Socialist Health Association

Scotland

SHA Scotland Response to the Scottish Government Consultation on Better Health, Better Care: A Discussion Document

November 2007

Introduction

The Socialist Health Association Scotland welcomes the opportunity to respond to the Scottish Government’s consultation paper Better Health, Better Care. The SHA was founded as a socialist organisation in 1930 to campaign for a National Health Service. We are an autonomous section of the UK Socialist Health Association with a wide ranging membership in Scotland who supports a socialist approach to the provision of health care.

Principles

Before responding in detail to the issues outlined in the paper we believe it is vital that the government establishes key principles that should underpin our nation’s health policy. We believe these are clearly set out in the SHA Scotland Principles for a Healthy Scotland:

· SHA Scotland is committed to a broad public health approach to health policy. Medical treatment and other therapeutic approaches will not, on their own, radically improve health in Scotland. There are unacceptable health inequalities in Scotland that must be addressed if we are to tackle the nation’s major health problems.

· SHA Scotland campaigned for devolution and welcomes the fact that health policy is devolved to the Scottish Parliament. Whilst we retain an international outlook we believe that devolution allows us to develop Scottish solutions to Scottish problems.

· The fundamental principle of NHS Scotland should be that treatment is provided according to need and is free at the time of delivery. Charging has no role to play in the funding of NHS Scotland. Whilst we accept that not every possible treatment or service can or should be provided by NHS Scotland, any decision to provide or refuse a treatment should be based on need not ability to pay.

· SHA Scotland supports an extension of democratic accountability at all levels. This is more than simply electing representatives, important though that is, to public bodies. It means encouraging full participation in decisions with a statutory duty to involve users, staff and the community. It also requires genuine freedom of information, effective communication and transparency of all contracts and partnerships.

· The patient and other users of health care should be the focus of the service. Not as ‘customers’ but as partners, concerned about the quality and timing of their care. Partners with rights and responsibilities towards their health, to be treated with dignity and respect, having a real say in decisions and getting clear feedback at every stage in their treatment.

· Health and social care are essential public services and should be provided by directly employed staff committed to a public service ethos that includes selflessness, integrity, objectivity, openness, accountability, competence and equality. Privatisation through Public Private Partnerships and other market-based mechanisms has no place in a modern health care system.

· Collaboration between health and social care will be essential to deliver an effective and seamless service. SHA Scotland supports the development of public service networks. In a changing environment networks are a more rapid and effective method of responding to change than constant boundary reviews and statutory reorganisation.

· SHA Scotland recognises that high quality health care requires the recruitment and retention of high quality staff. This requires genuine partnership working with health trade unions at all levels, training and development, together with fair pay and conditions for all members of the health care team. We also believe that all health service staff should be salaried and wholly committed to public service and the ethos described above.

· High quality health care requires the capacity to deliver an effective service. This means a sustained commitment of resources to rebuild the damage inflicted by the years of Tory rule. Building service capacity will also allow the development of innovative services to meet the needs of users.

· SHA Scotland welcomes diversity and campaigns for equal access to health care irrespective of race, gender, sexuality, disability, age or creed.

· Our public health approach means that we will support the development of decent housing, education, protection of the environment, a democratically accountable public water service, food policy and health promotion.

Public Health

It is fundamental to SHA Scotland that health, health care and well-being should all be tackled from a public health rather than a medical perspective, because the application of medical technology alone will not optimise health and well-being. Scotland’s health is poor in comparison with other European countries and our life expectancy is poor compared with the rest of the UK. More than a quarter of adults smoke, similar numbers of men exceed the weekly limits of alcohol consumption and half the population do not have a healthy diet. There remains a persistent health gap between the most affluent and deprived communities.

Despite these figures progress has been made since 1997. Smoking rates have dropped from 34% to 27% and the numbers of people eating five portions of fruit and vegetables per day has increased from 18% to 34%. Whilst the deep-fried Mars bar may not be dead - the culture is changing and political leadership has been vital.

Public Health Minister

Because the public health perspective is so important, SHA Scotland believes that there should be a Minister for Public Health in the Scottish Government. We therefore welcome the establishment of a cross cutting remit for the Cabinet Secretary. Public health is not simply a health care issue. It covers the widest spectrum of life experiences that can be influenced by Scottish government action. It requires joined-up thought and action across a whole range of Scottish government departments.

