as poverty, inequality, worklessness and other factors that endanger health and wellbeing.

Lessons from elsewhere

The transfer of public health from the NHS to local government and Public Health England (PHE) has been viewed in England as a significant extension of local government powers. Public Health England has published a range of resourcesi that promote good practice. Their focus is on good quality jobs, reducing social isolation and improving health literacy. While Scottish local government doesn’t have the same explicit powers, it shows the advantages of better links between public health practitioners and local authority teams. A number of local guidesii emphasise the role of councillors in health.

In London, there is a collective agreementiii with national partners to transform health and wellbeing outcomes, inequalities and services, through new ways of working together and with the public. The Marmot Review also includes examplesiv of how local action can tackle health inequalities.

Across Europe, local government and health work together more closely. In some cases unitary authoritie join up community health and other services. Norway, a country of similar size to Scotland does this. Although they would say that the division between acute and community services is just as challenging.

While the centralising tendencies of the Scottish Government means similar structural change is unlikely in Scotland, we can learn the lessons from elsewhere, use relevant resources and adopt best practice that can support local action. The Scottish government has set a direction for public health in Scotland.

Council Health Strategy

The starting point should be a political strategy for the council to engage with a health equality agenda. This strategy shows how the council can make positive interventions, sometimes described as ‘place-shaping’. Sir Michael Lyons in his influential report, ‘Place-shaping: a shared ambition for the future of local government’, described ‘place shaping’ as the creative use of powers and influence to promote the general well-being of a community and its citizens. He said that local authorities must use their ability to bring together local stakeholders and develop a vision for their area.

This should be developed in conjunction with community, voluntary groups and trade unions. Councils are the democratically elected representatives of their communities and should use that role positively to improve engagement in health issues. All policies should be measured against their contribution towards reducing health inequalities and resource allocation should be focused on disadvantaged areas.

The strategy should include a health profile that gives councils information about the health of there own residents. This should include data available about health inequalities between different groups, such as men and women, older and younger people, people from different ethnic groups, which enables councils to make interventions targeted at improving the health of groups most in need.

Councils are represented on health boards and Integrated Joint Boards, but rarely take a strategic approach to their role on these bodies. They should take their health agenda forward using these roles.

In a practical sense, councils can help health boards by refinancing health PPP schemes as set out in UNISON Scotland’s Combating Austerity toolkit. The money saved should be invested in tackling health inequalities that address the council’s health strategy.

Co-locating health and local government services is a good way of delivering seamless services, designed by staff and service users from the bottom up. Community hubs as described in the Health Inequalities Commission report and the Reid Foundation paperi, show how this can be done.

Conclusion

Local government can make a huge contribution towards a healthier Scotland. Both directly through the services they deliver and in partnership with the NHS and others. They can bring the authority of local democratic accountability to a wide range of services.

When we focus on the social determinants of health, rather than the medical cause of some specific disease, we see that local government services are health services. Without local government, adults and children would die sooner, would live in worse conditions, would lead lives that made them ill more often and would experience less emotional, mental and physical well-being than they do now.

However, strengthening the role of local government won’t happen by accident. Councils need to adopt health strategies that focus relentlessly on tackling health inequalities. And the Scottish government must stop slashing council budgets to enable councils, and better distribute resources based on socioeconomic deprivation to enable them to deliver their full potential to tackling inequalities in health and wellbeing. Health inequalities will not be eliminated unless we seriously address the social determinants of health – that is where local government must play a key role.

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NHS funding is not keeping pace with increasing demand and the needs of an ageing population. NHS boards are facing an extremely challenging financial position and many had to use short-term measures to break even.

That’s the key message in a report that makes grim reading from Audit Scotland on the NHS in Scotland. Although Scotland’s health budget increased by 2.7% in real terms from the previous year, it is not keeping up with growing demand.  Between 2010/11 and 2014/15, the annual percentage change in the total health budget has been less than 1% and below the UK inflation rate. Health inflation is generally higher and is estimated to be 3.1% in 2016/17.

A good example of this is drug costs. Spending increased by over 10% between 2012/13 and 2014/15 and it is predicted to rise further by 5 to 10% each year.

