Socialist Health Association
Scottish Labour Party’s manifesto 2011 first phase consultation paper
‘Working Together for a Caring and Healthier Scotland’
SHA Scotland Response
The Socialist Health Association Scotland welcomes the opportunity to respond to the Scottish Labour Party’s first phase consultation paper ‘Working Together for a Caring and Healthier Scotland’. The SHA was founded in 1930 to campaign for a National Health Service. We are a socialist organisation that is affiliated to and actively supports the Scottish Labour Party. Our response focuses on the health aspects of the consultation paper.
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.
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 not fully developed. 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 statutory responsibilities to consult over changes to services. Further change is being introduced through direct elections to Health Boards, a move warmly welcomed by SHA Scotland who has 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.
On health inequalities we should adopt evidence based principles including:
What works to address inequalities:
What does not work to address inequalities and we need to reduce:
This also means that HEAT targets should be explicitly focussed on inequalities.
Our specific policy responses on health cover policy, public health, practice and NHS Scotland.
§ 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 last 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.
§ 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.
§ 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. Good examples of these include:
v Free healthy school meals and breakfast clubs and ending commercial incentives for unhealthy eating.
v At least two hours of physical activity per week in schools together with safe walk or cycle to school schemes.
v Comprehensive health education in schools including sensitive issues like sex education, alcohol and drugs at an early stage.
v Healthier lifestyles should become the easy choice including through effective food policy initiatives like UNISON Scotland’s ‘Food for Good’ Charter.
v Pragmatic evidence based approaches to tackling drug problems that include abstinence, detox and harm reduction.
§ 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.
NHS Scotland and the delivery of care
Whilst the focus of health policy should be on inequality we still require a strong and well resourced NHS. NHS Scotland is in many ways 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. The Scottish health model with its partnership focus on co-operation rather than competition is the right model for a country like Scotland.
Despite these advances NHS Scotland is continually improving and further measures are needed including:
§ Confirming our support for direct elections to health boards and later CHPs, including deeper involvement of users through deliberative methods of engagement. Services should always be responsive to user need. We reject the false ‘choice’ agenda and support developing genuine partnership with patients.
§ Review the numbers and purpose of Special Health Boards. Whilst we are sceptical about the benefits of a large scale reorganisation of health board boundaries there is merit in small changes to improve coterminosity with local councils.
§ Develop Public Service Networks rather than further reorganisation of health boards and social care services.
§ Recognising that bigger hospitals are not better. Learn from the ‘Keeping the NHS Local’ strategy to maintain local facilities wherever possible.
§ Scotland’s hospitals should be cleaner with better resourced in-house cleaners. This is a key element of an effective strategy to reduce HAI.
§ Grow NHS capacity with service redesign to tackle waiting times and reject the use of private health care.
§ Strengthen the programmes for improving mental health by raising awareness, eliminating stigma, preventing suicide and supporting recovery. In particular there needs to be a greater emphasis on preventative services including crisis centres and community initiatives. Greater support for Cognitive Behaviour Therapy (CBT) may be one approach to reducing the prevalence of medication.
§ Improve hospital catering through the UNISON Food for Good Charter.
§ Support the phasing out of prescription charges and tackle the drug companies rising costs.
§ Raise the status, pay and conditions of nurses. Cut agency nursing costs, pay students a proper wage and end discrimination against overseas nurses.
§ Retain more of the doctors and dentists trained in Scotland. More salaried GPs and dentists and introduce specialist-generalist grades.
§ Fully recognise and reward the role of the rest of the health team.
§ Managed free car parking as set out in Paul Martin MSPs private members Bill.
§ Reject private finance including the SNP Scottish Futures Trust (including hub schemes) and promote a level playing field with conventional borrowing. This includes giving health boards prudential borrowing powers.
Housing, Sport and Social Care
Whilst we have responded to the health elements of this consultation it will be apparent from the above that housing and sport play an important part in achieving a healthy Scotland. In particular we support a radical council house building and refurbishment programme that provides a higher standard of accommodation and tackles fuel poverty. Poor housing remains a significant cause of ill health in Scotland.
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 work staff 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 the UNISON/BASW manifesto as a positive programme to attract more people into social work and develop a workforce capable of meeting new challenges.
Scottish Labour created a devolved NHS Scotland based on the principles of co-operation not competition. That was and remains the right structure for the NHS in Scotland. Our main focus now should be on tackling health inequalities. No democratic socialist party can be satisfied with its health policy when any Scot dies 15 years earlier just because he was born and brought up in a particular area.
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