The report makes ten recommendations for the next Scottish Government. The focus is on data and digital solutions, which, while important, somewhat misses the point. Scotland's poor health is almost entirely due to health inequalities and the structural changes brought about by Thatcherism, which Tony Blair did little to challenge. 

So, we are told all will be fixed by a MyCare.scot app. Health board numbers should be reduced "to accelerate the process of aligning interoperability and data standards." There is a case for reducing the number of health boards, but not without addressing social care and community services by reforming Integrated Joint Boards. Data is the worst reason for doing this. The same goes for "Boost digital maturity and reduce variation in digital capability." Whatever that means.

The paper is absolutely right to emphasise prevention. Although "Embed macroeconomic analysis in health-spending decisions, ensuring prevention is embedded in fiscal and economic strategy," is someway short of the cross-cutting action across portfolios that is required. I also think we have tried Tony Blair's 'innovative financing models' before with PFI, not to want to return there.

There is little doubt that NHS Scotland could do a lot better with decent IT systems. You only have to watch hospital staff using the current systems to see that. I am writing this in a hospital canteen after witnessing this. However, the idea that this will miraculously solve Scotland's deep-seated health inequalities is for the birds - even in the cloud.

​Dave Watson

There is also a human cost. In October 2022, there were 58,826 days spent in hospitals by people whose discharge was delayed. This is an increase of 17% compared with the number of delayed days in October 2021. No one wants to, or should, stay in a hospital any longer than they need to. This is on top of the financial cost, as hospital beds cost far more than social care provision.

The latest care inspectorate statistics showed that 60% of care services that employ nurses reported vacancies, creating a 16% vacancy rate. The staffing issues are not limited to social care. NHS district nurses play a crucial role in supporting people to return home from hospital. The vacancy rate for district nursing reached 16% last month. The Westminster Adult Social Committee has highlighted similar concerns in England.

The idea that more privatisation is the solution is risible. As Prem Sikka recently highlighted, social care companies are robbing the public purse, with profit margins of between 37% and 41.7%, and tax dodging is rife. This is the model that people like Karol Sikora want to expand! In addition, self-funding care home residents are now paying 40% more than publicly-funded residents, compared with 24% a decade ago.  

Sadly, the proposed National Care Service in Scotland will do nothing to challenge this, taking even more services from the public sector. Moreover, as the Scottish Parliament Finance Committee report highlighted, the costings of this over-centralised service are largely unknown. Still, we do know that it will divert much-needed resources from frontline services. Creating a National Care Service remains the right approach. However, its role should be to create a national framework, with services designed and delivered locally. Implementing organisational change of this magnitude will take a significant amount of time. In the meantime, we need to support the demoralised, tired, and financially stretched frontline staff who immediately need a break, decent pay and a vote of confidence. 

There has been a welcome initiative from former health ministers Alex Neil and Malcolm Chisholm to end zero-hours contracts. However, the response from Social Care Minister Kevin Stewart that companies bidding for government work are evaluated on their fair working practices "where it is relevant and proportionate to do so" - is not good enough.

Patients overwhelmingly access the NHS through GP services. However, patient surveys show this is becoming increasingly difficult despite GPs delivering more appointments (not all in person) than before the pandemic. Patient satisfaction is 12% down in the last year, with 10% saying it had become more difficult even to contact their GP practice. Some of the byzantine appointment systems don't help and put excessive pressure on reception staff, who take the brunt of patient dissatisfaction. 

This is primarily an issue for non-urgent treatment; charging better-off patients won’t help address this. While it may discourage some appointments, this short-term gain will result in long-term pain as conditions go undiagnosed, resulting in more severe conditions for the NHS to treat. The solution is recruiting more GPs and other health staff in primary care. GP numbers have fallen from 3,613 in 2019 to 3,494 in 2022. Scottish Government targets focus on headcount, which ignores the growing number of part-time staff. A BMA Scotland survey indicated that 75% are more likely to quit or reduce hours in the coming year due to ‘excessive workload’. Five years on, the deployment of multi-disciplinary teams has fallen short because of staffing shortages. 