Audit Scotland has helpfully highlighted a point about routing social care funding through the NHS that UNISON made when the Scottish Government published its plan. When social care money is deducted, the remaining £12.6 billion of the NHS budget equates to a 0.3% real-terms reduction in the revenue budget. As one health board director of finance put it to me, “I cannot spend every pound twice.  My English counterparts get the same increase, but they don’t have to fund the extra demands on social care as well”. That is not to say that social care isn’t the right priority given the huge cost to the NHS of delayed discharges. However, it does mean that the NHS in Scotland isn’t getting the resources it needs.

The report also shows that many health boards are struggling and the books are only balanced by payments from the Scottish Government and savings plans, many of which are not recurring. Short-term measures don’t deliver long-term financial viability. The total savings that boards are aiming to make has increased by 65% in real terms, from £293 million in 2015/16 to £484 million in 2016/17 (£492 million in cash terms). By any standard this will be extremely challenging.

Audit Scotland rightly suggests that NHS boards need to look at reorganising acute services to free up more resources for investing in community-based facilities. However, they recognise that boards are often faced with considerable public and political resistance to proposed changes to local services. The SNP government will find it difficult to challenge this opposition when they ran similar campaigns when in opposition.

NHS boards continue to find it difficult to meet key national performance targets. Overall NHS Scotland failed to meet seven out of eight key targets. The only standard met nationally was the drug and alcohol treatment standard, although it was close to meeting the cancer target.

Staff costs are the largest spending area in the NHS. In 2015/16, they were £6.2 billion, accounting for around 55% of total revenue spending. This is an increase of 6.4% in real terms since 2010/11. £175 million was spent on agency staff. Spending on temporary staff increased from 1.6% of total staff costs in 2012/13 to 2.8% in 2015/16. The average cost of salaried nursing staff was £36,000 per WTE, agency nursing staff cost more than twice this, at £84,000 per WTE. The report highlights risks to patient care from high use of temporary staff.

Staff turnover was 6.4%. Nursing and midwifery vacancy rates were 3.6% overall, 9% for health visitors. There are significant variations between boards. 5% of GP practices (49) are now being run directly by their local NHS board.

The Audit Scotland report is required reading for anyone concerned about our NHS. It clearly shows the increasing demand on services and the challenges in reforming the system. Most of all it shows that the NHS is underfunded, not overspending, and staff are under intolerable pressure to bridge the gap.

This is from the SHA Scotland blog

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I had a nasty experience a couple of weeks ago. I was booted out of the Royal College of Nursing congress in Glasgow while distributing flyers promoting my Parliamentary Petition calling for a whistleblower hotline for NHS staff. The nurses were interested- my flyers went like hotcakes- but after 30 minutes I was told to leave by RCN Scotland officials insisting the call for a hotline conflicted with RCN policy

Whistleblower nurse Danni Gray, from Stoke-on-Trent Hospital, was incredulous that I was ordered to leave. Danni had come a cropper herself when she blew the whistle (her story is featured in the May edition of the “Nursing Standard”, Volume 30). (The picture shows her and I outside the SECC after ejection.)

Peter Gregson and Danny Gray

The RCN is not the only staff association that fears having whistleblowing discussed by its members: UNISON, UNITE, RCN & BMA have all refused to allow their Scottish members to discuss the petition, which calls upon the Scottish Government to establish an independent national whistleblower hotline for NHS staff to replace the current helpline, widely derided as useless.

Because health workers in Scotland are being blocked from debating whistleblowing, I have launched a second petition to support the campaign- a petition for a Petition and is addressed to the aforementioned unions’ leaders.

The reasons unions don’t like my proposals are made clear in this petition: they give priority to relationships with NHS executive management over members well being. I aim to use public pressure to get the healthcare unions to reverse their stand and allow staff to discuss whistleblowing improvements at branch meetings.

I am calling upon the Scottish Parliament to replace the impotent National Alert Line with an effective hotline with investigatory teeth. When staff contact the current helpline, they are referred back to their trade union or manager – which more often than not has led to either nothing happening or, worse, the whistleblower being victimised. Staff surveys found only 57 per cent of staff thought it was safe to speak up and challenge the way things were done if they had concerns about quality, negligence or wrongdoing.

The new proposal would differ in that it would independently investigate reports about mismanagement and malpractice. It would explore perceived negligence or ill treatment of a patient by a member of staff. And bullying too: the 2015 NHS Scotland staff survey revealed 15% of staff are bullied by bosses or colleagues.

The Petition is shortly to go before MSPs and union support is crucial to parliamentary approval. Please help me make Scotland’s health service safer.

Sign the petition.

