This is a paper from the Tony Blair Institute for Global Change. When we think of Tony Blair and 'change', the immediate reaction is centralisation and marketisation, which were features of public service delivery under his government. Although, to be fair, it was also a period of increased spending.

The paper starts with a positive take, saying "Scotland has structural advantages that make it well-placed to test and adopt new technologies at pace. It has a density of academic and clinical expertise, strong public-health infrastructure, and relatively direct lines of accountability between the organisations delivering health care and politicians who are responsible for delivery. This enables Scotland to act cohesively." This is an interesting position, given that he was less than pleased when the Labour/Lib Dem coalition refused to adopt the NHS market model he introduced in England. We went for coherence, not marketisation.

It is hard to disagree with the paper's take on the state of health in Scotland. Healthy life expectancy has fallen to a ten-year low, and NHS productivity has declined. The number of Scots out of work due to sickness and disability is at a 20-year high. "The next government must now convert long-standing ambition into delivery."

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

With NHS reform getting a lot of attention, the Socialist Health Association Scotland has published a discussion paper I drafted that outlines the issues and seeks views on the way ahead. It is vital that those who support the founding principles of the NHS engage in this debate and don't leave it to those who use 'reform' as a code for the privatisation of healthcare.
 
Nicola Sturgeon’s resignation has reminded everyone that she was the first SNP Health Secretary in 2007, holding the post until 2012. It has to be said she started well, building up constructive relationships with the trade unions. The previous Labour Health Minister, Andy Kerr, did many positive things but could be abrasive. In the main, she continued with the previous government’s policies. Labour had ended the marketisation of the NHS, abolished NHS Trusts, and introduced cooperation rather than competition. She went a little further by outlawing private companies running GP practices, a growing trend in England, and further developed the NHS partnership model of industrial relations. But, overall, it was continuity with emollience.
 
However, while continuity has its strengths, it also meant tough political decisions were ducked. Nicola Sturgeon binned a report by Professor David Kerr that proposed a shift from hospital to community care, with better social care integration. Consequently, when budgets tightened with austerity, bed numbers fell, but social care capacity did not respond to growing demand from an ageing population. After promising to scrap PFI, they rebranded it. Instead, we got worthwhile reforms around minimum alcohol pricing and free prescriptions, but the significant structural challenges were ignored. The focus on inequality and prevention, recommended by the Christie Commission, is still gathering dust on the shelf.
 
Now, in the wake of a pandemic, these long-standing issues are biting the NHS with a vengeance. Waiting times have spiralled along with staff vacancy rates, ambulances queue outside A&E, cancer treatment has slowed, drug deaths have doubled, and health inequalities are worsening. Even when they eventually got around to reforming social care, they took a sensible National Care Service plan around national frameworks and turned it into a centralised monster - devouring local government and community services in its wake. 
 
So, it is now left to others to pursue genuine reform. Not Tory privatisation or insurance systems which, as Gordon Brown highlights, would add more costs to an NHS whose spending levels have not matched similar countries. A point seemingly lost on a particular Green Scottish Government minister as well.
 
As for Scottish Labour's new plan to merge health boards, that is fine as far as it goes. I recall coming across the same plan presented to a pre-devolution health minister when I worked in the health department. The problem is that merging acute boards makes sense only if you manage community services in another way. We have tried many different ways of doing this since Joint Finance in the 1970s, and none have been a complete success.
 
An actual reform programme would start by tackling the underlying causes of ill health. It is a national disgrace that men in the most deprived areas of Scotland not only live 14 years less but can expect to spend 35% of their lives in poor health. NHS capacity has to be grown, not cut. That means better primary care, dentistry and more beds in our hospitals. A fully integrated NHS that ends the costly small business model and the growth of corporate dentistry, financed from tax havens. 
 
A National Care Service based on local accountability, which improves pay and conditions for carers in Scotland, improving the quality of social care and relieving the pressure on hospital capacity. We now have more patients that don’t need to be in a hospital than the number of beds in our largest hospital. We also need proper workforce planning and fair pay and conditions to tackle recruitment and retention in health and social care, ending reliance on exorbitant agency costs, locums, staff banks, and the private sector.
 
And last but not least, recognising that one size does not fit all in a diverse Scotland. A strategy for rural health care services.
 
The NHS is on life support. However, real reform must address the underlying pressures, which means tackling health inequalities and social care.

The current NHS crisis has spawned a flurry of proposed reforms to the National Health Service. They range from privatisation to the use of volunteers. However, most miss the point. The underlying problem facing the NHS across the UK is the failure to invest in social care.

