Socialist Health Association
Scottish Labour Party Stage 2 Consultation Paper
A Caring and Healthier ScotlandSHA Scotland Response
The Socialist Health Association Scotland welcomes the opportunity to respond to the Scottish Labour Party’s second stage consultation paper ‘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.
Tackling Health Inequalities
SHA Scotland believes that this section is rightly at the start of the consultation paper because it should be the key priority. 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.
Our specific policy responses should be evidence based recognising what works and what doesn’t.
What works to tackle inequalities:
What does not work to address inequalities and we need to reduce:
This also means that HEAT targets should all be explicitly focussed on inequalities.
Specific policy responses cover policy, public health, and practice.
§ Social and health policy should be interchangeable including education and the living wage.
§ Policy needs to be directed toward tackling root causes of disadvantage. 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.
§ The public health and health inequality impact of all polices should be assessed.
§ 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.
v Support for the Living Wage.
§ 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’.
Improving our Health Services
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 on the principle that democracy is what separates public services from the commercial realm. This is in addition, not a substitute, for 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.
§ Grow NHS capacity with service redesign to tackle waiting times and reject the use of private health care.
§ 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 whole health team.
§ Managed free car parking as set out in Paul Martin MSPs private members Bill.
§ Recognise the value of the no compulsory redundancy guarantee and organisational change policy in fostering a positive approach from NHS staff to service redesign.
§ 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.
Safer Care in Scotland
Scotland’s hospitals should be cleaner with better resourced in-house cleaners. This is a key element of an effective strategy to reduce HAI.
SHA Scotland supports the implementation of Scottish Labour's 15-point plan for tackling hospital superbugs, which was drawn up with assistance from Britain's leading expert in infection control Professor Hugh Pennington. This builds on the work of the HAI Task force.
Changes to skill mix and staffing levels should be driven by patient need – not cost savings. SHA Scotland rejects the false distinction made between so called front line staff and others. NHS services are delivered by a team.
Tackling drug and alcohol misuse
As we set out above under tackling health inequalities approaches to address behavioural risk factors need to be undertaken with full appreciation of the underlying socioeconomic and cultural factors influencing these behaviours. Efforts to reduce exposure to drug and alcohol misuse alone are unlikely to succeed unless they are supported by measures designed to improve and to reduce socioeconomic inequalities. There should be greater support for residential rehabilitation facilities.
SHA Scotland believes that a minimum price for alcohol is a blunt instrument for addressing this issue. Whilst there may be some health gains we believe taxation is a better approach. However, the Labour Party does need to develop a credible alternative if it is to oppose minimum pricing and therefore we welcome the work of the Commission on this issue.
SHA Scotland believes that sexual health is integral to general health and wellbeing.
Sex and relationships education is a lifelong learning process based on the acquisition of knowledge and skills and the development of positive values. The responsibility for sex and relationships education of children and young people should be shared between parents and a range of professionals. This education should help to equip young people to enjoy sex and relationships that are based on mutual respect, trust, negotiation and enjoyment.
Sexual health strategies should value all people equally and an understanding of and support for other people’s sexual orientation should be actively promoted. Similarly we should recognise the value and diversity of families that exist and should not value one family structure as superior to another.
All children and young people have the right to comprehensive sex education. Schools should ensure that they work closely with parents to develop an inclusive programme for all pupils, however, the rights of the child are paramount. All those involved in the delivery of sex education should be required to have initial and in-service training in the subject.
Improving Scotland’s mental health
We should 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. Waiting time guarantees should also apply to mental health services.
Obesity in Scotland
Achieving the recommended levels of moderate intensity physical activity can reduce premature mortality by between 20-30%, therefore measures to promote greater physical activity are essential to improving Scotland’s health. These should include sport in education, including at least two hours physical activity per week. In addition there should be safe cycle/walk routes to school.
A Food for Good programme should be introduced (see UNISON programme) and fast food outlets near schools should be strictly licensed.
Ensure oral health improvement initiatives and new dental services focus on meeting those with the greatest need – including deprived / rural and remote communities.
Permit local consultation on the introduction of water fluoridation.
Develop a dental contract that rewards quality (in its broad definition) of service provision with a greater use of salaried dentist.
Health in the Workplace
Creating a healthy workplace can be of great benefit to both employees and the organisations they work for. How healthy a person feels affects their productivity and how satisfied they are with their job affects their own health, both physical and psychological. Where organisations proactively improve their working environments, by organising work in ways that promote health, all adverse health-related outcomes, including absence and injuries, decrease.
Good occupational health schemes have a major part to play in preventing ill health through work and a greater priority and higher profile needs to be given to them. Public bodies must ensure that their employees have reasonable access to occupational health services that are not only cost effective but also maintain staff confidence in both their quality and independence.
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.
SHA Scotland is committed to the principle of the right to independent living for all care users. We believe there should be a clear national strategy followed by appropriate legislation to govern and regulate the use of self directed support. However, we have concerns over the long term future of core services which we believe should be maintained at a sustainable level, to provide real choice for people who do not want to use direct payments or individual budgets. Personal budgets should not lead to vital local services being shut down, and trained staff being replaced with cheaper workers in a race to the bottom of care quality.
There should be stricter regulation of private care homes with a focus on quality of care, fire risk and the exploitation of staff, particularly migrant workers.
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