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The health debate in the Scottish Parliament election didn’t inspire many in the health sector. It rarely got above the level of NHS targets and there was very little focus on health inequalities. At least the Scottish Labour manifesto led with that issue.

As we look ahead to the new parliament there are going to be a few challenges for health. The biggest is austerity, as the SNP have largely boxed themselves into following George Osborne’s spending plans. Health spending is to increase broadly in line with the Barnett consequentials of English health spending, although the extra (and much needed) social care funding (£1.3bn) is to come ‘from the NHS’. As this is a local government function that is a big chunk out of NHS spending at a time when many health boards are reporting serious budget problems. Many suspect a number of difficult decisions have been kept under wraps until after the election.

All the manifestos had a welcome focus on mental health services and £150m is committed in the SNP manifesto. There is another £200m for elective treatment services, although doctor’s organisations have queried the cost of this. It is a suspiciously round number! Other commitments included 500 extra health visitors – primarily for the controversial ‘named persons’ scheme; 500 advanced nurse practitioners and 1000 paramedics working in the community.

There is at least the prospect of structural reform. The SNP manifesto has a commitment to review the ‘number, structure and regulation’ of health boards and their relationship with councils. The renegotiation of the GP contract might form the basis for a necessary shift of resources into primary care, but this won’t be easy.

A number of MSPs retired (voluntarily!) at this election. SHA Scotland would like to pay a particular thanks to Malcolm Chisholm who gets insufficient credit as the health minister who stopped the marketisation of NHS Scotland. Our history lesson, especially for those who try and rewrite it!

Mental Health

Our Action on mental health services blog post welcomes greater media attention given to mental health issues. If acute services were this limited there would be a major public outcry.

Doctors look after our mental health, but who looks after theirs? A new study reports that 60% of doctors have suffered mental illness and psychological problems at some stage of their career.

Alliance of service providers, which support vulnerable young people, has made their own demands for fixes to what it describes as a “mental health crisis storm” in services for young people.

NHS Scotland

Problems with the troubled NHS24 computer system have rarely been out of the media. The latest concern is a six and a half hour training session for staff. No one listened to staff.

Surgeons are warning that the future of six rural hospitals is ‘precarious’ due to recruitment problems.  NHS Lothian approves £25m of cuts, including 200 beds, as they struggle to tackle a £77 million funding gap against a backdrop of rising demand and an ageing population. And they are not alone.

Pharma greed kills. The campaign that confronts big pharmaceutical companies about their rip-off prices. It threatens to ‘bankrupt’ NHS Scotland. Some progress has been made on cancer drugs, but why did it take so long?

The government’s latest £100m to tackle cancer has been welcomed but money alone isn’t enough.

42,021 patients were moved between Scottish hospital wards between 11pm and 6am in 2015, with critics warning the actual number is likely to be even higher. That’s what happens in a target culture.

Public Health

Obesity Action Scotland highlights the fact that 65% of Scottish adults are overweight, including 28% who are obese. The problem is more complex than simply behavioral change.

Expensive health promotion campaigns have failed repeatedly because of a failure to tackle the root causes of inequality says new research from University of the West of Scotland. The people who respond best are those who are already healthy. We are ignoring inequalities and blaming the victim.

Bowel cancer ranks as the fourth most commonly diagnosed cancer in the UK. But take up of screening is still poor in many areas. Reluctance to discuss our bowels?

Over 276,000 people live with diabetes in Scotland, 500,000 at high risk of developing Type 2 diabetes and 45,500 living with it undiagnosed. Bellwether Report makes the case for greater support.

Study suggests adults slumber average of 6.8 hours, missing an hour, and calls for national strategy to publicise importance of good sleep.

Greater fuel poverty awareness could save NHS Scotland up to £80m. A perfect example of the wider impact of inequality on health.

Social Care

Adult social care is rarely out of the headlines. It is underfunded; it is damaging the NHS through delayed hospital discharges; it is financially crippling for users; care workers are being sold short; there are serious concerns about the quality of care; and providers say they are about to go bust. The common feature? It’s largely outsourced. Call for overhaul of system in Scotland.

More from Socialist Health Association Scotland

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The Central Council of the UK wide SHA has highlighted the need for more work to be done on social care as part of building a sustainable health and care system.

The Health & Social Care Centre reports that in England expenditure of adult social services over the five year period from 2009-10 ( when the figure was £16.8 billion) expenditure has increased by one per cent in cash terms, a decrease of eight per cent in real terms. This is a reflection of the unbalanced approach to care being taken in that country.