Action to reduce health inequalities goes way beyond health care and involves devolved services like housing, education, the arts, the environment, leisure and transport. Each major department should therefore have its own health champion, and each department's contribution to public health should be audited annually. Scottish government, agencies, NDPBs and local government should undertake health and health inequalities impact assessments of any major new policy that is mooted.

Targets for improving the health of the population should take priority over targets for treatments, waiting lists and operations and they should be integral to the role of senior managers and members in local government as well as in NHS Scotland. The SHA Scotland's public health model of well-being requires government to focus far more on the prevention end of the spectrum than it currently does. Health care services do have a part to play, but only alongside a much wider range of activities.

Inequalities

Poverty and social inclusion are at the root of much of Scotland’s ill health. One in five people in Scotland live in low income households compared with 16% in Germany and France and 12% in Holland. 7.5% of the Scottish population are permanently sick or disabled and 20% have a long term illness that affects their daily activities. Average life expectancy for a boy born in Glasgow Shettleston is 64 compared to 78 in North-East Fife. The level of underweight babies in Glasgow, the most significant indicator of risk of chronic health, is almost at levels found in developing countries.

Some key determinants of ill health, such as poor educational attainment, income inequality, and child and family poverty are seldom mentioned in a health context, and the drive for new initiatives gets in the way of sustained follow through. The many excellent local initiatives to tackle poverty and deprivation must be accompanied by robust monitoring systems that can measure progress made in developing healthier communities.

Inequalities in dental health are even more marked, and the Scottish government should be pro-active in encouraging local authorities to use the existing provisions to fluoridate as much of Scotland’s water supply as possible at the earliest opportunity.

A healthier nation begins with healthier babies. It is known that poor health and nutrition in pregnant women causes health problems throughout the lives of the resulting children, yet young women are expected to subsist on benefit levels that are too low to support a healthy diet. We should support campaigns to press the UK government for an immediate increase in benefit levels for pregnant women, and policies should be put in place to help them consume healthy food.

We welcome the ministerial task force on health inequalities led by the Minister for Public Health. To take effective action on underlying problems such as quality of life, deprivation, homelessness, barriers to employment, addiction and the family environment in children’s early years, effective measures are needed to eradicate childhood poverty. As highlighted above most human diseases are strongly related to the socio-economic circumstances of individuals. We would argue that efforts to reduce our unacceptable level of child poverty will lead to narrowing of health inequalities. Others have drawn attention to the recent Unicef Report Card number 7, entitled, “Child poverty in perspective: An overview of child well-being in rich countries.” Despite criticism of the methodology the main finding was that using the 18 indicators in 6 domains the UK is the worst country in the developed World for children. The highest position the UK achieves in any section, the Health & Safety section, is 12^th not even half way! This is a very poor performance. The countries at the top of the league; Holland, Sweden, Denmark and Finland are where we should be looking if we want an effective model to improve our society, improve our health and reduce health inequalities. The model of a country with low poverty rates and narrower income inequalities; a more inclusive and we would argue more socialist society.

Schools

Free, healthy school meals should be universally available. Many children entitled to free school meals don't take them because of the stigma. We therefore welcome the pilot scheme for free school meals that we believe will deliver similar health benefits to those gained in Hull under the previous Labour administration. Children should be able to drink water freely throughout the day, and free school milk should be available to all. Cooking is an important skill in its own right, and government cannot assume that this is learned in the home. Budgeting and shopping for healthy food, and then cooking it, should be a part of the curriculum. The duty of care owed by schools to their pupils extends to their diet. Young children should not be given the freedom to eat too much fat, salt and sugar at school just because the damage done to their health is not immediately apparent. Diet can also be used to approach indiscipline problems in schools - a much sounder way than relying on medication for poorly defined conditions like "attention deficit disorder".

