Category Archives: Scotland

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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Ali Syed Memorial

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While the NHS in England has embraced patient choice and provider competition, the other three health systems of the UK have taken alternative routes in the quest for improved health services. Since 2004 Scotland’s approach has been to remove the purchaser-provider split and unify management into territorial Health Boards responsible for all health services in a geographical area.

Last month’s much-publicised Nuffield Trust and Health Foundation report comparing the performance of the four systems concluded that (with the exception of Wales, which is falling behind on some key indicators) the remarkable structural differences which are now evident within the ‘UK NHS’ are not translating into significantly distinct performances. But this report concentrated on costs and patient outcomes, and made no mention of other aspects of health systems we might value as a society. Accountability to the public is one such value. While in the English NHS the key mechanism of accountability has been recast (at least rhetorically) as patient choice between competing providers , in Scottish policy circles there is a perceived distaste for competition in public services. This has led to some interesting, if not always coherent, experiments in alternative means of ensuring ‘voice’ in the NHS.

 Back in 2004, Scott Greer identified the primary levers driving the four health systems of the UK in the years since devolution. He saw Scotland’s system as ‘professionalistic’, arguing that by and large Scotland had “placed a distinct bet on professionalism to run its health service”. The role of the public is a rather glaring omission from this formula.

 In the early years of devolved health policy in Scotland public involvement, an ever-present component of New Labour NHS policy (albeit alongside more consumerist formulations), was a fairly unimaginative affair, broadly replicating the model of the Community Health Councils, and then the Patient and Public Involvement Forums, which existed south of the border. A series of contentious decisions about the closure of hospitals and accident & emergency departments escalated rapidly to the national political arena, even drawing the fire of prominent Scottish MPs at Westminster. The absence of any public voice in Scotland’s bet started to look a little unwise. But the unexpected SNP victory in 2007 (bringing to power a party with a long history of shouting from the sidelines but minimal experience of governing the NHS) brought with it a period of experimentation and new ideas. The headline idea was ‘mutuality‘, and a determined reassertion of the public ownership and unity of the Scottish NHS.

 So what does public accountability look like within a ‘mutual’ NHS? The ‘John Lewis model’ of running an organisation through partnership has many advantages, but one major disadvantage is that it offers little space for dissent and conflict. If, as the SNP’s flagship health white paper proclaimed, we are all (NHS staff, patients and tax-payers) ‘co-owners’ of a public service, then we need some mechanisms to navigate moments when the (real or perceived) interests of these groups clash.

 The key answer to this dilemma was a proposal for direct elections of members of the boards which govern Scotland’s regional Health Boards. This idea, while innovative in the UK – where England’s elected Foundation Trust governors run ‘oversight’ bodies rather than engage in actual decision-making – has been a feature of the New Zealand NHS for decades, and has also been attempted (and abandoned) in various Canadian provinces. The idea of inserting structures of local representative democracy into the NHS, in the same way that education is overseen by elected councillors in local authorities, has intuitive appeal, not least to elected national politicians, and the proposal to pilot direct elections in two health Boards won cross-party support at Holyrood.

 However, in operation, the pilots failed to live up to their radical potential or, indeed, to the fears of ‘politicisation’ which numerous stakeholders had expressed. First, turnout in the postal elections was low, mirroring the Canadian experience of health board elections and disappointing those who had argued that there was a great public appetite for influencing the NHS. Second, the public who did vote were particularly drawn towards electing health professionals, both practising and retired. While marking a shift from the retired business people or senior managers who tend to populate public sector boards in the UK, the pilots did not inject many new public perspectives into the world of NHS management.

 Third, having been duly elected, new Board members were thoroughly and effectively socialised into behaving much as their predecessors had: understanding their primary accountability as being to the Minster; respecting the ‘corporate responsibility’ according to which disagreement among board members was to be quietly negotiated in private, not publicised; and minimising their engagement with members of the public. Some of these limitations were resisted more than others, and not all elected members fell into line, but those most committed to an alternative model of their role were more likely to resign their positions than stay and change the way Boards did business. Following the report of an independent evaluation, the Government decided to discontinue the pilots in favour of encouraging Boards to broaden their non-executive recruitment processes.

