Sir Harry Burns: devolution has been good for Scotland's health, but approaches still need to improve

The National Health Service, which the Holyrood Parliament inherited in 1999, was fundamentally different from that in any other part of the UK. In 1991, the Conservative Government introduced the concept of the ‘internal market’ in healthcare. Hospitals became providers of care, competing with each other to obtain business from purchasers – GP fund holders and health authorities. This system applied in Scotland until, in 1997, the Scottish Health Minister, Sam Galbraith, began the process of dismantling the market and replacing competition with a culture of partnership.

In 1999, the Scottish Parliament, under the Labour/Liberal Democrat coalition, continued the work Sam started and, by 2004, the final vestiges of the market disappeared as NHS Trusts were finally abolished. This difference in governance between England and Scotland has remained to this day.

While the changes returned Scotland to a system in which health boards were responsible for planning and managing the delivery of care to the citizens in their area, England continued to bear the cost of managing a market. Estimates of the cost of the internal market in England suggest that up to £10 billion of funding intended for healthcare might be spent on market management. Without this overhead, Scotland was able to spend a greater proportion of its health budget on staff. 

The Centre for Health and the Public Interest pointed out that, although in 2010-11 Scotland spent only eight per cent more on health per capita than NHS England (£2,089 vs. £1,932), NHS Scotland was able to employ 19 per cent more hospital doctors, 27 per cent more GPs and 31 per cent more qualified nurses per capita than NHS England. Scotland also had 48 per cent more staffed beds in acute specialties and 81 per cent more staffed beds in all specialties per capita than England. 

In addition, clinical colleagues in England also report that a considerable amount of their time is involved in recording data required for managing the internal market and which brings no benefit to the patient. In 2018, an article in The Spectator described the NHS internal market as “an expensive catastrophe...a dangerous festering wound which may prove fatal to the NHS.” 

The decision to remove Scotland from the internal market appears to have paid off handsomely. Holyrood found itself with a health system that was better staffed than England. Freed from the need to resource an unnecessary contracting and purchasing infrastructure, Scotland was able to distribute its NHS revenue more effectively than NHS England, and so obtained better value for money. While England has been struggling with the consequences of an ill advised, ideologically driven system, has Scotland been able to deliver better health outcomes for the population? 

It would be fair to say that Scottish governments have been consistent in their efforts to come up with plans to tackle the challenges of health and care in the 21st century. In 2005, the Health Department published a report entitled ‘Building a Health Service Fit for the Future’. Written by Professor David Kerr, it discussed the possible responses to the challenges facing healthcare. The ageing population with its increasing incidence of chronic disease would, Professor Kerr argued, require a service geared towards long-term conditions. Embedded in communities, multidisciplinary teams would deliver care with strong patient involvement in decision making. There should be a focus on prevention and the issue of health inequalities should be tackled. The Kerr Report became associated with the concept of ‘shifting the balance of care’ from hospital to the community.

Two years later, the SNP Government produced ‘Better Health, Better Care’. This action plan outlined the government’s vision of a mutual NHS in which the public and staff were seen as partners in the service. A commitment to local access to high quality care and shorter waiting times was made. Again, the report emphasised the government’s intention to focus on preventing ill health and closing the health inequalities gap. 

by Liam Kirkaldy

How devolution changed Scotland

Although these themes of prevention and narrowing inequalities have consistently featured in policy statements throughout the life of the parliament, it is difficult to find consistent evidence that policy intentions have produced effective action. Judged by premature mortality rate – the number of people dying before the age of 75 – the overall average health of Scotland has improved. However, the gap in mortality between rich and poor has increased. Between 1997 and 2017, the premature mortality rate in the least deprived areas of Scotland fell by 43 per cent. Relatively, inequalities in mortality have widened. 

The most deprived areas experienced a fall of only 21 per cent. The gap in mental wellbeing also remains significant, with 24 per cent of adults in the most deprived areas experiencing low wellbeing while only seven per cent of those in affluent areas experienced similar problems. 

A further challenge for efforts to improve health and wellbeing is the observation that, for the first time in several decades, overall life expectancy has fallen in Scotland. Inevitably, this has provoked a political reaction in which opposition politicians are attributing this fall to government policy. The reality is that several countries are seeing growth in life expectancy stalling as a result of the post-2008 economic situation. 

Policies to improve health seem relatively ineffective in the face of economic adversity. Why should this be? 

The reason that many well-intentioned policies seem to have failed to deliver the desired change is probably because they have not articulated an effective method of implementation.

The assumption that a ministerial directive for changing a complex system will produce the desired outcomes is usually wishful thinking. Wellbeing is an outcome of a complex system in which many factors interact. The problem facing those who wish to improve wellbeing and narrow inequality in health is that conventional management approaches to implementation and management of complex systems are ineffective. If we are to make the desired improvements in health in Scotland, narrowing inequalities, we need an appropriate method for improvement. 

At present, the performance management system in the NHS across the UK is based on the ‘New Public Management’ approach introduced in the 1980s as an initiative of Margaret Thatcher’s government. NPM focuses on increasing efficiency, ensuring value for money and financial control. Performance targets are set and continually monitored.

Studies of the impact of targets have shown a mixed picture. Targets have resulted in a reduction in waiting times for treatment. However, they tend to focus on those things that are easily measured, not what matters. Targets can widen inequalities in health by being unrealistic and unattainable in deprived populations. 

Lord Prior, the Chair of NHS England, has recently described the NHS as “dysfunctional”. The culture of managing by setting targets had produced a disjointed system and demoralised staff. “Targets,” he has said, “have had their day.” If Scotland is to make real progress on health and wellbeing across the whole population, it needs a method for change based on redesigning whole systems, not one which makes it chase targets. It needs a method for change which takes account of the complexity of the problem it is trying to solve.

Fortunately, NHS Scotland has experience of such a method. Indeed, we probably have more experience of such a method than any other healthcare system in the world. In 2008, NHS Scotland became the first health system to implement a national approach to improving safety in all its hospitals. 

The Scottish Patient Safety Programme (SPSP) uses improvement science to engage frontline staff in designing and testing the effectiveness of interventions to improve outcomes across the whole system of care. The results have been dramatic. In its first four years, the NHS saw a reduction of 9.3 per cent in standardised mortality in our hospitals. This was achieved by improvements across many aspects of acute care. 

The lessons of the SPSP were next applied in the Early Years Collaborative. Dramatic improvements in stillbirth rate and infant mortality were seen from 2008 to 2014. Frontline staff learned to design and test innovations and then applied, at scale, those interventions that produced desired change. 

As confidence in this system has increased, momentum for change has built across health and social care throughout Scotland. This is already evident in the system-wide Health & Social Care Integration, also in the integration of the work on early years and education into a joint collaborative.

The new parliament served Scotland well in ending the internal market. During its first decade, the importance of the prevention of illness, health improvement and reducing socioeconomic inequalities were clearly acknowledged but evidence of solid progress in these areas was hard to establish. 

Parliament’s second decade has been marked by the introduction of new thinking which has been associated with significant improvements in health and wellbeing. The introduction of disciplines such as improvement science and process engineering based on modern data analytics rather than on the pursuit of targets, could transform Scotland’s NHS into one of the most effective and efficient systems in the world. That is surely a target to aim for in the next decade of the parliament’s existence.