Our comrades in Scotland are also obviously aware of these concerns as well as judged by these comments on their dedicated SHA site which merit further consideration.

http://www.shascotland.org/blog/quality-care-commission-report

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While sound and fury explodes all around us on NHS spending, spare a thought for the crisis in Scotland’s social care system.

Today, I was in parliament for the launch of the Commission for the Provision of Quality Care in Scotland report. The Commission was established by Neil Findlay MSP when he was Shadow Cabinet for Health and Wellbeing with the aim of reviewing how we can improve the way adult social care is delivered. It was Chaired by David Kelly who was a Director of one of the first Community Health and Care Partnerships in Scotland and brought together all the main stakeholders.

The strength of this Commission and the earlier one on health inequalities is two fold. Firstly, they address issues that don’t get nearly enough attention in the Scottish health debate, that at times seems obsessed by A&E waiting times to exclusion of all else! Secondly, Neil was very clear in his remit that he didn’t just want another analysis of the issues (something we are very good at in Scotland), he wanted solutions. Even if the solutions might be politically difficult.

The report starts with a stark assessment of the current position. We have an ageing population with an increase in multi-morbidity and long term conditions. In disadvantaged areas the most common co-morbidity is mental health and this combination has a strong association with health inequalities and negative outcomes for individuals and families.

These additional demands bring with them associated costs. The report estimates a real term increase of up to £2bn per annum will be required by our health and social care system by 2025. With a small growth in the size of the overall population this is likely to place an increasing tax burden on the working age population. The recent IPPR report reinforces this point.

During the years of Tory austerity the Scottish NHS budget has had a degree of protection at the expense of other public services including social care.This approach has failed to recognise the inextricably linked relationship between acute hospital care and care in the community. The consequences can be seen in the numbers of patients blocking beds in our hospitals and a £5million increase in the amount councils are having to generate from charging income for social care in order to compensate for the financial shortfalls.

The report describes the complex and frankly inadequate ways the quality of care is assessed in Scotland. UNISON Scotland’s ‘Time to Care’ report starkly set out the views of care staff over the quality of care they are forced to deliver. While in the main health and social care services are provided good levels of quality, there are still too many examples of poor quality. The report concludes that general trends about quality cannot be ignored. In particular, the connection between the quality of staffing, working conditions, and quality of care is a matter of primary importance.

The workforce chapter seeks to address a key component of this. The Commission recognises that more than anything else, the payment of the living wage and a general improvement of terms and conditions will be required to deliver a social care workforce consistent with our aspirations for quality care. This view is shared by the evidence submitted to the Commission from both trade unions and employers across the public, private and voluntary sectors. The contracting race to the bottom in care provision has to stop.

Since the report was written the social care crisis has if anything got worse and today councils and providers in England are making similar points. We have residential and homecare providers in in very difficult financial circumstances, drawing on reserves and some are struggling to meet even day to day cash flow. Others have significant vacancy rates and increasing staff turnover. Social workers in care of the elderly teams report that it is becoming increasingly difficult to find a provider to deliver care packages in some parts of the country.

Pay is but one element of fair work. The Commission commends UNISON’s Ethical Care Charter that includes the wider considerations that commissioners of home care should account for when contracting. These include training, induction, travel time, ending zero-hours contracts and most importantly ensuring that there is time to care.

The Scottish Government’s standard response to concerns about social care is to refer to the new Integrated Joint Board’s that aim to provide a seamless care service. While the Commission supports this approach, it recognises that this structural change will not in itself be enough. The recent Audit Scotland report confirms this. Despite the Kerr report and much talk about preventative spending, we have not been able to break the public perception that everyone should have a district general hospital within ten minutes of their house – nor the political pressure to satisfy that thirst.

The Commission argues that a top-down approach to the commissioning of services will fail to deliver responsive care and support. The report places an emphasis on getting locality planning right building on the knowledge and capacity of local people about their own wellbeing. It also recognises that best practice needs to be supported and rewarded. Equally, there is a need to work with poorly performing locality teams to improve outcomes. We need to recognise that not all differences in outcomes are down to differential resources. It can reflect poor leadership, organisation and bad practice.

Housing provision also needs to change if we are to address the needs of an ageing population. All too often, a person will move from their family home into a care home via a period in hospital.This is partly because of the lack of suitable alternatives at local level. We need to build new, affordable and sustainable housing, with a range of house types and sizes that encourages mobility in the housing system and enables downsizing for those that wish it. Housing support services currently play a small, but significant, role in supporting older people to remain living at home and needs to be expanded.