 By concentrating on who sits round the table, this leaves unresolved the question of what these non-executive Board members are there for, and particularly their role in public accountability. The basic NHS model of accountability, through the Minister to parliament, has always been questionable, and the Public Partnership Forums which still exist at local level have no formal clout at the Board table, and are better understood as consultative devices. The under-explored role of local authority councillors on Health Boards undoubtedly has some potential, but we know little about how this role is fulfilled in practice, and councillors are in any case heavily out-numbered on Boards.

 Recent speeches by the Scottish Health Secretary have stressed measures to strengthen ‘patient voice’, and entirely ignored whether and how the public’s stake in local services is to be made meaningful. Scottish advocates of a genuinely public NHS look south, at a system so fractured that public accountability has in some cases been outsourced to privately run ‘consumer watchdogs’, and feel thankful for what has been protected in Scotland. However in doing so we must avoid complacency and acknowledge the continued challenges of our ‘mutual’ NHS.

First published by the Centre for Health and the Public Interest

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Since devolution, the NHS in Scotland has taken a very different path to that of NHS England. It has embraced co-operation rather than competition. And new figures show that Scots reckon that it delivers for them.

Findings just released from the Scottish Social Attitudes Survey (SSAS) 2013 have found satisfaction with Scotlands NHS increased by over 20 per cent since 2005. The official survey of around 1500 Scots found that 61 per cent of people in Scotland were either very or quite satisfied with the NHS, compared with only 40 per cent in 2005.

 This high level of satisfaction is reflected in the patient experience as well. In last years Health and Care Experience Survey, 85 per cent of Scottish inpatients say their overall care and treatment was good or excellent, and 87 per cent also rated the overall care from their GP surgery as good or excellent too.

The findings contrast with a reduction in UK-wide NHS satisfaction levels since 2011Comparisons must be made with care – but the survey authors speculate that the different trend may be due in part to concerns about the changes in the English NHS following the introduction of the Health and Social Care Act in 2012.

Scots continue to reject the commercialisation of care, both in hospitals – where few have ever wanted the private sector or even charities running things – and in care services.

Private sector involvement in the NHS may be minimal in Scotland, but it is common in the social care sector, particularly residential and home care.

Most (59 per cent) thought the government would provide better quality care services than the private sector. There has even been a drop in support for charities running care services. 

Scotlands approach to health care organisation has cross party support. There is little difference between the SNP and Scottish Labour positions.

Rather than having lots of fragmented trusts competing with each other, one of the first actions of the newly devolved Labour administration in Scotland was to halve the number of NHS trusts in Scotland from 47 to 28. Susan Deacon, the first health minister, left people in no doubt that the market was not the future for health care in Scotland. The NHS was no longer put under pressure to offer the private sector the chance to run NHS services and they started to come back in house.

In 2001 Malcolm Chisholm took over as health minister. Chisholm completed the reform process with the NHS Reform Act of 2004. This Act formally abolished trusts and established a duty of cooperation. This radical policy was viewed as the right approach for a country the size of Scotland and more in keeping with Scottish collectivist traditions. For this reason it was maintained even when New Labour implemented market based reforms in England.

The SNP administrations since 2007 have continued this approach. In 2009, they made it unlawful for health boards to contract with private companies for GP services.

Not everything is perfect. One area of private sector involvement common to both administrations has been the use of expensive PFI schemes. Even if this is driven more by financial considerations than ideology. Scottish health ministers have always used PFI reluctantly but the application of the block grant and no devolved borrowing powers led to PFI being the only game in town approach that remains to this day.

Politicians in Scotland will therefore take comfort from the latest survey that the political consensus against the marketisation of health services has broad support amongst people living in Scotland. 

 Whilst its for voters in England to decide the future of their NHS, polls suggest that most people in England dont want a privatised NHS eitherScotlands NHS demonstrates that a better way is possible and popular.

This was first published by Open Democracy

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June 2014 edition of Healthier Scotland, the E-Bulletin of the Socialist Health Association Scotland.

Health Inequalities

Tackling inequality in health and disease and in life and death is, arguably, the greatest challenge we face as a society. There is still time to submit views to the Commission established by Neil Findlay MSP to find some solutions. Scottish Labour’s new manifesto puts health inequality at the centre of party policy. A series of reports published in recent weeks on poverty and inequality in Scotland is summarised at UNISON’s Public Works blog. They include some recommendations for action as well.
Giving evidence to the Health Committee the public health minister acknowledged that health inequality remained a “blight on our society”, but said it was “not a problem to be solved by just the NHS” as its genesis was from social inequality. For example, one in four baby boys in Glasgow won’t live to 65.