The most obvious symptom of the NHS crisis is Accident and Emergency (A&E). Less than 68% of people were assessed, treated, admitted or discharged within the Scottish Government’s four-hour A&E target. More than 6,800 people spent more than 12 hours in A&E in October. While there is much in the Scottish Futures report to agree with, including patient-centred care, more volunteers doesn’t hack it. While the different NHS systems in the UK should cooperate, their emphasis on this is more political than practical. NHS Scotland is big enough to operate mainly on its own. More UK bureaucracy won't help.

​The latest NHS Scotland delayed discharge statistics illustrate the need to focus on social care. A delayed discharge occurs when a hospital patient who is clinically ready for discharge from inpatient hospital care continues to occupy a hospital bed beyond the date they are ready for discharge. In October 2022, the average number of beds occupied per day due to delayed discharges was 1,898, the highest figure since the current guidance came into place in July 2016. To put this number in context, the Queen Elizabeth University Hospital in Glasgow has 1677 beds. So, delayed discharge is the equivalent of our largest hospital and then some. The chart below shows this is not a short-term blip.

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.

As the UK and Scottish Governments start the process towards another round of Austerity, we need to remember the impact this will have on health inequalities. Those in Scotland’s most deprived areas are 3.9 times more likely to die from an avoidable death than those in the least deprived areas. The leading causes of avoidable deaths were cancers, circulatory system diseases and alcohol and drug-related issues, and Covid-19. In addition, life expectancy in Scotland has been two years lower than in other UK countries for decades.

Mortality rates in higher-income countries have steadily improved for more than a century. However, these improvements started to stall after the last round of Austerity in 2012, actually increasing in the most deprived areas. In 2019, the UK ranked 24th in the OECD in life expectancy, behind all other English-speaking countries (except the US) and nearly all countries of Western Europe.
​
These trends were noticeable before the pandemic, which has exacerbated them, but there has been no return to pre-pandemic levels. As a GCPH/University of Glasgow report highlighted, ‘there has been a stalling of improvement overall, accompanied by increasing death rates among large sections of the population living in more socioeconomically deprived areas. This is hugely worrying. Put simply, we should not see such trends in a wealthy society such as the UK.’ Austerity is evidenced as making an important and substantial contribution to these trends.

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.

Audit Scotland has published a pretty scary analysis of NHS Scotland today as we hopefully move into the post-pandemic recovery phase. There are four key messages:

1  The NHS in Scotland is operating on an emergency footing and remains under severe pressure. Covid-19 has created a growing backlog of patients waiting much longer for treatment. The backlog poses a significant risk to the Scottish Government’s recovery plans, which aim to transform how care is delivered. 

2  NHS and social care workforce planning has never been more important. It must also prioritise addressing workforce availability challenges if its recovery plan is to be successful. Its plans to recruit and retrain staff are ambitious and will be challenging to achieve given the NHS’s historical struggles to recruit enough people with the right skills.

3  The NHS’s ability to plan for recovery from Covid-19 remains hindered by a lack of robust and reliable data across several areas. This includes workforce data, as well as primary, community, social care and health inequality data. 

4  The NHS was not financially sustainable before the pandemic and responding to Covid-19 has increased those pressures, and there is uncertainty about future Covid-19 funding levels and the longer-term financial position. The key to financial stability remains a clear focus on the Scottish Government’s long-standing commitment to transform how health and social care services are delivered.

When the auditor says the recovery plan is "ambitious" that ought to be translated to something more like "unlikely to be achieved" or even "unrealistic", and from paragraph 79, "not thought through". A good example is delayed discharges, which have returned to pre-pandemic levels. A clear indication that social care needs immediate action.

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 pandemic has seen many key workers going far beyond their contract of employment to keep services running. That is particularly the case for health and care workers who have worked incredibly hard, at no small risk to themselves, to prevent the spread of the virus and treat those affected. It is time we recognised this commitment through a Health and Care Workers Covenant and that employers take action to minimise the impact on workers and their families.

Research shows that people who work in jobs like care, which are often called a calling, tend to have higher levels of resilience against the negative effects of overwork and stress and are less likely to experience burnout. However, that resilience can come at a price, both individually and for their friends and families. In a recent article, the authors argue that the families of workers in such roles also suffer massively. Called people can struggle to switch off after work and are less able to manage a balance between work and private life. Divorces and difficult relationships with children are not uncommon, as are exhausted family members. That is bad enough for the individual workers, but families shouldn't pay the price of their loved ones’ self-sacrifice.

Too many employers in the health and care sector have an operating model that depends on these workers going the extra mile. And we as a society also expect these workers to go beyond their contracts, particularly during the pandemic. They have delivered for us in challenging circumstances through governments' faltering actions and often without proper protective equipment and other safety measures. Employers have a duty of care to address this. I have recently been working with one social care organisation who have recognised this and taken a range of actions. But others take this level of commitment for granted.