A key recommendation of the Commission is that we fundamentally rearticulate the basic social contract between the citizen and state based on the principle of reciprocity.That people contribute to the wider social good through payment of tax and direct contribution to care and support – and in return people receive high quality care and support when they need it and irrespective of their financial circumstances. This means addressing the current differences between services free at the point of use such as healthcare and some social care, but not for those under the age of 65.

As such, the Commission arrives at a new and more robust social contract: the responsibility of the state is to ensure that citizens with personal care needs receive that care free at the point of use; and that citizens are otherwise responsible for their daily living costs and additional support requirements, funded from personal wealth or income, or for those citizens who are less well off, from welfare support.

Finally, the Commission addresses the question of funding. A properly funded and organised social care system would actually save money. For example, a bed in a District General Hospital costs in the order of £2,500 per week, as compared with £500-£800 per week for a care home and even less for home care. The Commission points to work done elsewhere in the UK on the options for addressing the funding gap, something we have simply ducked in Scotland. A national conversation needs to be informed by a detailed examination of the spending gap and how that might be funded. The Commission makes no claim that its work is sufficiently detailed to be a definitive statement on this issue. However, they do say that it is sufficiently large that it cannot be wished away or ignored.

The value of this Commission report is that it does more than simply analyse the scale of the problem, important though that it is if we as citizens are to grasp the importance of social care. The Commission goes much further in describing what a quality care might look like and how it should be delivered. It also doesn’t duck the need for a new social contract and the necessary conversation about funding.

WATCH the video of Gordon Aikman to see why paying care workers the Living Wage is so important.

Care staff in Scotland

First published on the SHA Scotland blog
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Persistent health inequalities in Scotland is a scandal and our foremost national shame. We are experts at describing health inequality, but dismal at fixing it. A new report by the Health Inequality Commission takes the radical path of offering solutions.

Allowing so many people to die or become ill earlier than their neighbours because of a simple accident of birth underpins our national ignominy in this policy field. We know both what causes and what will solve health inequality. As a society we comment and frown about how terrible unequal health outcomes are, but we don’t devise, and then put in place, the bold polices that we know could go some way towards tackling the biggest policy failure of our times.

In case anyone needs reminding of the scale of the problem this chilling example says it all: “A boy born in Lenzie, East Dunbartonshire, can expect to live until he is 82. yet for a boy born only 8 miles away in Calton in the East End of Glasgow life expectancy may be as low as 54 years, a difference of 28 years or almost half as long again as his whole life.” (SPHC, 2015). And it’s not only life expectancy – in the most deprived areas, males spend 22.7 years ‘not in good health’, compared to 11.9 years in the least deprived areas.

The practical actions in this report cut across almost all government portfolios – this is not an issue that can simply be tucked away in the NHS. Health inequalities have been too often written off as a problem of individual behaviour.This is not to say that this does not contribute poor health, but behaviours are impacts, not causes, of wider inequality.

Employment and income are fundamentally associated in attaining either good or bad health outcomes. Work in Scotland is characterised by underemployment and insecurity, zero-hours as well as low pay. Action on the real Scottish Living Wage and reversing the shift from wages to profit are essential if we are to tackle inequality. Equally important, is the quality of work and improving health and safety in the workplace. However, wages alone are not enough. For families in particular, the social security system has an important role to play, as the savage cuts in tax credits will highlight.

Community Planning Partnerships must have an understanding that health inequalities are about social inequality rather than purely a concern of the NHS.The Christie Commission and the Equally Well test sites highlighted this in 2008. Key messages included the strengthening of democratic accountability, joined up public sector leadership, working with communities and giving public service staff the autonomy to develop approaches in accordance with local circumstances, rather than top down structural change. A key recommendation in the report is the establishment of community hubs that will physically bring together public services in real communities, together with the voluntary sector.

Other public services need to play a key role in reducing inequality. The report covers the need for affordable and accessible public transport; sport and recreation facilities; housing; schools and further education. Crucially, there must be an unrelenting focus on early years by supporting parents and through universal high quality early years provision. Stimulating learning in very young children and preparing them for primary school is essential to help break the cycle of health inequality.