ScotSID report shows Suicide is now three times more common in deprived areas.

Public Health

In Scotland, more than a quarter of a million people have diabetes, costing the NHS more than £1bn a year. While numbers haven’t come down, obesity has slightly and there are some signs that the Scottish research strategy is having a positive impact.

Council leaders point to poor food labelling, with high salt and sugar content in foods marketed as ‘healthy’. However, Glasgow Games chiefs appoint drink firms as sponsors while 300 Glaswegians die every year from alcohol related illnesses. And children in Scotland are among the least active in the world.

MSP’s approve deregulation of food safety with visual only inspection of pigs. Thousands of tumours and abscesses to be minced into sausages and pies.

Scottish Social Attitudes survey revealed an increase in people who thought it was easier to enjoy a social event if they had a drink, up from 35% in 2004 to 39% in 2013. Although more recognise the public health problems and support action like minimum pricing. Alcohol is 60% cheaper in real terms.

Mental Health

The treatment of patients with dementia has come into focus with a damning  Mental Welfare Commission for Scotland  report and a call for the illness to be given greater priority in treatment and research. Patients with mental health conditions are dying too young and care is not on parity with physical illness, says a BMA report.

NHS Scotland

How Scotland rejected marketisation, a history lesson from Dave Watson. When we see what’s happening to the NHS in England, we should remember to say, thanks very much comrades!

Stopping Pfizer taking over AstraZeneca isn’t enough. Scott Nicholson on why we need a publicly owned pharmaceutical option. Are patient groups being used by big pharma as marketing ploys?

Pressures on A&E departments have been well documented in recent months. Even the head of NHS Scotland now admits concerns over moving patients. A particular problem in Highland with ambulances stretched to cover a shortage of out of hours GPs. Hairmyres also turning patients away and Aberdeen doctors warn of unsafe care.

Hospital doctor hours to be cut with seven night rotas banned after doctor died on journey home from work. After cutting medical trainee posts, numbers are set to be increased to cope with demand. Meanwhile, health boards spend up to £9m a year on plugging staffing gaps with agency nurses, while more than 1500 permanent posts are lying vacant.

Experts point to the dangers of boarding patients in unsuitable wards due to the pressure on beds. Dr Richard Simpson MSP highlights poor data collection. One example of many in Glasgow.

MSP’s on Public Audit Committee say patients not being treated quickly enough after Audit Scotland investigation. Waiting list guarantees not met. Chronic pain patients waiting two years. The OECD report Scotland is losing more beds than other countries.

The cost of clinical negligence cases in NHS Scotland has doubled in six years to £36m.

Financial problems at the State Hospital, Carstairs are leading to potential ward closures.

The public are getting more cynical about health polices they believe are politically motivated, according to a new poll for the BMA. However, an official survey of almost 1,500 people found that 61% were either very or quite satisfied with NHS Scotland, compared with 40% in 2005.

All opposition MSPs combined to support vote of no confidence in the Health Secretary after he directed a change of policy in his own constituency.

Social Care

Health and care integration is right in principle but it will take more than new structures to deliver quality care. One of those challenges is the national disgrace of social care in many homecare and residential settings as explained in UNISON Scotland’s, Time to Care report. This was also the subject of SHA Scotland’s succesful motion to the 2014 Scottish Labour Party conference.

The Self-Directed Support Bill comes into force. The rhetoric of choice and control through personalisation is often used as cover for a deteriorating service and isolation for service users.

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Scotland has had full responsibility through devolution for our Health Service since 1999. The result has been that the NHS here now looks substantially different from that in England, our approach being one of collaboration, cooperation and minimal use of the private sector. It has many unique features.

Some, such as the staff partnership, have been recognised by commentators like the King’s Fund as world leading. Others, like our managed care networks, could only develop effectively in a collaborative system and are beginning to deliver results. Our patient safety strategy is also world leading.

The challenge for the Yes Campaign is to explain what possible advantages there are to patients through independence? The Union provides many advantages which will be put at risk with independence and will over time I believe degrade our Union advantage.
The biggest challenge to Scotland’s current preeminence in health will come about indirectly. We have five medical schools. This is far more than would be required for an independent Scotland. Students from England pay tuition fees and it is very unlikely that this will be allowed under EU rules. The loss of income to Scottish Universities of fees has been estimated at £140 million. Over time the Crerar Report’s prediction that we would half our medical student intake could happen. This would mean two fewer medical schools.
The current situation within the UK is that Scotland punches substantially above its weight in medical research. In competitive research applications we win around 14% of the UK Medical Research Council’s (MRC) funding compared to a population-based share which would be 8.3%. The position is similar for UK medical charities like Welcome, the National Institute for Health Research (NIHR)and the 13 other research councils. Indeed it is uncertain that we would be eligible for any NIHR funding. Any delay in EU membership could interrupt Horizon 20/20 funding as well.