Moving away from the expensive small-business model would also help in the longer term. Many more GPs, particularly younger staff, are coming to this view. For example, GPs at the Lothian LMC have recently said that the independent contractor model ‘is no longer fit for purpose.’

​The NHS as an institution rightly attracts almost universal support, primarily because we all rely on it. That doesn't mean it is sacrosanct, and it is perfectly reasonable to debate reform. However, we must be wary of those who use reform as a trojan horse to promote their ideological agenda. The founding principles of an NHS free at the point of need, funded by general taxation, is the best way to organise healthcare. The NHS's main problem is the absence of adequately funded social care and primary care. That should be our focus right now. Anything else is a distraction.

While drug-related deaths, in Scotland in particular, are an important factor, they are not the sole or majority contributor to stalled mortality trends. Changes in rates can be observed even when drug-related deaths are excluded, and the increase in drug-related deaths is likely to have been partly caused by the same underlying factors associated with the overall mortality changes.

An independent review by the Health Foundation found large and sometimes widening health inequalities among children living in Scotland’s most and least deprived communities. They found that by 2016-18, infant mortality was 2.6 times higher for babies born to women in the most deprived areas compared to those of the least deprived, compared to a difference of 1.8 times in 2000-02. A key issue is obesity, which by 2019/20, was around 6% among the least deprived five-year-olds compared to roughly 13% in the most deprived. In 2001/2 there was no gap. This will not be resolved simply by targeting behaviours because there is no difference in physical activity by deprivation. There are differences in diet, and a healthy balanced diet is considerably more expensive calorie for calorie and therefore increasingly inaccessible to those on the lowest incomes.

Child poverty has long-term implications. People who experience deprivation as children are more likely to choose to do things that, although pleasurable in the short term, are unhealthy in the long run. This includes overeating, taking drugs, smoking cigarettes and gambling. This can help to explain why some people go on to become addicts while other people can avoid some of the more harmful effects of drugs and alcohol.
Politicians are failing to address the underlying causes of inequality. In Scotland, we have plenty of analysis but limited action. Audit Scotland recently reported that ‘the Scottish Government has not yet demonstrated a clear shift to preventing child poverty.’ Others, like Suella Braverman, seek to cover it up by focusing on immigration. Public anger at a lack of affordable housing and secure work, declining living standards and austerity has been redirected at the caricatured foreigner. Instead, we should be focusing on the economy and public services with actions such as those suggested in the GCPH report, including:
•    Changing the economic structures that lead to immense wealth and income inequalities.
•    Increase all benefits and tax credits in line with inflation every year, and put in place a one-off increase now to compensate for the loss of real income since 2010. Using devolved fiscal powers to top up reserved benefits and reverse UK cuts. Create new devolved benefits and increase existing benefits to support those in low-income households.
•    Improve the availability of ‘good work’ by increasing in-work benefits, strengthening trade unions, minimising health and safety risks and increasing the statutory living wage to the Real Living Wage.
•    Address tax evasion and avoidance and increase taxation of wealth, assets and corporate profits.
•    Increase public sector funding for preventative services, and reinstate cuts in public services, particularly local government.
•    Eliminate fuel poverty through action on housing insulation and heating and grow a social rented housing sector that is accessible, affordable and provides secure tenancies.
More than ten years ago, the visionary Christie Commission highlighted the impact of inequalities on the economy and our public services. They recommended more collaborative working, preventative spending, and building services around people and communities. Sadly, we see greater centralisation, silo working and little preventative spending. So, it was good to see the recent report of the Scottish Parliament’s Health Committee on health inequalities reference the report. What we now need is some focus on delivering its recommendations. Tackling health inequalities should be the priority of all governments.

Demand for services is rising, while activity levels are still down. That is resulting in long waiting times as this graphic shows.