Regular sports, dance and other exercise must be re-introduced to the school timetable to tackle the increasing problem of childhood obesity. Two hours of physical education per week will not suffice particularly as Scottish pupils now take part in less PE than nearly any other country in the developed world. Physical activity should also be complemented with a full arts curriculum to enhance self-esteem and mental well-being. Parents should be actively discouraged from taking their children to school in cars, and each school should be set a target to increase the number of children who get to school by walking or cycling where this can be done safely.

There should be a total ban on the advertising of unhealthy food that is directed at children, and machines selling fizzy drinks and unsuitable foods should be removed immediately from all schools and colleges. Commercial schemes that encourage children to eat unhealthy food to obtain "benefits" for their schools must also be outlawed.

At school, learning to live healthy lives should have a place in the Curriculum, where young people can discuss their own and their community's health. Informing children about the realities of drugs, the dangers of smoking, the need for healthy eating and sensible drinking, and the social, interpersonal and health aspects of sex should all form part of a broader health and social education.

Sensitive issues must be tackled head on. The topics of drug, alcohol and tobacco abuse are often avoided because they are controversial, yet children respond well to factual information on such matters. Education in sexual health and teenage pregnancy issues must not be left to the sole discretion of schools, and the Dutch experience indicates that this should start early in primary school. Health Boards and local authorities should jointly employ community health advisers to provide practical outreach support to schools and communities, drawing in additional support from the voluntary sector. School health would also be supported by a commitment to provide at least one full-time qualified school nurse for each secondary school and its primary cluster.

Healthy Lifestyles

The Scottish government must continue to mount regular healthy living campaigns through the media, supported by high quality public information material on healthy lifestyles suitable for a wide range of audiences available at local and community outlets.

Healthier lifestyle choices must become easier choices. Most poor people know what they must do to keep themselves healthy, but lack the means to do so. It is time for Scotland and the UK to have a proper measure of the income level needed to avoid both absolute and relative poverty and ensure good health, satisfactory child development and social inclusion. This measure should determine the UK government’s benefit, pension and minimum wage levels and it should inform the practices of debt collectors and the courts. SHA Scotland supports the abolition of all prescription charges and therefore welcomes the commitment to this policy in the consultation paper.

Drugs, alcohol, smoking, inactivity and unhealthy eating habits between them account for a massive proportion of ill health, and differences in their prevalence reflect social and economic inequalities, which will be addressed as part of the Scottish government's social inclusion policies. Government should work with the food and drinks industry to help them develop an informed public health approach to the merchandise that they produce.

The food industry should be encouraged not to use excessive amounts of sugar and fat in prepared foodstuffs, and salt should be excluded altogether where practicable. The addition of salt to any food should be a matter of individual choice. All food and drink should be clearly marked with the percentage of salt, fat and sugar that they contain. Common Agricultural Policy subsidies to support the production of tobacco and sugar should end forthwith. They give very mixed messages when government is exhorting people not to smoke and to reduce their consumption of sweet foods.

Whilst we recognise that this is a reserved issue we also suggest that fluoride toothpaste should be reclassified to make it exempt from VAT and therefore cheaper to buy. We do recognise the need to maintain tax revenues and we suggest the addition of VAT to confectionery and foodstuffs with a high proportion of added sugars. Improving diet will have wider benefits on other key Government priorities such as obesity, coronary heart disease, stroke, cancer and diabetes.

We strongly supported the Scottish government’s legislation banning smoking in enclosed areas.

Tobacco is a major cause of premature death and disease including oral diseases. It specifically causes oral cancer and is a contributory factor in periodontal (gum) disease leading to tooth loss. It also stains teeth and restorations and a tobacco-smoking habit produces serious oral malodour (halitosis or bad breath) for the tobacco addict. We welcome plans to increase the age at which individuals can buy tobacco to 18 years. Stricter enforcement of laws on underage tobacco and alcohol sales would directly benefit young people and send a powerful message to change the culture on tobacco and alcohol use.

SHA Scotland recognises the dilemma the Scottish government faces in striking the right balance between persuasion and prescription over individual lifestyles. However, it believes that at the moment the government errs too far on the side of persuasion. Individuals are often denied the information they need to make informed choices. Manufacturers do their best to confuse the public about health risks of many foods and drink, and government at all levels does too little to stop them.