Of course the Nationalists will promise to match the research funding. But it is the competitive winning against the whole of the UK that is equally important in maintaining quality. The MRC stopped funding research in Eire three years after they gained independence.

Scotland has evolved already its own world-leading approach to medicines. But currently the larger UK Union has ‘clout’ in negotiations with the pharmaceutical industry. A smaller Scottish budget, whilst still significant, would inevitably have less influence.
There are also savings through size from the regulation of health professionals. Scotland has no guarantee that it would be able to retain the UK General Medical Council, the General Dental Council, the Nursing and Midwifery Council and the Health Professional Council. Costs are likely to increase from having to set up our own bodies in Scotland. On becoming independent, we would need our own regulatory body for medical devices (MRHA), Vaccines Advisory Committee and regulation of substances. This parallels concerns generally about setting up separate different and costly regulation.

There are also seventy UK wide disease registers which with their size is of great benefit in monitoring patient outcomes.
We already have our own separate institutions where these are useful like the Scottish Medicines Consortium and the Mental Welfare Commission

What has all this to do with patients? These underlying and unnecessary structural disruptions will lead to a parochialism and diminution of an integrated system which has built up over three hundred years of the most successful Union in the world with Scotland’s contribution to that union in medicine exceeding almost every other region.

We could lose medical schools. Our research base will certainly not get better and we could lose funding. We are likely to pay more for our medicines. We would pay more for registration and regulation of health professionals. We would still be able to access the NHS in England but it is very likely that the favourable terms arising from being part of the UK would not continue.

Scottish Health Boards would be charged full price for the 24,000 patients treated annually in England.

So why risk our preeminence within the UK? Scotland under devolution has all the powers we need to progress an NHS which is world leading. What would we gain from separation?

Dr Richard Simpson MSP is Scottish Labour’s Public Health spokesman.

This article first appeared in Healthier Scotland – The Journal Published by Socialist Health Association Scotland March 2014

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The Scottish Parliament has proved itself in areas of health. Certainly there are disagreements and differences in administration and priorities. But whereas the English NHS is undergoing privatisation with clear for-profit motives, the cross-party consensus in Scotland is to deliver health service in the public interest, to keep the health service well-funded and in public hands.
Yet chronic health problems remain almost as severe as before devolution, and powers to change this lie beyond health policy. The great opportunity of a Yes vote is to bring to Scotland the deeper powers – over areas like the economy, jobs, incomes, welfare and other social security – which can begin to alter not the symptoms but the causes of an unhealthy nation.

Despite being one of the richest countries in the world, the unequal division of wealth and economic security in Scotland explains the shocking differences in healthy life expectancy between the richest and poorest parts of the country. Other inequalities matter too, like gender and ethnicity – but often these are linked to material deprivation or social discrimination, creating or exacerbating ill health.
Consider the health of the up to 100,000 children in Scotland who will be plunged into poverty by 2020. Take the Westminster welfare changes, not only certain policies like the bedroom tax, but the overall approach that leaves those with the least facing the greatest impact of austerity. Many thousands have to choose between heating and eating and are frozen out of even a basic living standard by falling wages and too few working hours. Under this government the Red Cross has started handing out food for the first time since World War Two. These are the symptoms of a profoundly unhealthy society, and ill health follows as a sad matter of course.
Preventative care mitigates the impact of social injustice, but poor health is not a disease isolated from deeper conditions of life, or something people are endowed with – like an asset or a liability. To properly address health challenges, we need to integrate powers over health with the powers to rebuild the economy and share the wealth we produce more broadly. The integration of social and economic policies to tackle the injustice in society is a significantly different approach from our Westminster system, which looks unlikely to invest in the social change we need, even if Labour wins in 2015.