While tackling health inequality is a cross cutting issue there is still a role for the NHS. However, resources and priorities are not always focused on health inequality. As the Deep End GP’s told the Commission; “NHS Scotland should be seen at its best in areas of greatest need, or inequalities in health will widen”. We have a raft of targets and measures of NHS activity, but little that addresses health inequality. The report recommends measures to put inequality in the centre of NHS Scotland activity.

Health inequality has to be put in the centre of all policy development. It needs a cross cutting minister and every legislative proposal and plan should have a health inequality impact assessment.

Health inequalities are a manifestation of socioeconomic inequalities, they also reflect political inequalities. How we organise society creates inequalities.Therefore, how we organise society in the future can eliminate them.To do so means tackling injustice, unfairness and inequality.This report is an appeal to the Scottish Labour Party and other policy makers to take this challenge head on. This report proposes a transformative agenda for Scotland – where we shift from health inequalities to health equity.

(The Commission on Health Inequalities was established by Neil Findlay MSP. It was chaired by Dr David Conway from SHA Scotland. It took evidence from a wide range of organisations and held evidence sessions in communities. Contributing authors were Dave Watson and Tommy Kane)

A full copy of the report can be downloaded from our website. Contact the Secretary if you would like a hard copy. Here is some of the media coverage.

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The social care crisis in Scotland is not given the priority it deserves, but there is a growing consensus about what needs to be done.

I was speaking at the Care Scotland, care at home conference. The panel was asked to set out what’s wrong with home care and how we would fix it.

On a national and local level we need to fix the crazy commissioning system that isn’t working for anyone. It isn’t working for providers who are struggling to maintain a viable business model. It isn’t working for staff; either social workers that are trying to put packages of care together, or home care staff that are the real victims of the race to the bottom in pay and conditions. Most importantly, it isn’t working for service users, who suffer from the high turnover of staff with little continuity of care, or are stuck in a hospital bed because there are no staff to care for them at home.

The solution primarily needs proper funding. It’s easy to blame politicians for obsessing about the NHS, but they are often just following public opinion that rarely understands that social and NHS care are interlinked. Personally, I am coming to the view that we need an agreed national rate for home care, as we have for residential care. This would be a rate that is dependent on providers paying the Scottish Living Wage and maintaining a range of other workforce standards. One of the merits of a national rate as against a local top up is that it wouldn’t just reward the bad employers in the sector.

That leads me to the second issue, employment standards. Any funding agreement has to include the key elements of UNISON’s Ethical Care Charter. The new procurement guidance rightly recognises that paying the Scottish Living Wage alone is not enough because some providers will simply cut other conditions. There needs to be action on zero and nominal hour contracts, sick pay and travel time. In addition, what comes through strongly in all our surveys is the importance of giving staff time to care and proper training linked to career progression. A recent UNISON surveyhighlights frighteningly low levels of training. Caring should be a great job and many staff I meet recognise that. But the household bills have to be paid and so many end up stacking shelves in supermarkets instead.

I am pleased to say that there was a broad consensus amongst the panel at yesterday’s conference on what needs to be done. Scottish Care also launched their latest research report on this issue, which is well worth a read.

The media headline was all about freezing heath spending, but the key finding is that investment in better social care for older people would improve their lives and help to cut emergency hospital admissions. In 2012-13, the average emergency hospital admission for over-65s lasted for 11.8 days, at an average cost of £4,846. That amount could fund either care at home for a week for 27.7 older people or 9.28 weeks in a residential care home for one pensioner.

Ranald Mair, chief executive of Scottish Care, said: “If we’re going to manage to keep more people out of hospital, to maintain them in their own homes and also to prevent them going into long term care at an early stage, then we actually have to invest in home care. The danger at the moment is that we’re continuing to invest in hospitals and as you know, all politicians want to be the defenders of the NHS. This isn’t an attack on the NHS, let me be clear. If people need to go to hospital that’s where they should be. But what we know is that over 20% of admissions of older people to hospital are ‘unnecessary’ admissions. They’re not going in because of their clinical needs, they’re going in because of their circumstances and because of the lack of alternatives.”

It’s hard to disagree with that. Investment in social care and in particular the staff who deliver care, needs to be one of our highest priorities.

This was first published on Dave Watson’s own blog.

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General Practice in Scotland is facing significant challenges. Could now be the time to move to a fully salaried service?