Drug Misuse

SHA Scotland believes that we need to open up a comprehensive debate on drug misuse in Scotland including whether or not it is now time to de-criminalise the use and supply of drugs.

There are those (including the SHA in England) who argue that prohibition has failed, and worse, that it has brought with it other issues such as organised crime, street crime and gun crime that all impact adversely on community safety and hence on health and well-being. It is therefore argued that the only rational response is to provide the requisite drugs on prescription to addicts, within a regulated framework that assures an adequate supply, the purity of the drugs; and mandatory participation in a care, treatment and rehabilitation programme. This is what is done, more or less, with alcohol misuse. They contend that the legalisation of drug use and supply will have a direct and positive impact on health and well-being; and the indirect impact on crime reduction might be even greater, with a differentially beneficial effect on socially excluded communities living in areas of high deprivation.

SHA Scotland acknowledges that this is not a matter to be addressed without a great deal of thought, consultation and debate, but it believes this is an issue that the Scottish government should take very seriously by promoting an informed debate on drug policy.

In the short term we remain unconvinced that zero-tolerance drug policies adopted by the UN Office on Crime and Drugs (heavily influenced by the US) are the right solution for Scotland. We should support pragmatic evidence based approaches to tackling drug problems that include abstinence, detox and harm reduction. Harm reduction programmes have substantially reduced the problem with both HIV and hepatitis in Scotland. Methadone and needle exchanges remain an essential element of a balanced programme to address the drugs problem.

Alcohol Abuse

Alcohol is estimated to be a factor in half of all violent crime, a third of domestic violence incidents and a quarter of all suicides. Not to mention thousands of assaults on public service staff every year. Again multi-agency approaches are best including reform of the licensing laws being promoted by the Scottish Government. We are not convinced that the 24 hour ‘liberalisation’ of licensing laws in England is the best way forward in Scotland.

The NHS should work with Community Safety Partnerships to assist with the collating and analysis of data and channel solutions into national strategies.

NHS Scotland

NHS Scotland is a victim of its own success in delivering major advances in medical science which have transformed the outcomes of many formerly untreatable illnesses. Despite its relatively poor health record, people in Scotland are healthier than ever before. This has created rising demand for accessible healthcare from finite resources leading to demand-supply imbalances. The latter are being accentuated by an ageing population whose health needs increase inexorably with advancing years.

NHS Scotland, most obviously in the acute hospital sector, suffers from a range of capacity constraints. Between 1990-91 and 2002-03 Scotland’s hospitals lost 22% of their adult acute beds and 41% of their geriatric beds. Although Scotland had 10% more doctors and 5% more nursing staff in 2002-03 than in 1998-99, constraints imposed by the European Working Time Directive (EWTD) on doctors working hours, new training requirements for trainee specialists, and new contracts for Consultants and General Practitioners has all reduced effective working times for medical staff. Imbalances between the output of doctors from the medical schools and increased demand have created shortages of specialists in key areas. Stressful working conditions and low morale have led to high wastage rates of trainee nurse, losses of trained nurses leaving the profession and resort to costly agency staff.

Whilst additional resources have been ploughed into NHS Scotland this has been at a slower rate than in England. Over the past five years expenditure in Scotland has risen annually by 6-7% compared with 8-9% South of the border. Rapidly closing the gap in expenditure from 20% to 12% per person more, barely enough to reflect our geography, demography and levels of deprivation. In England this additional funding has supported special initiatives including waiting times.

Centralisation and Local Care

The balance between centralisation of specialist treatment and locally delivered care has been in the forefront of public debate in Scotland over the last year leading to the inquiry led by Professor David Kerr. The cause of widespread protest is the prospective closure of smaller hospitals and/or the withdrawal of key services, particularly for acute surgical specialties. These now involve Health Boards across Scotland. The advocates of centralisation have two main arguments for their belief that “big is better”. First, it is argued, principally by the surgical Royal Colleges, that outcomes are better in large hospitals, ideally serving catchment areas of 500,000. Second, it is argued that pressures on medical staff resulting from compliance with the European Working Time Directive, new training requirements for junior doctors and the emergence of medical manpower shortages make the closure of small hospitals inevitable.