We need powers over welfare, work and wages, held by a government willing not just to attend to the effects of social inequalities, but to work against the divisions in society. It will be up to socialists in Scottish Labour and beyond to champion social justice, and work for an independent government in 2016 that tackles the causes of ill-health in society: creating the work that gives people the security and living we all deserve; and ensuring that social security means more than sanctioned welfare, but is genuine support for all to attain a healthy living standard. A Yes vote is a means to this end, bringing to Scotland the powers we need to eradicate the causes of ill-health in our society.

Cailean Gallagher is a researcher for Yes Scotland, and a member of the Campaign for Socialism

This article first appeared in Healthier Scotland – The Journal Published by Socialist Health Association Scotland March 2014

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The NHS in England is under threat from the pro market lobbyists and under great strain due to financial pressures. It’s not a happy story.

Shortly after the 2010 election rumours began about a monster Health Bill – 400 clauses and designed for change over 2 terms. Despite lies in the coalition agreement about no reorganisation of the NHS by 2012 we had the Act.

The Lansley blueprint to bring in a regulated market for healthcare, like the utilities, began with a white paper promising things which fooled many who should have known better, into vague support. The SHA was in the forefront of opposition pointing out the dark side, but only the leading health unions and Labour were openly opposed. The pretence that somehow the Tory proposals were some kind of continuation of existing policies was rapidly refuted. This was making competition and markets the strategy for healthcare not about the occasional and managed use of competition if appropriate.

The Bill was shorter than expected but was obviously about moving to a market. Labour fought the Bill line by line in Commons and Lords to no avail. Many amendments were made, making the result virtually unworkable, but the essence of the market was fixed into Part 3. By the time the Bill became an Act the opposition was virtually unanimous. It was too late.

The disaster might have been prevented had the GPs collectively signalled they would not accept the changes they had to be involved with or if the Royal Colleges had collectively signalled their opposition. It didn’t happen. The LibDems ensured the Act was passed although they never got the payback they were promised in terms of constitutional changes.

The Act set up the structures and mechanisms by which healthcare moves to a market. It reinforced the commissioner/provider split with Clinical Commissioning Groups (led by GPs) and set out the architecture for greater competition amongst providers. It removed some of the political levers and downgraded the role of the Secretary of State; and it removed the idea of any local strategic leadership – not necessary in a market. Monitor was set up to be the economic regulator, fixing the prices and stamping out any anti-competitive behaviour.

The Act included, as an afterthought, Health and Wellbeing Boards to be vehicles for local integration of care services, and Health Watch as some king of body to facilitate public and patient involvement.

The greatest threat came from the pressure on commissioners to use competitive tendering . This was a one way process as it meant NHS providers could only diminish in terms of their share of the “market”. There is no doubt that the Act opens up greater opportunities for private providers to have access to NHS provision.

The Act fundamentally changed the NHS and paved the way for the end of the NHS as provider, for co-payments, top up fees and even the possibility of an insurance based system.

Which is bad enough, but this massive and expensive reorganisation took place against the background of severe cuts in funding levels forcing the NHS to try to find savings on a scale never achieved before, anywhere. Cuts in budgets for social care have magnified the problems. Tory controlled communications attacked the NHS at every opportunity, distorting and exaggerating know issues.
Implementation of the changes has been patchy as it becomes clear that the original Lansley model has been quietly dropped and some pragmatism is coming into play. You would struggle to find any open supporters of the market, competition, privatisation model. There is already talk of amending some of the worst (unintended?) aspects. It is still early to judge the true impact of the Act but the negative impact of the combination of structural changes and funding cuts is becoming clearer as many NHS providers are now either officially or just obviously in financial difficulty. They are threatened with various forms of intervention and “failure regimes” which are likely to involve offering private providers and the leading private sector management consultancies rich pickings.
Some of the provisions in the Act around public and patient involvement have some positive aspects but there is little sign yet of activists engaging in the new structures.

Some CCGs are virtually ignoring the regulations and are not planning to competitively tender everything. Some CCGs got involved in tendering and make a mess of it! In a number of places local groups and trade unions are actively opposing tendering activity – with some success.

For the SHA in England the position has always been total opposition to the Act and to the whole idea of a market of any kind for healthcare. We have strongly lobbied the Labour Party and believe that our policy is quite well aligned to that being advocated by Andy Burnham and the Labour Team.

If the Tories get a majority at the next election in 2015 they can complete their plan to dismantle our NHS, everything is in place to do it.

If Labour wins then they are committed to repeal of the Act. They will remove all the market structures (in Part 3 of the Act) and restore the political and legal accountability of the Secretary of State. They will do this in a way which does not trigger yet another wasteful and destabilising set of structural changes. The SHA is working to find the best ways to bring this about as we need workable answers not just slogans and rhetoric.