GP surgeries face a recruitment crisis – with a survey earlier this year finding 17 per cent are short of at least one doctor. In Forth Valley there are three practices that have been taken over by the health board because of an inability to recruit doctors. The Leith Links Medical Centre, Edinburgh has had its boundaries redrawn to cut its patient list from 8,300 to 6,300 after two unfilled recruitment rounds left the three remaining GPs dependent on locum support. One third of existing GPs are likely to retire within the next five years.

Proposals are being considered which may mean family doctors in Scotland no longer employ their own practice staff and pass on jobs such as ensuring patients with long term conditions are regularly monitored.

Health Minister Shona Robison in an interview with the GP magazine Pulse said:
Something quite compelling came from those discussions: we need to work towards a model that has a wider primary care team of various health professionals, to remove some of the workload from GPs. The GP would still provide services and be the clinical expert to that primary care team.”

Dr Alan McDevitt, chair of the British Medical Association’s Scottish GP Committee (SGPC) said: “The reason we are doing this is all about making sure we free-up GP time not just for more appointments but also because the complex care we have to do for elderly patients means 10 minute appointments are not long enough. We have to start preparing for the future (with more elderly patients). We need to make sure we can give more time to older patients with complex conditions.”

So could this mean a fully integrated service with salaried GP’s? Well, there are of course many salaried GPs in Scotland. In the main they work for independent GP practices, employed on a standard contract. These proposals are not aimed at ending the independent contractor status, but they might take away some of the ancillary and administrative tasks. The new Health and Social care partnerships could take over more of these roles.

The old school BMA approach is set out by Brian Keighley in the Herald:
“A salaried service will not fix it. The independent contractor status of GPs is good for the sanity of doctors. It’s easier to face local problems with local leadership and solutions. But independent GPs are also good for patients who look to their doctor to be their advocate in an NHS of byzantine complexity and to provide continuity of care in the face of super-specialism in other parts of the service. So, it’s good news that there is a commitment to adapt and improve the GP contract that could allow the NHS to begin again to value its highly skilled workforce.”

In England, Labour’s Andy Burnham was proposing ‘whole person care’ centred on full integration of health and social care in a single service. While he pulled back from requiring GPs to be salaried, conceding that independent GPs could be part of the system, it was clear that he expected far more salaried GPs.

Many potential GPs, particularly women, are put off becoming GPs by the prospect of having to become a partner in a small business. As the income comes almost entirely from the NHS, the model has always been an anachronism. The first stage may well be to employ all the practice staff, leaving GPs to do what they are trained for. That could lead, over time, to greater integration and contractor status withering on the vine. We are a long way from that position in Scotland, but it may be that we are seeing the first steps towards a more rational system.

Lets give the last word to Glasgow GP Dr Margaret McCartney’s alternative health manifesto for GPs. Her final line:
“Let GPs get back to the job they love – that is, getting to know their patients, having conversations over time, understanding what’s important and what’s not, sharing decisions, making plans, supporting families, understanding the area they work in. Make GP the incredible job it is.”

First published on the SHA Scotland blog

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Socialist Health Association Scotland backs Neil Findlay and Katy Clark for Scottish Labour leadership

SHA Scotland, one of the most active socialist societies affiliated to Scottish Labour, is to nominate Neil Findlay MSP as Leader and Katy Clark MP as Deputy Leader.

As Shadow Cabinet Secretary for Health and Wellbeing, Neil Findlay has built a close working relationship with organisations like SHA Scotland working on key issues such as health inequalities, social care and strengthening NHS Scotland.

The establishment of the Health Inequalities Commission and the Quality Care Commission shows that he is interested in solutions to these major problems. He has also involved a wide range of people from within and outwith the party in this work – demonstrating that he will be an inclusive leader, prepared to look outside the political bubble.

SHA Scotland Chair, Dr David Conway said:

“Neil’s future focused ambitious policy commissions, the importance he places on listening and engaging with communities, and his fighting for difficult campaigns – makes a compelling case for Neil Findlay to lead the Scottish Labour Party at this time.”

SHA Scotland also recognises that Katy Clark understands the need for a fundamental redistribution of wealth and power if Scotland’s deep-seated health inequalities are to be seriously tackled.

SHA Scotland Secretary, Dave Watson said:

“Katy has a proven track in campaigning on difficult issues. She understands that politics as usual simply wont do. Scottish Labour has to take radical measures to address inequality in Scotland and that’s why we believe Katy Clark is the right choice as Deputy Leader.”

SHA Scotland Chair, David Conway sets out his reasons for supporting Neil Findlay on our blog.

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