|
NHS Scotland 60th Anniversary
The SHA was founded in 1930 to campaign for a National Health Service. We
are therefore particularly pleased to wish NHS Scotland a happy 60th birthday.
In this paper we rightly celebrate the 60th anniversary of the National Health
Service as one of Labour’s greatest achievements in public office. However, the
main focus of this paper is to look forward. To identify some of the major
challenges facing the health of the nation and how our NHS and other public
services can best respond to these challenges.
The creation of the NHS in
Scotland
In the years immediately prior to the
creation of the NHS, Scotland had pioneered new forms of organised health care
that reflected a distinctive Scottish medical culture. These included the
Highlands and Islands Medical Service [HIMS] (1913), and the Clyde Basin
Experiment in Preventative Medicine (1941). Mainstream Scottish health care
combined elements of voluntary, municipal, provident, private and government
provision at both the hospital and community level.
The depression in the 1920s and 1930s, the lack of systematic provision for
health care at that time, the experience of communal action in war and the
efficiency of the wartime medical services all pointed to the need for a
national health service. Julian Tudor Hart, a Welsh GP and SHA activist,
believed that people who had experienced the effect of the market on services
meeting basic human needs, and the revelation that in wartime the market could
be overridden for great purposes, were resolved never to return to the old
system. It took a visionary Minister of Health, Aneurin Bevan to deliver the
wartime blueprint in the post war Labour government.
As a result of the National Health Service [NHS] (Scotland) Act 1947, the NHS
came into being in Scotland on 5 July 1948. It aimed to meet all health needs
free of direct charge to the citizen. It inherited over four hundred hospitals,
with accommodation for around sixty-thousand patients, formally vested in the
Secretary of State for Scotland [SSS] operating through the Department of Health
for Scotland [DHS]. Five Regional Hospital Boards [RHB] were created to
administer Scottish hospitals on a regional basis, through eighty-five local
Hospital Boards of Management [HBM].
The DHS also assumed overall responsibility for twenty-five Local Health
Authorities [LHA] which co-ordinated a variety of community based services.
General practitioners [GP], dentists, chemists and opticians remained
self-employed although they received payments for treating NHS patients and
there was co-ordination through local and national committees.
In 1948, at the launch of the NHS, a leaflet was delivered to every home – the
cover of which read:
“Your new National Health Service begins on 5th July. What is it? How do you get
it?
It will provide you with all medical, dental, and nursing care. Everyone – rich
or poor, man, woman, or child can use it or any part of it. There are no
charges, except for a few special items. There are no insurance qualifications.
But it is not a “charity”. You are all paying for it, mainly as taxpayers, and
it will relieve your money worries in time of illness.”
This perfectly captures what the NHS meant then and still means today. So 60
years of quality health care – 3 simple principles – free at the point of
access; free for all; and based on need. Brought to us by a Labour government at
Nye Bevan’s insistence that: “It will be a great contribution to the wellbeing
of the common people of Britain”
NHS Scotland Today
Over the last sixty years, the NHS in Scotland has cared for millions of people
and saved many hundreds of thousands of lives. It has been at the forefront of
innovation in healthcare too; pioneering advances in medical treatment, surgery
and imaging. With its unique offer of healthcare free for all at the point of
need, it has liberated all of us from the fears of unaffordable treatment and
untreated illness.
Ten years ago people questioned whether the NHS could survive. It is a testimony
to the extraordinary work done by all NHS staff, backed up by Labour’s extra
investment - that ten years on the NHS is now more firmly than ever part of the
fabric of British national life. This includes support from across the political
spectrum as reflected in the recent Scottish Parliament motion and debate on the
anniversary sponsored by Labour MSP Bill Butler.
This consensus goes further in that NHS Scotland is organised very differently
from England with the emphasis on co-operation not competition, reflecting the
geographic and cultural differences in Scotland.
Most people in Scotland now recognise the need to move the focus of NHS Scotland
from being a reactive service for ill health, towards being a proactive service
for health and wellbeing. That requires an NHS that provides an effective and
comprehensive service delivered as local as possible and as specialist as
necessary.
There remain many challenges for the NHS today. These include patient discharge
from hospital following shorter stays coupled with elderly readmission rates and
pressure on Accident and Emergency (A&E) with attendances reaching their second
highest level in the last ten years.