Richard Bourne is the immediate past Chair of the UK Socialist Health Association

This article first appeared in Healthier Scotland – The Journal Published by Socialist Health Association Scotland March 2014

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The independence referendum takes place on 18th September 2014. But it is the days that follow which are more important. It is what Scotland does with its existing, or future further devolved, or independent powers which matters most – not simply where the constitutional border is drawn. The argument is not therefore primarily about the constitutional power, but about what we do with them.

The NHS in Scotland is THE case for Devolution – choosing public over private health services, and mitigating against the whims of Westminster ideology. However, it is public health policies and legislation including smoke-free public places and minimum unit pricing which mark the key achievements of the Scottish Parliament and of devolution. Successes which have also become central to the Scottish Government’ s case for independence in their White Paper – Scotland’s Future. Nevertheless, both the preservation of the values and quality of the NHS in Scotland and the pioneering of public health legislation are key achievements of devolution.

Both devolution of more powers or independence could bring further opportunities for progressive public health action. The White Paper states an independent Scotland would “use the full range of levers to promote good health,” but there is little detail on specific policy, nor is the future of public health or health services given much attention. Under current devolution arrangements, health is one of the largest budgets and highest profile policy areas controlled by the Scottish Government. But, the questions need to be asked: if Scotland were to become independent, would the attention given to public health be substantially less when the focus will inevitably be drawn to fiscal, foreign and defence powers, as well as the substantial efforts needed to disentangle the country from the rest of the UK and establish the independent state bureaucracy? And, how radical could public health policy be in terms of taking on big business, for example, the alcohol, tobacco, or food industry on advertising regulation or taxation policies? when at the same time the independence white paper sets out a business friendly low corporation tax priority that undermines the determination that would be needed to take on big business in these areas.

However, it is on health inequalities that the recent Audit Scotland report was damming on health policy. Despite the investment from successive devolved administrations, inequalities in health have just not budged. It is well recognised that health inequalities are the result of the unfair distribution of income and power and to a degree they are also associated with the inverse care law of wider public (as well as health) services – where those who need them the most are least likely to have access to them. So, on this count, it could be that our failure on health inequalities is because we do not yet have enough fiscal or economic levers. However, it could also be that we have not yet fully utilised the powers we currently have at our disposal including our lack of will or action to meaningfully reallocate resources (in our current gift) towards those who need it most. Couple this to the proposed low corporation business friendly taxation system proposed in an independent Scotland and it does not bode well for demonstrating that an egalitarian society will emerge and deliver us justice on health inequalities. First independence then equality? A leap of faith is needed here, because the case is not convincing.

The Scottish Government’s White Paper sets out the health case for independence:

This Scottish Government plans to continue with current arrangements for the management of the NHS in Scotland, focussing on sustainable quality and for the integration of adult health and social care services. Services will be accessed in the same way as under the devolution settlement.

Despite efforts to address the challenge of health inequalities in Scotland over recent years, health inequalities persist and demonstrate that the “fundamental causes” of health inequalities – the socio-economic inequalities in society – are the most important. Recent research shows the strong correlation between poor health and poverty. It suggests that the reason for Britain’s high health inequalities is the failure of successive Westminster governments to choose to reduce inequality.

Independence will also allow us to do more to tackle major causes of ill-health, which disproportionately affect poorer communities. In March 2006, Scotland was the first country in the UK to enact a ban on smoking in public places. This has resulted in a dramatic reduction in smoking related diseases. We have also led the way in developing ambitious proposals to tackle harmful drinking by legislating for a minimum unit price for alcohol.

We have maintained our commitment to strong action to tackle smoking and alcohol misuse with all the powers available to us. In contrast, the Westminster Government has chosen to put on hold proposals for plain packaging for cigarettes, and abandon plans for minimum pricing for alcohol. With independence, we will have greater scope and clearer powers to regulate alcohol and tobacco, including through taxation – reducing the opportunities for legal challenge which have held up several of our initiatives to date.

We are already taking a distinctive approach to food standards. Independence will allow this to be linked to tax policy and advertising regulation – allowing a coherent and concerted approach to issues of obesity and poor diet, which disproportionately affect poorer communities.

