Health inequalities remain Scotland’s most enduring problem as this week's GCHP report shows yet again. Life expectancy between the wealthiest and poorest areas remains stubbornly high. The SNP manifesto included a brief mention of health inequalities and that in the context of public health, with the promise of a new strategy on diet and obesity. Of much greater significance will be commitments to new housing and income support through devolved welfare powers. However, these measures will be constrained by the impact of austerity on public spending in Scotland and the limited use of new taxation powers.
One of the few SNP manifesto spending commitments is an increase in the NHS revenue budget by £500m ‘by the end of this parliament’. This is a modest increase over five years that should be funded from the Barnett consequential of English NHS spending.
As we will be relying on these Barnett consequentials, we should take a closer interest in what is happening south of the border. Professor Andrew Street at the University of York points out that the claimed £8.4bn increase in English spending by 2020-21 is actually closer to £4.5bn. The average 0.8% looks very low. The modest £500m increase promised for NHS Scotland therefore looks like John Swinney’s pragmatic assessment of the Barnet consequentials.
NHS England has highlighted a £30bn spending gap by 2020/21, of which the UK government claims to be providing £8bn. Wage and drug costs; a growing and ageing population; and a trend in activity demand, over and above the demographics, explains the gap. There are similar pressures in Scotland. Even if our population growth is slower than England, we have an older population and poorer health that drives up costs. NHS England’s ‘Five Year Forward View’ has some pretty optimistic solutions, including ‘a radical upgrade in prevention and public health’ and a shift to primary care.
It is not even clear that the Barnett consequentials will reach actual health board budgets, which are already under pressure. The SNP manifesto unhelpfully compounds the annual increase and claims it totals £2bn over the parliament. However, they are also committed to investing £1.3bn ‘from the NHS to integrated partnerships to build up social care capacity’. It is unclear if that is over and above the NHS revenue increase. It wasn’t in this year’s budget and it is hard to see where else this money is going to come from.
As councils deliver social care, this is a big dent in the NHS spend, although few would dispute the priority given to social care that is in a state of crisis and the need to end the waste in bed blocking. It will also help pay for the commitment to pay the living wage - an important first step in improving the recruitment and retention of staff in the sector.
There are some other specific spending commitments. £150m has been identified for mental health services. This is welcome and there were similar commitments in all the party manifestos; demonstrating that the underfunding of these services, particularly for children, has attracted everyone’s attention. There is also £200m for five elective treatment services, although the adequacy of that budget has been questioned and it is a suspiciously round number!
The number of staff working for NHS Scotland recovered to its pre-crash levels last year and is likely to grow again. There is a commitment to an extra 500 health visitors, training for an additional 500 advanced nurse practitioners, 250 Community Link Workers and 1000 paramedics ‘working in the community’. There will be another 100 GP training places and £23m to increase the number of medical school places. Extra staff on the establishment will be welcome, but given the number of vacancies at present, it may be some time before actual bodies appear on the ground.
As in England, the Scottish Government is looking to reform to plug at least some of the financial gap. The SNP manifesto says “The number, structure and regulation of health boards – and their relationships with local councils – will be reviewed, with a view to reducing unnecessary backroom duplication and removing structural impediments to better care”.
Reducing the number of health boards is a practical proposition when it comes to acute services and could be built around three or four major trauma centres. It is much more challenging when it comes to community services.
It is here that much will be expected from the new Integrated Joint Boards and it remains to be seen if these will continue as joint boards or morph into stand alone bodies. That will probably depend on how successful they are. Another option, as happens in other parts of Europe, is to move these services into local government. That option is unlikely in Scotland given the Scottish Government’s antipathy towards councils. The next GP contract could also be an opportunity to reform the antiquated small-business model, into something that is more integrated into the NHS or the IJBs.
What seems clear, is that the additional NHS staff and investment in social care are primarily focused on achieving what the SNP manifesto describes as “ensuring that our NHS develops as a Community Health Service”. Few would argue with that priority, as shifting resources from acute to primary care makes absolute sense. However, it has been an objective of many different governments over the years, in less challenging financial circumstances.
This is of course a minority government, but despite regular squabbling in parliament, there is a large degree of political consensus over health. Even the Tories are not immune from that consensus with little evidence of the market ideology that drives their counterparts in England. Labour and the Greens both put greater emphasis on tackling health inequalities and that also requires a shift from acute to preventative primary care services. If there is a difference in approach, it is structural - the opposition parties have a common preference for localism over centralisation.
On this basis, there appears to be a common understanding of the problems. The challenge remains to deliver the solutions in the context of austerity.