Problems remain in accessing NHS dentist services in many parts of Scotland and
charges are high. Smoking has reduced from 25% of the population to 22% in the
past four years. However this figure rises to 41% in the most deprived areas of
Scotland. In the last four years there has been a consistent downward trend in
the number of suicides although they are still high. There is also a need to
reduce the dependence on anti-depressants and reduce readmission rates to
psychiatric hospitals.
Despite the additional funding Health Board’s continue to operate in a tight
financial envelope often using non-recurring income to support their revenue
position. This tight financial position will get much worse next year with the
SNP’s real term cut in funding to Health Boards. In addition the new resource
allocation formula replacing the Arbuthnott formula may not fully recognise the
challenges of delivering services to deprived and remote communities. We need to
focus spending on real need.
NHS Scotland is redesigning its services to face many of these challenges. Not
least of these is an ageing population, which could see a rise of 81 per cent in
the number of over 75s between 2006 and 2031, and an increasing number of people
with a long-term condition, of whom there are estimated to be one million in
Scotland.
Whilst there is an understanding of the need to shift resources into community
settings and anticipatory care, the balance of expenditure between hospital and
community services has not yet changed significantly. There are a number of
barriers to moving resources, including the significant amount of resources tied
up in secondary care and the need to maintain hospital services during periods
of change. Community Health Partnerships (CHP) are a key element of this change
but most are still at the early stages of development. Workforce planning will
also be a key requirement to facilitate this change and more needs to be done.
NHS Scotland is also responding to increased demands for greater patient
involvement. This includes implementing the new statutory responsibilities to
consult over changes to services. Further change is being proposed through the
Local Healthcare Bill including direct elections to Health Boards, a move warmly
welcomed by SHA Scotland who have long campaigned for greater democracy in
health care.
Scotland’s Health Challenges
As we celebrate the achievements of the NHS over the last 60 years, it is also
right that we look ahead and address Scotland’s major health challenges.
SHA Scotland believes that we need to focus on the poverty and inequality that
underlies poor health. Inadequate housing, low confidence and wellbeing, low pay
and unemployment all impact on health. This is evidenced by the fact that
children from poor backgrounds are more likely to leave school with no positive
destination and this also affects their health. Furthermore, smoking, poor
diets, excessive alcohol intake and drug use are more prevalent in areas of
deprivation. We therefore need to take co-ordinated partnership working across
policy areas if we are to make a real impact on Scotland’s most persistent
health problems.
These health challenges are reflected in our life expectancy which is still
lower than the EU average by almost a year for men and almost two years lower
for women. The gap between the council areas with the highest and lowest life
expectancy has not decreased over the last ten years. Overall, 34 per cent of
all premature deaths can be attributed to deprivation. At a younger age suicide
and drug-related problems are more prevalent for people in deprived areas; at an
older age key diseases are more prevalent. Mental health problems remain a
significant challenge.
Alcohol-related discharges from hospital and deaths increase with higher levels
of deprivation. Mortality rates from chronic liver disease have also risen over
the last 20 years, and the increase has been more pronounced for the most
deprived areas. Drug-related deaths increased by 25 per cent between 2005 and
2006, from 336 to 421. Thirty-eight per cent of these deaths occurred in the NHS
Greater Glasgow and Clyde area.
Obesity is increasing from 16% to 24% of men aged between 16 and 64, and from
19% to 27% for women between 1995 and 2003. Scotland has the second highest rate
of obesity among the OECD countries, behind only the USA. Only 36 per cent of
adults in Scotland meet the recommended level of physical activity per week.
Levels of childhood obesity are building up even greater health issues for
future generations.
Scotland is ranked 22nd out of 24 in a recent report on the wellbeing of
children, with suicide rates, dental health and teenage pregnancy rates
contributing to this low ranking. We have a high rate of teenage pregnancy.
Scotland (and the rest of the UK) is the fourth highest among the OECD
countries.
Tackling Scotland’s Health Challenges
The major challenges facing NHS Scotland going forward are those of inequalities
in health outcomes and inequalities in access to care.
The WHO (1986) Ottawa Charter remains a robust framework with which to address
inequalities – if only we could fully implement it. It stresses the need to:
build healthy public policy, encourage community action, develop personal
skills, create supportive environments, and reorient health services in order to
ensure effective public health actions.
This remains a useful framework to ensure the comprehensive range and levels of
action on addressing issues related to health inequalities. In addition, the
‘PESTLE’ management tool may be a useful method also to analyse the complexity
of the problem. It may provide a different perspective through which to consider
the range of dimensions related to addressing the health inequalities challenge:
political, economic, social and cultural, technological, legislative, and
environmental. Recommendations will be provided for policy, public health, and
practice.