Rising health inequality is not due to the pandemic, but it hasn't helped. The gap in healthy life expectancy, before chronic conditions set in, is now more than 20 years. The challenge is not just in socio-economic gaps, but on disability and ethnicity. Audit Scotland says: "there are no separate plans for people with disabilities or those experiencing homelessness... The Scottish government should develop an overarching strategy for tackling health inequalities and develop work programmes for all target groups."

On the Recovery Plan, Audit Scotland is sceptical, "The recovery plan will involve new ways of delivering services and these will take a lot of work. There is not enough detail in the plan to determine whether ambitions can be achieved in the timescales set out."

This is particularly true for the workforce. Plans to recruit more staff are not the same as actual workers on the wards or in the community. Staffing plans continue to be hobbled by a "lack of robust and reliable workforce data", and "innovative recruitment methods" will be required to deliver on staff goals. This was also clear pre-pandemic - little has changed.

BMA Scotland summed up the report well, "Today's report also supports the view we have long held - and was clearly the case pre-pandemic - that the NHS in Scotland is financially unsustainable, and that position is worsening," He said there was a "clear danger" that a lack of proper workforce planning would undermine any possible NHS recovery.

Audit Scotland's report is a welcome reminder that glossy documents that set out ambitious plans are not the same as actual delivery. That is what the Scottish Government should be focusing on.

​The authors conclude:
 
“the most likely explanation for these trends is the UK Government’s programme of so-called ‘austerity’: unprecedented cuts to public spending including social security budgets, which has impacted on the most vulnerable members of society. It is therefore important to use this evidence, alongside other research findings, to bring about changes in policy to protect the health of the poorest and most vulnerable in society. In addition to the action that must be taken at a UK level to address this, the research emphasises the importance of using all devolved and local powers and opportunities that exist to mitigate the effects of such policies and protect and improve the lives of all in society, particularly the most vulnerable.”
 
Commenting on the paper Danny Dorling points out that; “Outside of wartime, pandemics and epidemics, increases in mortality rates are unprecedented in the UK in the twentieth and twenty-first centuries. This rise in deaths has coincided with the imposition of austerity which has most harmed people in poorer cities….the deterioration of the health of the population in the decade before the pandemic struck meant that when it struck, we, and especially those in the poorest places, were weaker than before.”
 
A further paper written by Gerry McCartney (Sociology of Health and Illness) and others examines power inequalities, including discrimination, to explain inequalities in health outcomes. This distinguishes from behavioural or other explanations of the inequality between the working class and the rest of the population. They map different forms of power and the space they operate in to inform action.

The lockdown associated with the Covid-19 crisis highlighted the importance of social connection to public health. As Guardian columnist Owen Jones put it before the crisis:
 
“Imagine there was a virus you’d never heard of which increased the likelihood of mortality by 26%, or a condition which had a death rate comparable to smoking 15 cigarettes a day. A national health crisis would be declared, and judging by the reaction to the coronavirus, panic would ensue. This public health crisis, which leaves its victims more than twice as likely to develop Alzheimer’s and other dementias, has a name: loneliness.” 
 
More than two million adults in the UK suffer from chronic loneliness, across all age groups, although older people often also feel socially isolated. Changes in the workplace, church attendance and the closure of social spaces like pubs and clubs have all contributed to this condition. 
 
There is a wealth of evidence that place impacts on health and wellbeing and contributes to creating or reducing inequalities.
 
The Place Standard Tool[1] was developed in collaboration with NHS Health Scotland (NHS HS), provides a framework for place-based conversations to support communities, public, private and third sectors to work together to deliver high quality, sustainable places.
 
The Royal Society for Public Health recommend[2] measures to make our high streets more health promoting including differential rent classes and business rates relief based on how health promoting their business offer is. Planning should also restrict the opening of unhealthy outlets where there are already clusters.
 
With rising levels of poor mental health in Scotland, we overlook the importance of social cohesion and social support. A 2017 Harvard study, by Michael Zoorob, shows that communities with strong social capital were more likely to be insulated from the opioid crisis. Other studies[3] point to the value of community gardens or allotments and how responsible citizenship improves mental wellbeing. In Singapore, the open spaces associated with housing projects are used for exercise, meetings, affordable dining and markets.
 