A major advantage of independence for health and wellbeing in Scotland is therefore to have the ability to use the full range of levers to promote good health. It is matched by the opportunity to grow Scotland’s economy for the benefit of all and address inequalities in Scottish society that have not been, and will not be, addressed under Westminster.

After independence, Scotland will maintain a very strong relationship with the other countries of the UK. Scotland will continue to work with other parts of the UK to provide services where this provides access to the highest quality of care and delivers the best outcomes. There are already effective cross-border working arrangements in place, which will provide a strong foundation for continued co-operation, just as there is with Ireland. Partnership arrangements are also in place with a number of European countries, including, for example, Sweden.

Services provided for patients outwith Scotland include highly specialised care for people with rare diseases or conditions, and certain types of transplantation. The rare cases of transplants being conducted outwith Scotland are for lung, small bowel and paediatric transplants. Because there is a relatively small number of these procedures, contracting these services from clinical specialists offers the best health outcomes for Scotland’s patients. These arrangements will continue exactly as they are at present after independence.

On independence, Scotland will continue the current arrangements for organ donation across the UK, maintaining one donor register and sharing donated organs. This will ensure that all organs are placed with the best matched patient. The Irish Health Service Executive also co-operates on organ transplantation with NHS Blood and Transplant (NHSBT), who co-ordinate transplant services across the UK. This reflects international best practice in transplantation where groups of countries work together, for example Eurotransplant in mainland Europe (Austria, Belgium, Croatia, Germany, Luxembourg, Netherlands and Slovenia), and Scandiatransplant in the Scandinavian countries (Denmark, Finland, Iceland, Norway and Sweden).

Arrangements for reviewing NHS pay are already devolved but NHS Scotland currently operates within UK structures and modifies UK agreements to reflect Scottish circumstances where necessary. With independence, we will review the machinery for pay determination in partnership, including the potential for improvement across the wider Scottish public sector. The Scottish Government has developed a Scottish GP contract in partnership with the BMA, and with independence we will continue to work with them, and all relevant partners, to ensure that GP contracts are developed to meet the needs and circumstances of the people of Scotland. Similarly, for hospital based doctors and dentists, the Scottish Government will work with all relevant partners in Scotland, and seek to co-operate with Westminster where appropriate, to negotiate pay, terms and conditions.

Scotland is already responsible for the regulation of some health professions – those who came to be regulated after the establishment of the Scottish Parliament. After independence, we will become responsible for all regulation. We will seek to co-operate with Westminster, and the devolved administrations, to ensure that health professional regulation is maintained in the best interests of patient safety and the consistent treatment of healthcare professionals. We will also maintain the existing professional healthcare regulatory bodies, which are funded by fees from registrants, and will continue to operate in Scotland after independence.

With independence, we can build on the gains of devolution for our health and social care services to enhance the health and wellbeing of people across society.

This article first appeared in Healthier Scotland – The Journal Published by Socialist Health Association Scotland March 2014

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Sexually transmitted infections (STIs) have a significant impact on the health of Scotland. STIs cause mortality via human immunodeficiency virus and human papilloma virus; pelvic inflammatory disease and reproductive complications via gonorrhoea and chlamydia yet also infect the unborn foetus by syphilis and herpes.

Figures released by the Information Services Division of National Services Scotland (part of NHS Scotland) in January 2014, highlight that across all age groups, there has been a 43 per cent increase in STIs since 2003. The figures, covering chlamydia, herpes and gonorrhea, show a rise over this period from 15,601 to 22,306. Most interesting to me, was that the number of Scots diagnosed with gonorrhea rose by 133 per cent from 808 in 2003 to 1884 in 2012.

Antimicrobial resistance is a serious issue in gonorrhoea treatment and has caused the last-line drugs (ceftriaxone combined with azithromycin) to become the standard therapy in the UK.  There is no reserve drug available if ceftriaxone resistance – already found in France, Spain and Japan – spreads across Scotland.  Without dependable therapy, many Scottish women with gonorrhoea will remained untreated and develop the associated pelvic inflammatory disease, ectopic pregnancy, infertility and even disseminated infections in synovial joints.

Between 1929 and the 1970s, pharmaceutical companies developed more than twenty novel classes of antimicrobials. Since the 1970s, only two new categories of antimicrobials have arrived. This has caused Gregory Daniel to write about market failure in antibiotic development.