NHS workers have had to deal with much larger numbers of critically ill patients than normal. Often in a far from an ideal situation, knowing this may lead to poor outcomes for their patients. This is having an impact on their mental health. A recent study of staff working in critical care during the pandemic showed they report more than twice the rate of probable post-traumatic stress disorder (PTSD) found in military veterans who’ve recently experienced combat. The authors of this study argue that there might be some lessons we can learn from PTSD in military veterans to help NHS workers cope during the pandemic. Both during the trauma and in the recovery period.

The link to the military is one made by a number of Socialist Health Association Scotland members who raised the idea of a Health and Care Workers Covenant. This is modelled on the existing Armed Forces Covenant while recognising the important differences between the groups of workers. Not least gender, insecure work and the wider range of employers and unpaid carers. Their proposal, published today, outlines and promotes the concept of a covenant. The elements could include commitments on pay and conditions, training, safety equipment, and occupational health. It should also engage the wider community as some business have already done with staff discounts. It should be taken forward as a partnership involving government, local authorities, trade unions, care providers, carer representatives and others. 

It is important to emphasise that a Health and Care Workers Covenant is not a substitute for collective bargaining and strong trade union organisation. This remains the best way to protect and improve the pay and conditions of these workers. The implementation of the Fair Work Convention recommendations, as supported by the Review of Adult Social Care, would be an important starting point. 

We need to pay workers with something more than just gratitude, and a covenant is an additional way of society recognising the sacrifices these workers and their families make for us all.

​cross posted from Dave Watson's blog.

We are conducting a snap poll of members to decide our nomination. After that members who are Affiliated and Full members of the Labour Party will get an individual vote. Here are statements from the candidates.

Monica Lennon
As a working-class girl growing up in Lanarkshire, it never crossed my mind that one day I would be seeking to lead the Scottish Labour Party.

I learned about the workplace from my dad, who got a second chance at education and worked his way up to be a health and safety manager within the local council. He cared about people having dignity at work and for their physical and mental well-being, when stress and mental health was rarely discussed.

My dad had his own battles, mainly with alcohol, which led to early retirement at fifty and his death from his alcohol-related illnesses at sixty. This left me heartbroken but determined to fight for better healthcare and support for people before they reach a crisis.

First as a local councillor, and now as an MSP and party health and social care spokesperson, my politics remains rooted in making life better for working people and ending poverty. In my first term in Parliament I have delivered the world-leading Period Products Bill, working with trade unions and people from all walks of life.

The pandemic has exposed and exacerbated the health and wealth inequalities that existed before Covid-19.  Our NHS and social care services have been pushed to the brink.  With too little support, our front-line workers have battled every day saving lives while risking their own.  Health and social care must get the attention and resources it needs. 

As Scottish Labour leader, I will be a friend and ally to the Socialist Health Association, I will work with you to realise our shared ambition of a world-leading integrated healthcare system, including a publicly-owned National Care Service. 

I am seeking a supporting nomination from the Socialist Health Association Scotland, so that we can demonstrate together how we will put our socialist principles into action to meets the needs of Scotland today and for the future. We need to protect and build on a progressive policy agenda, one that I helped Richard Leonard to build. There is too much at stake to let the Scottish Labour Party drift in another direction.

Working people need the Scottish Labour Party to be in safe hands. Too many people in Scotland have nothing and that’s why I’m not prepared to sit on the side-lines. I am part of a new generation of leadership. 
​
I can promise you that I will be true to our shared values and I have the best interests of the Scottish Labour Party and our affiliates at heart. It would be an honour to have your support.

Anas Sarwar
The last year has been a very difficult one for people across the country, with lives and livelihoods tragically lost. 2020 demonstrated who the real heroes are that keep our country running. Our wonderful nurses, carers, cleaners and so many more key workers sacrificed so much to keep Scotland going.  These are the workers who must be respected, rewarded and appreciated.  
 
We learnt how, despite the incredible commitment by NHS staff – by the nurses holding the hands of those all alone in ICU, the cleaners and porters working longer and more gruelling hours, the doctors fighting against the virus on the frontline day in, day out – our National Health Service has been left severely vulnerable, underfunded and left behind.
 
It taught us about some of the deeply ingrained, systemic injustices running deep through our society – the poverty that can lock families out of opportunity for generations, the racism that has taken a deep root and the impact of climate breakdown on communities across the planet.
 
2020 was the year that Labour needed to be there. To call out injustice, to fight for our workers and protect the hardest hit in society. The Labour Party in Scotland was not there and I am determined to change this, make a stand and work together with our trades union movement to ensure that key workers, who have scarified so much are championed and supported. 
 
I’m clear the next Parliament has to be a Covid recovery Parliament. We need a period of healing, to bring the country together, to build back better, to protect jobs and to fix our education system.
 