SHA Scotland organised a conference to discuss this issue. The overwhelming view of the politicians, health professionals, campaigners and members of the public attending the conference was that centralisation is driven by financial constraints, short term staffing problems and the convenience of consultants. Detailed sources were given that for the majority of common medical and surgical conditions, there is no statistical evidence of poorer clinical outcomes for patients in small compared with large hospitals.

We therefore welcome the commitment in the consultation paper to a presumption in favour of local care. It is rightly for those who wish to centralise to make the case. On this issue SHA Scotland believes we can learn from the Department of Health (DOH) in England approach to these issues as set out in “Keeping the NHS Local: a new Direction of Travel”.

In February 2003, the DOH produced a consultation paper, entitled “Keeping the NHS Local – biggest does not necessarily mean best”. This suggested a number of options for delivering acute inpatient and day case services from smaller hospitals without resorting to closure. A series of definitive papers from the DOH followed in July 2004, setting out these options in more detail, with examples of their implementation in smaller English hospitals. In two documents (The Configuring Hospital Evidence File: Parts One & Two), the DOH set out detailed evidence, which it fully accepts and forms the basis of current policy, that for the majority of common medical and surgical conditions, there is no statistical evidence of poorer clinical outcomes in small compared with large hospitals. Large hospitals are not ‘safer’ than smaller hospitals for the treatment of these conditions.

The Configuring Hospital Evidence File commends the use of Managed Clinical Networks, telemedicine and video links to ensure close communication between smaller and larger central hospitals with flexible rotation and on call rotas to facilitate compliance with the EWTD. Underpinned by this evidence, smaller hospital closures in England have reduced considerably.

Since our conference Professor Kerr published the inquiry report ‘Building a Health Service Fit for the Future’. This report sets out a framework for a health service focused on preventing ill health and providing as much care as possible in communities. Whilst there is much to do in implementing this framework, and in particular the balance of care, we believe it offers a positive way forward. Whilst we welcome the commitments on local care in this paper it has to be recognised that health boards have to be fully funded to implement the strategy.

The centralisation agenda being pursued by Scottish Health Boards is therefore not part of the Department of Health’s agenda for NHS modernisation in England or reflected in the Kerr recommendations. SHA Scotland believes that we can learn from this experience and develop a policy that will be warmly welcomed by the majority of the people of Scotland.

Choice for Patients

We particularly welcome the continuation of the Scottish public service model in relation to health as developed by the previous administration. This specifically rejects the approach in England based on the concept of ‘choice’. The SHA opposes any "choice" programme that treats health care as a commodity. A better principle is ‘responsiveness’.

At first glance "choice" appears attractive, but it should not be exercised at the expense of high quality, comprehensive and responsive health care that is locally provided. Patients will need much more information so that any choice they exercise will be based on a sound knowledge of alternatives, outcomes, and benefits. Patients should exercise choice as a part of the overall management of their own condition in partnership with health care professionals. Choice will be particularly important in the arena of mental health care.

Currently, choice is exercised mainly through the power to go elsewhere. That sort of choice outside urban areas can be difficult and with current centralisation of services, increasing meaningless even there. Choice of this sort is rarely a realistic option for those who are socially excluded and becomes merely an extension of the privileges of the middle classes. If active patients exercise choice by shunning a local provider because it cannot offer high quality care, it is likely that this provider would be allowed to fail, to the obvious detriment of those people who are unable to travel elsewhere

This is not to deny the importance of providing services that are responsive to user need. The aim should be to provide more convenient services delivered more quickly as locally as possible.

The best way to improve health care is through the universal application of the principles of clinical governance, supported by new NHSiS investment where needed. That ensures everyone has access to local comprehensive, high quality health care services, managed and provided by the NHSiS.

Cleaner Hospitals

Dirty hospitals increase the risk of hospital acquired infections such as MRSA and is unacceptable to patients and staff. Yet the number of cleaners working in the NHS has almost halved in the last 18 years.

SHA Scotland believes that more and better-trained cleaning staff is key to improving standards of hospital cleanliness. Hospitals need to have sufficient, properly trained and equipped cleaning staff, who are valued and rewarded as an important part of the healthcare team.