Market failure is an issue as, when used appropriately, a single £100 course of antibiotics could treat an infectious disease like gonorrhoea. However, being clinically effective after short-term use has the unfortunate consequence of making antimicrobials significantly less profitable than the drugs used in – for example – cancer therapy, which can cost £20,000 per year.

In September 2013 the Department of Health published its UK Five Year Antimicrobial Resistance Strategy.[11] The strategy called for “work to reform and harmonise regulatory regimes relating to the licensing and approval of antibiotics”, better collaboration “encouraging greater public-private investment in the discovery and development of a sustainable supply of effective new antimicrobials” and states that “Industry has a corporate and social responsibility to contribute to work to tackle antimicrobial resistance.”

As socialists, I think that we should have three major objections to these statements. One, managers in the pharmaceutical industry have no responsibility to contribute to work tackling antimicrobial resistance. They have a responsibility to make profit for shareholders or be replaced. It is the state that has the responsibility for the protection and wellbeing of its citizens.
Secondly, following last years’ horsemeat scandal we, as socialists, should object to companies cutting corners in attempt to increase profits. This leads on to the final objection, that inpromoting public-private collaboration all the state is doing, is subsidising share holder profits by reducing their financial risk.

Mariana Mazzucato in her 2013 book, THE ENTREPRENEURIAL STATE, discusses how the state can lead innovation and criticises the risk and reward relationships in current public-private partnerships. I feel that significant advances in the prevention, diagnosis and treatment of STIs could be made by undertaking basic scientific research and we in Scotland should campaign for state funded researchers working within the public sector.

These scientists could study the mechanisms of antimicrobial entry into bacterial cells or screen natural antibiotic compounds to develop novel antimicrobials but also develop technologies such as point-of-care diagnostic devices that allow healthcare professionals to prescribe the most effective therapies. Point-of-care diagnostic devices like these would also help to tackle the development of antibiotic resistance in diseases like gonorrhoea by preventing the use of inappropriate antibiotics in patients who do not require them.
In addition to these, scientists could also develop vaccines. The human papilloma virus vaccine shows the great potential of this field and there is no reason why this approach could not be adopted for gonorrhoea but also additional STIs like chlamydia and syphilis. With regard to other STIs, our current therapy options for human immunodeficiency virus are very expensive and drug resistance is a continual threat. Development of a vaccine would reduce cost to the NHS and mortality in Scotland but also allow the UK to provide greater assistance with international development.

The state could choose to build laboratories researching STIs in areas of Scotland with high unemployment and that have been neglected by private sector investment, to help promote regional recovery. Even more radically, if novel antibiotics are produced for their social good rather than the financial return from the volume sold, they can be reserved indefinitely – as a last-line drug – until a time of crisis.

Finally, with regard to democracy, patients and the general public in Scotland could have a greater say as to which STIs are researched and it would help us shift away from our reliance on the market to provide what society needs. As we all know the market responds, not to what Scotland needs, but to what will create the most profit.
Scott Nicholson is a PhD Student, University of the West of Scotland

This article first appeared in Healthier Scotland – The Journal Published by Socialist Health Association Scotland March 2014

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The care of older people in Scotland is a national disgrace. Fairly paid, well-trained staff on proper contracts with time to care is the very least older people in our communities have a right to expect.
Like others in the sector I have written reports highlighting staffing levels, budgets, structures and care strategies. Words have been written and numbers crunched – but that doesn’t tell the whole story. I participated in a couple of focus groups made up of care workers last year and the messages from the workers who provide care were deeply disturbing. They painted a picture of care in Scotland that nobody would want for their elderly relatives, including my own.

I summarised a key impact of poor employment standards when giving evidence to a Scottish Parliament Committee considering the Procurement Bill:

“The other day, I was doing a focus group with a group of care workers and I said to those who were on zero-hours or nominal-hours contracts, “Would you raise health and safety issues with your employer?” They said, “We’re on these contracts. If we raise health and safety issues, we will not be asked back.” That is exactly the position that colleagues were in with blacklisting. Sadly, when I then asked them, “What if you saw care abuse?”, they said, “We’d be pretty reluctant to raise that as well, to be honest, for the same reason.” People on zero-hours or nominal-hours contracts who raise difficult questions do not get asked back, and people are concerned about that.”

Having experienced those messages first hand I decided we would ask a much larger group of care workers and the outcome of that work is in UNISON’s ‘Scotland – It’s Time to Care’ report. This report gives staff at the front line of care delivery the chance to tell their story about care in Scotland and it doesn’t make comfortable reading.