And I will work every day to deliver an NHS that never again has to choose between treating a virus or treating cancer.
 
The pandemic has exposed the need to look again at our NHS and how we do health in this country. Ill health and life expectancy isn’t just a health issue, its economic, its social, educational and environmental. Social and economic inequality lies at the heart of health inequality.
 
And some say that Covid was a great leveller. They are wrong. It’s the poorest, it’s BAME communities, the most excluded or vulnerable who are paying the greatest price. This has to change.
 
The pandemic has also taught us that our social care model isn’t working. The National Care Service is an idea whose time has come. The current system is broken, often overlooked by policy makers and undervalued by Government. For those receiving care, their families and care workers, we need to do better.
 
With your support, I will ensure Scottish Labour becomes the credible and trusted opposition I know we can be. l'll do this by working with key workers, trades unions, experts and business leaders across Scotland to build a platform that looks to the future.
 
With your support, I will champion voices from across Scotland and our movement. I will work hard to bring all of us together, so we can rebuild our party, and rebuild Scotland.

SHA Scotland and SHA Wales/Cymru are holding a joint event on the future of social care in the devolved nations.

The aim of his event is to understand the challenges facing social care in the devolved nations and the lessons learned during the pandemic. It will then look at the way forward and how social care might be reformed to meet these challenges.

The event will take place on Monday 1 February 2021 starting at 7pm and finishing by 8:30pm. It will be held over Zoom.

This is an open meeting. SHA members in the devolved nations will be sent a direct invite, others will have to register by emailing: [email protected].
The link will be sent to all those registering the day before the meeting. 

After introductions from the Chair, Alison Scouller (SHA Wales/Cymru), Tony Beddow (SHA Wales/Cymru) and Dave Watson (SHA Scotland) will make presentations on the social care delivery, challenges and reform initiatives in their respective nations. This will be followed by responses from two political leaders; Julie Morgan MS the Deputy Minister for Health and Social Services in the Welsh Government, and Monica Lennon MSP, Scottish Labour’s Shadow Health and Social Care Minister.

Speaker biographies
 
Julie Morgan MS
Julie been a Member of the Senedd for Cardiff North since the 2011. She was previously the Westminster MP for Cardiff North from 1997 until 2010. Before entering parliament she had a career in social work with Barry Social Dervices and the charity Barnardo’s. She is currently the Deputy Minister for Health and Social services in the Welsh Government.
 
Monica Lennon MSP
Monica has served as a Member of the Scottish Parliament (MSP) for the Central Scotland region since 2016. She has been its Spokesperson for Health and Sport since 2018 and was previously the spokesperson for Communities and Local Government. Before entering politics, she had a career in planning. Most recently she championed a members bill to tackle period poverty which is the world's first legislation to make it mandatory for all public institutions to provide sanitary products. 
 
Dave Watson
Dave is the Secretary of the Socialist Health Association Scotland. He retired as head of policy and public affairs at UNISON Scotland in October 2018, and currently works on policy development projects, including leading work on Scottish Labour manifesto for the 2021 Scottish Parliament elections. He was previously seconded to the Scottish Government to implement a radically new human resources strategy for NHS Scotland. He subsequently served on the NHS Scotland Management Board and was an expert advisor to the Christie Commission on public sector reform. 
 
Tony Beddow
Tony is a career health service administrator and planner. He held a range of posts in the NHS including Chief Executive for Morriston NHS Trust. He then joined the Welsh Institute for Health and Social Care at the University of Glamorgan undertaking projects for the Welsh and UK, governments and international bodies. He was seconded to the Welsh Office and was a special advisor to Edwina Hart, the Welsh Health Minister, when the devolved Labour Welsh Government removed the internal market. He was secretary of SHA Cymru Wales for many years until 2020, has been a member of Central Council and UK Vice Chair.  He is currently an independent member of the Adult Social Services Performance and Scrutiny Committee of the City and County of Swansea.

New research published in BMJ Open looks at recent changes in mortality rates (pre-pandemic) across the countries and key cities of the UK.
 
Mortality rates in Scotland and the UK have fallen consistently over centuries. However, since 2012, the rate of improvement has slowed, with a ‘levelling off’ of previously falling rates – and some suggestion of increasing rates in some parts of the country. This is unprecedented and is indicative of serious problems occurring in society.
 
There were four key findings:

• The stalling or slow down of improvements in mortality happened across the countries and cities in the UK. 
• The data masks increasing death rates in deprived communities, widening mortality inequalities.
• There are a broad set of different causes of death. These include both chronic conditions such as respiratory and cardiovascular diseases, as well as more socially influenced causes such as alcohol and drug-related deaths.
• Scotland stands out in terms of its much higher rates of drug-related deaths. Among all the UK cities, Dundee now has the highest rate of death for this cause.

​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