All cleaning services have suffered from the process of market testing, with even in-house services having been reduced to the lowest common denominator. It is the process of market testing that has driven down cleaning standards. In Scotland substantial progress has been made in bringing cleaning services back in-house, an important first step towards raising standards. The profit motive will always be an incentive to cut standards and all cleaning services, including PFI hospitals, should be managed in-house.

Cleaner hospitals also require all staff to play a role ensuring cleanliness and good infection control procedures.

Waiting Times

Long waiting times for treatment is obviously undesirable from any point of view. What matters to patients is not an endless argument over statistics or how many other people are on a list. What matters is how quickly they will be treated. The simple truth is that too many patients are waiting for too long.

This has been an issue of funding and capacity but it is also an issue of organisation. The solution is service redesign together with growing capacity. There are many local examples of good practice that need to be better shared as we end the market culture that has fragmented the service for so many years. One such example is the difference nurse-led services can make to waiting times. We remain unconvinced that a waiting time guarantee as outlined in the discussion paper is the correct way ahead.

Private Health Care

Whilst we recognise the modest scale of private sector expansion under the previous administration we believe that this is wrong in principle and in practice. We therefore welcome the Cabinet Secretary’s statement on this issue. There is no practical way the NHS can stop capacity being poached from NHS Scotland. Private medicine has always been a parasite on the NHS and it should not be encouraged with public money. In practice even the English approach of private treatment centres is running into major difficulties with both unhappy patients and the undermining of NHS capacity.

Studies from North America have confirmed that proposals to buy more clinical care from the private sector will cost more and deliver less. Investor owned hospitals had 19% higher costs largely because they are profit ‘maximisers’ not cost ‘minimisers’. Administrative and management costs were higher and nurse care lower. Worst of all skimpier care and lower quality resulted in 4547 unnecessary deaths. We have been warned!

Welcome initiatives such as the nationalisation of the Golden Jubilee hospital by the last administration is the correct way forward and should be developed further.

Hospital Catering

SHA Scotland commends the UNISON Scotland NHS Food for Good charter which seeks to ensure that the spending power of Scotland's biggest food buyer is used to improve the food economy and health of Scotland, whilst fulfilling its social and environmental responsibilities. The charter covers Organic Food; Animal Welfare; Meat Quality; Fair Trade; 5 Portions a Day; Recycling/Composting; Patients not Profit; Resources; Real Food; and Fair Pay. We should turn NHS catering into a world leader. One that benefits patients' health, improves the diets of tens of thousands of workers and significantly improves the food economy for all.

Prescription Drugs

SHA Scotland believes that we should follow the lead of the Welsh Assembly and abolish prescription charges. It makes more sense to abolish this charge and help those on low-income and also the chronically sick who otherwise go without buying much needed medicines prescribed by their GPs.

This could be funded by a radical approach to tackle the ever rising drug bill. Drug companies make a lucrative income from the NHSiS and much of the additional government cash for the NHSiS is being swallowed up by rising drug costs.. Pressure sales techniques on doctors have been well documented and SHA Scotland particularly supports the ‘No Free Lunch Organisation’ that campaigns for greater openness in the contacts between the medical profession and the drug companies. Nursing staff have now been subjected to these pressures since the introduction of nurse prescriptions in 2002.

Staff

The NHS is one of the largest employers in Scotland with around 147,000 staff (124,000WTE). Half the NHSiS budget is spent on pay. Therefore staffing issues are key to improving the NHSiS.

The NHSiS must engage with its entire staff, develop their vision and utilise their unique experience of delivering health and social care. The Scottish NHS partnership approach to industrial relations acknowledges the depth and strength of the commitment of all NHS staff to the ethos and values of public service.

Nurses

Increasing the supply of well-trained and qualified nurses, allied health care professionals, social workers, care assistants, and ancillary workers will make a huge difference to the provision of equitable services across all parts of the health care system.

Encouraging the large pool of qualified nurses doing other jobs, or not working, to rejoin the service could increase the supply of nurses relatively quickly. Raising the status of nurses, and changing the medical culture that treats them as second-class citizens will take longer, but clear signals should be given now. In the meantime, better pay and conditions, and more attention to team building and morale will be popular with both the public and the nursing profession.

