Analysis: a year in health - supply and demand
A&E - credit John Garghan
Health is the biggest spend of the Scottish Parliament. Indeed, the health budget stands at its highest ever level, with close to £13bn being spent in 2016/17 and a commitment by the Scottish Government to increase the funding by £500m over inflation during this parliament.
But as people live longer and develop more complicated health conditions and needs, the demands on the health service is outstripping this increased investment, a fact which has come to light in the first year of this parliamentary session.
This was characterised by the response to a Scottish budget which announced more money than ever for health.
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Among measures announced by Finance Secretary Derek Mackay was an additional £304m in resource funding for the NHS, £120m above inflation, including £72m investment in “improvements to primary care and GP services” and £107m further investment in social care.
Yet doctors and the third sector warned that more long-term solutions were needed to pay for the new models of care, including more investment in communities.
Scotland’s A&E departments have performed better against targets than elsewhere in the UK this year but still struggled in the winter months, while the first year of integrated health and social care authorities have not eliminated issues around delayed discharges from hospital.
The country’s spending watchdog raised the issue of health board finances several times during the year, warning that financial shortfalls have had a direct impact on services, particularly at boards such as NHS Tayside and NHS 24.
In October, Auditor General Caroline Gardner said the rising cost of drugs and an ageing workforce have contributed to the problem, which was also reflected in a report in July which showed rising vacancy rates have coincided with reported increases in workloads, particularly from nurses and midwives.
“Major challenges lie ahead for the NHS in Scotland. There are growing pressures on health boards which are struggling to juggle service delivery and progressing major reform whilst also managing considerable financial challenges,” she said.
“The Scottish Government has had a policy to shift the balance of care for over a decade but despite multiple strategies for reform, NHS funding has not changed course.”
The Scottish Conservatives, Scottish Labour and the Scottish Liberal Democrats all blamed an SNP obsession with independence for NHS Scotland’s failings, but the reality was far more complicated.
As health boards looked to shift funding from the acute sector into the community, proposals to consolidate and centralise local services were met with public concern and protest.
In September, the SNP suffered its second defeat in the Scottish Parliament since it lost its overall majority during a Labour debate on cuts to local services.
Labour’s motion for the debate used the examples of proposed changes to services at the Vale of Leven Hospital, the Royal Alexandra Hospital, Inverclyde Hospital, Monklands Hospital, Lightburn Hospital, the Royal Hospital for Sick Children in Glasgow and the controversial Centre for Integrative Care, which uses homeopathy.
Health Secretary Shona Robison said no final decisions had been made by health boards, and accused Labour of “inappropriately” trying to undermine local decisions.
“This government remains committed to robust, evidence-based policymaking. I am prepared to take difficult decisions where the evidence supports it.
“What we will not countenance is change being dictated to local communities as has happened in the past under a Labour administration,” she said.
But the government’s own national clinical strategy called for a need for more local community health centres and hospitals. The question is, can health boards afford it?
And the financing of integration through an already stretched health service was also questioned.
In December, the Scottish Parliament’s Health and Sport Committee told the new integrated health and social care partnerships to better coordinate budgets and link them to outcomes.
“We recommend realigning budgets should not just be encouraged by the Scottish Government but there should be a clear commitment by the Scottish Government to ensure NHS boards set their budgets in alignment with local authorities,” the report said.
By June, doctors’ union the BMA warned integration would need additional funding to succeed.
Former SNP Health Secretary Alex Neil published a discussion paper in April which said the Scottish Government needed to be “much more specific, detailed and much broader in scope”, including accepting “difficult choices” on the long-term viability of the NHS.
His proposals included an NHS-specific tax which would require additional powers transferred to Holyrood, a restructuring of health boards to cut down on administrative costs and a “substantial” increase in doctor and nurse numbers.
“A ring-fenced, hypothecated tax may provide the best means of obtaining the level of public accountability and acceptability needed to raise the funding needed to realise our aspirations for health and social care,” he said.
And foremost in those aspirations is a commitment to place a greater emphasis on prevention and bold public health policy, something the Scottish Parliament built an early reputation for with its innovations in smoking restrictions and other matters.
But those anticipating a similarly bold approach at the start of the parliament’s fifth session will have been disappointed.
Minimum unit pricing for alcohol, passed by parliament in 2012, has since been tied up in appeal courts amid a challenge from the drinks industry. Meanwhile alcohol-related deaths increased by ten per cent in one year to the highest level since 2010.
Calls for a similarly tough approach on obesity have not yet been rewarded with a strategy, despite one being due last year and Scotland’s obesity rates amongst the highest in the world, even higher than in the rest of the UK.
Could the protracted legal wrangling with the drinks industry have tempered the Scottish Government’s appetite for imposing tough restrictions on food manufacturers and supermarkets? It will be clearer when the obesity and diet strategy emerges in the winter.
Meanwhile the emerging science on air pollution has revealed traffic fumes are having more of an effect on people’s health than originally thought, directly impacting rates of heart and lung diseases.
Scotland’s cities, however, contain illegal levels of pollution, and a refresh of the clean air strategy in July came under attack from environmental lawyers and campaigners for being “simply plans for more plans”.
One long-awaited strategy which did see the light of day was the new mental health strategy, launched by Maureen Watt in March, but the minister may well have been disappointed in the response.
The document “lacks the ambition and investment that Scotland deserves” said the Scottish Association for Mental Health’s chief executive, Billy Watson.
The question, as with the rest of NHS Scotland’s challenges, is how would it be paid for?
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