Healthy communities also have to be sustainable communities. For example, tackling air pollution involves difficult decisions, but when it contributes to 2,500 early deaths in Scotland every year, urgent action is necessary. We need clean and fair transport systems, where public transport, walking, and cycling are valued as much as motor vehicles.
 
The latest NHS Health Scotland statistics suggest that 65 per cent of adults are overweight, with 29 per cent of this percentage being obese. Better access to community-based sports facilities would be an investment in addressing this issue – not a cost. The Scottish Parliament’s Health and Sport Committee report[4] on social prescribing argues that; “social prescribing, can contribute as part of preventative care for health and wellbeing. Addressing accessibility to, and awareness of, community and voluntary schemes will improve individuals' health and wellbeing outcomes.”
 
This would be easier to achieve if GP practices were physically situated in the community hubs we describe above in the chapter on public service reform. Social prescribing could be available to a range of health staff, including link workers and requires dedicated preventative budgets. The MSP report also highlights the growing inequality between active and non-active populations by area of deprivation, with its consequential health and wellbeing impacts.
 
During the pandemic, there has been brilliant community support for our NHS hospital, community and social care workforce who have responded magnificently. Welcome though the claps were, workers were all too often left exposed to unacceptable safety risks. 
 
One of the lessons learned must be the importance of local health planning and public health. Centralised solutions and computer apps took too long to organise and were often unfit for purpose. Countries with strong locally based systems of contact and trace using staff who know their local community did markedly better.  
 
The pandemic has also exposed the frailty of our fragmented and under-resourced social care 'system' in Scotland. A disproportionate number of deaths from Covid-19 were in care homes, who have struggled with inadequate staffing and very limited PPE. As Nick Kempe’s paper[5] for Common Weal points out, this was a predictable crisis, exacerbated by the decision to transfer people from hospitals without proper testing in the early weeks of the crisis. He argues that:
 
“Scotland has a regulatory framework which puts private ownership and private financial interests before care and there are no effective mechanisms for improving standards of care in failing Care Homes. 'Partnership working' (cooperation with private companies) comes before standards.”
 
If you talk to care staff in countries like Norway, who have a more local system of care, they emphasise the importance of local accountability. As one care home manager explained, “a man from Oslo comes once a year with a clip board. But real accountability is being challenged by local people in the shops”. We need to rethink the whole approach to care homes, including privatisation, and strengthen links with communities, rather than segregating older people.
 
The home care system is equally fragmented, even if somewhat less privatised. There is a strong case for setting a consistent framework for social care while retaining local delivery. We need integration and parity of esteem and a Scottish Care Service could be part of that solution. We should also not forget support for informal carers who have faced additional pressure during the pandemic. 
 
It has been claimed that COVID-19 is a 'great leveller'. The emerging data shows it is nothing of the sort. As ever, it is the poor and vulnerable who suffer the most, with particular concerns for BAME groups and the elderly. The ‘Black Lives Matter’ protests have highlighted many aspects of racism, few of which Scotland is exempt from. Stronger communities are open, welcoming communities, where racism is recognised and challenged. 
 
The pandemic is already increasing health inequalities and any return to austerity economics will exacerbate inequality. The new normal requires a public health approach that tackles health inequalities locally and nationally.


[1] http://www.healthscotland.scot/media/1394/place-standard-process-evaluation_may2017_english.pdf
 

[2] https://www.rsph.org.uk/uploads/assets/uploaded/dbdbb8e5-4375-4143-a3bb7c6455f398de.pdf
 

[3] https://theconversation.com/volunteering-mutual-aid-and-lockdown-has-shifted-our-sense-of-happiness-141352
 

[4] https://digitalpublications.parliament.scot/Committees/Report/HS/2019/12/4/Social-Prescribing--physical-activity-is-an-investment--not-a-cost#Background-to-the-inquiry
 

[5] https://commonweal.scot/policy-library/predictable-crisis