SHA Scotland is particularly concerned over spending on agency nursing. The cost of which has risen by more than 80% in four years. This is not only poor value for money, but as highlighted by the Accounts Commission the use of temporary staff could affect quality of care.

A BBC investigation revealed that the drop-out rate of student nurses could be as high as 50% at some universities with millions of pounds is being wasted on training nurses who do not stay the course. Drop out rates in Scotland range between 19-35%. Much higher than other professions such as teaching with drop out rates as low as 8%. Among the reasons for the problem, were accommodation costs, child-care costs, the lack of professional support while on placement in hospitals and even a lack of academic support. SHA Scotland therefore supports UNISON’s Pay Not Poverty campaign, which calls for nursing and midwifery students to be given a proper salary rather than the meagre bursaries they receive now. Also reinstating nurses homes (or key worker housing support), many of which have been sold off, instead of forcing students to find expensive accommodation away from the hospital.

Over recent years, there has been a significant increase in the number of nurses working in Scotland from overseas, due to shortages in Scotland. However, many have experienced bad practice and discrimination, particularly in the private care sector. If the Fresh Talent initiative is to have real meaning we must provide better protection for staff recruited from abroad. Of course overseas recruitment must be based on ethical principles so that developing countries do not lose skilled healthcare staff.

Doctors

Further measures need to be taken to retain the 40% of doctors who train in Scotland and leave to work elsewhere before they qualify. More salaried GPs might also make that speciality attractive to those doctors who do not wish to run a small business. The creation of a new ‘specialist - generalist’ doctor might also be attractive to some staff and address the need to retain hospitals in rural communities.

Social Work

Health care cannot be considered separately from social care, and greater co-operation between the NHS and social services is essential. The poor image of social workers has become acute, and there should be regular campaigns to counter the low morale of social workers and the negative and unfair media coverage they often receive. The Scottish Government’s 21^st Century Action Plan should be implemented fully.

Other NHS Staff

For most people, the image that immediately springs to mind when they think of the NHS is doctors and nurses working in hospitals. But this isn't the whole story. The modern NHS team is made up of many different professions and skills working in different jobs and different settings. All play a crucial role in ensuring that patients receive the best care available.

Far from obstructing the work of doctors and nurses, managers and support staff are vital if clinicians are to be able to deliver first-class services to patients. Accusations that there has been a proliferation of 'pen-pushers' may make irresistible headlines. But, the claims are not only misleading, they are hugely damaging to the morale of hardworking NHS staff, and to the quality of the health debate.

Whilst Agenda for Change provides a modern pay system for the NHS there remains a need to finance compensation for the historic pay discrimination against women in NHS Scotland. NHS Scotland should positively implement the various equality duties.

Community Care

With the emphasis in public debate on the role of hospitals it is often overlooked that most health and social care is delivered in the community. 90% of patient contacts with NHS Scotland take place in primary care, increasingly with practice and community nurses as well as GPs. With an extension of staff roles, service redesign and technology far more services can be safely delivered in community settings including local diagnostic and treatment centres.

SHA Scotland believes that greater use should be made of salaried GPs. This is right in principal but also in practice as many doctors wish to focus on health care not running a small business. We also reject the provisions in the Smoking, Health and Social Care Act to allow joint venture companies to run health centres.

Community Health Partnerships should develop into the primary delivery mechanism for local care including all the staff and user interests including GPs. They should have a strong public health focus and we should examine ways of creating democratic accountability in the running of these services.

SHA Scotland fully supports the concept behind NHS24 as providing real support to many patients requiring help. The very real initial problems partially reflect its success in attracting many more callers than managers expected. Contrary to much of the media attention it is not a substitute for local out of hours services.

Dentistry

Dentistry in Scotland is in crisis with many patients unable to find NHS care. One-third of Scots are not registered with a dentist and children’s dental health in particular is suffering with no real improvement since 1998. Six out of ten children have dental disease by the age of 3.

The problem was caused by the Tories introducing a new contract in 1990 that cut fees together with the closing of some dental schools and a reduction in dentists in training. The result is a classic example of the damaging impact market forces can have on health care.