Policy
Policy needs to be directed toward
tackling root causes of disadvantage. Crombie et al. (2004) set out a range of
potential structural, social, and economic policies which could tackle the
underlying inequalities. These include: taxation and tax credit measures,
old-age pensions, sickness or rehabilitation benefits, maternity or child
benefits, unemployment benefits, housing policies, labour market policy and
developments, community developments, and care facility infrastructure. Many of
these levers are devolved issues that the Scottish Government can act on.
Legislative challenges include converting healthy public policy to law, but
also to monitor all legislation, not only for health impact, but for impact on
inequalities (to apply the ‘inequality lens’ to all policy and legislation).
Major efforts to change social and economic conditions are necessary to
eliminate inequalities in health. A hypothetical analysis undertaken in the US,
published earlier this year, found that giving everyone the health of the highly
educated would save more lives than those of medical services by a ratio of 8:1.
Thus, education and opportunities for education are both integral and
symptomatic of the wide social change advocated for.
Globally, health policy also needs to continue to shift its direction toward
tackling the root causes of poverty and inequalities, and the WHO Commission on
Social Determinants of Health can be commended in driving this forward.
Public Health
There needs to be a concerted shift in public health, health promotion, and
health service action from a narrow focus on behaviours and lifestyles to one
that addresses wider social factors.
Rather than target interventions to deprived communities, activities should
be undertaken with communities as full participants, partners and even leaders.
To these ends, all public health programmes in Scotland need to embrace the
recommendations of the Community-led Supporting and Developing Healthy
Communities Task Group (2006) including: engaging with, working in meaningful
partnerships with, building the capacity of, and providing funding for the
sustainability of the community and voluntary health sector within Scotland.
This approach will foster social networks and social capital and help create
supportive healthy environments in communities.
There remains a need to continue to develop the evidence base in relation to
reducing health inequalities.
It should be more explicitly recognised that public health strategies, and
health services need to be appropriately targeted and resources allocated to
addressing the problem in low socioeconomic groups and deprived communities
where the greatest risk and need lies.
Practice
Health services have a role to play in terms of ensuring access to all,
irrespective of socioeconomic background, and also in relation to a shift
towards a preventive, anticipatory model of care. Further technological
solutions could also be pursued in relation to preventing conditions with a
predisposition to those from low socioeconomic backgrounds.
While continuing to develop approaches to address behavioural risk factors
(such as continued smoking cessation and alcohol counselling services), these
activities need to be undertaken with full appreciation and consideration of the
underlying socioeconomic and cultural factors influencing these behaviours.
However, efforts to reduce exposure to behavioural risk factors alone are
unlikely to succeed unless they are supported by measures designed to improve
socioeconomic circumstances and to reduce socioeconomic inequalities.
One of the first goals is to create a mindset shift in clinical practice
colleagues and public policy makers – described by Watt (2007) as shifting ‘from
victim blaming to upstream action’.
Health professionals and policy makers need to consider advocating for
socioeconomic change in addition to health behaviour and service change.
Conclusion
In summary, health inequalities, is a
complex challenge. It needs a concerted effort to meet the challenge – building
bridges and meaningful partnerships between and with: (i) policy and practice,
(ii) research and development, (iii) multiple sectors, agencies, and
organisations, and (iv) all communities. In addition, to take on the challenge
of tackling inequalities, a fresh and enthusiastic approach is required,
involving: passion and commitment, a willingness to take risks, and commitment
to work with others – in short, a new ‘can do’ mindset.
To conclude, the following three quotes seem to capture in turn: the truth, the
knowledge, and the challenge in tackling health inequalities as we look forward
to the next 60 years of NHS Scotland.
‘Massive poverty and obscene inequality are such terrible scourges of our
times…that they have to rank alongside slavery and apartheid as social evils’
(Nelson Mandela, 2005).
‘The primary determinants of disease are mainly economic and social, and
therefore its remedies must also be economic and social’ (Geoffrey Rose, 1992).
‘Economic injustice will stop the moment we want it to stop and no sooner, and
if we genuinely want it to stop the method adopted hardly matters’ (George
Orwell, 1937).
A hard copy or PDF file of this publication is available from the Secretary
d.watson@unison.co.uk
| 