The Scottish government has begun to correct this problem by increasing the number of graduates and offering other financial incentives. But more radical action is required. There should be a step change away from private dentistry towards a comprehensive NHS service. This means salaried staff in local health centres achieved by a massive expansion of community dental services. Graduate numbers must be increased and in the short term additional dental staff should be recruited from overseas. The Action Plan for Improving NHS Dentistry was a welcome step forward but perhaps not as radical as claimed.

SHA Scotland welcomes the commitment to free prescription charges. At the very least Charges for NHS dentistry need to be reviewed urgently with a view to abolition. At present patients pay 80% of charges up to a maximum of £384 per course of treatment, by far the highest anywhere in the NHS.

For children and adults, the priority should be those with no dentist, particularly those from families with low income, or people who have chronic conditions. Over the last 20 years or so, the UK policy has favoured plurality of provision and ambivalence towards dental health as part of healthcare. This has to be reversed. We have to tackle the privatised structure of dentistry if we are to make a real step forward.

Social Care

Social care cannot be considered separately from health care, and greater co-operation between the NHS and social services is essential. More resources are needed to keep people in their own homes. Personal care contributes greatly to keeping people out of hospital, yet the role of carers is neglected. They also need proper support and resources.

The poor image of social workers has become acute, and there should be regular campaigns to counter the low morale of social workers and the negative and unfair media coverage they often receive. SHA Scotland commends recent initiatives between the trade unions and the Scottish government to attract more people into social work and develop and workforce capable of meeting new challenges.

Joint Future is an imaginative way of facilitating joint working between health boards and local authorities in order to provide seamless care. There are substantial challenges in providing services across different professional cultures, systems etc - but this approach is more flexible than structural change.

Direct Payments

On Direct Payments SHA Scotland recognises the impact that control over service provision can have in the enhancement of the independence and well being of many service users including, for example, disabled or elderly people. We are also aware that many people with significant care needs struggle to source a personal assistant or care provider for reasons connected to race, gender, location and other factors. However, in general we believe that appropriate user-focused care services can be delivered flexibly by public sector care providers and that employment under direct payments cannot be on terms any less favourable than those offered in the public sector. We particularly welcome the agreement reached between UNISON and users of direct payments to address these issues through a government funded project.

Within the direct payments sector there is a danger that a culture takes hold under which agencies and funders seek to avoid examining employer obligations in full detail for fear of scaring service users from taking on the role of employer. These are substantial responsibilities and must be taken seriously. Given the rationale behind the establishment of the Care Commission and the Social Services Council; and given what we know about the level of violence and abuse perpetrated by close family members; there is no good reason why the regulation of care and the registration of care staff should not extend to include the direct payments sector.

Mental Health

Mental health problems are among the commonest causes of ill health in Scotland. Around 30% of GP consultations relate to mental health. Scotland spends 40% more per head on antidepressant drugs than in England. 30,000 people are admitted to mental health hospital units, 10% under the age of 24. Scotland’s suicide rate (600-800 p.a.) is much higher than the UK rate and is increasing at the fastest rate in Europe. Child mental health is a particular concern. A study in Edinburgh identified that one in three senior schoolgirls admitted some form of physical self-harm.

SHA Scotland welcomes the National Programme for Improving Mental Health and Well-Being and its action programme. Raising awareness, eliminating stigma, preventing suicide and supporting recovery are clearly the right priorities. It is an oft quoted cliché to say that mental health is the ‘Cinderella service’ of the NHSiS – but it remains a truism. In particular we doubt if the limited funding for the action programme is sufficient to make a radical impact on Scotland’s poor mental health record.

There needs to be a greater emphasis on preventative services. The funding for crisis centres is a welcome recognition of need but can only be a limited response. The ‘Doing Well’ programme for people with depression is a welcome initiative and the lessons learned need to be supported. Greater support for Cognitive Behaviour Therapy (CBT) may be one approach to reducing the prevalence of medication.

As with other conditions we have to recognise that mental health is closely related to levels of poverty and deprivation. Whilst at least 5-10% of the population are suffering from depression and a further 10% from anxiety disorders, this rises to as high as 50% in areas of deprivation.

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