Analysis: a year of familiar frustrations in health

In many ways, the parliamentary year in terms of health ended as it began, with warnings over an ageing population, treatment waiting times and levels of obesity. 

However, the year was eventful in other ways, too.

A bill to ensure nurse staffing levels are safe was published by the Scottish Government in May after spending watchdog Audit Scotland warned staffing issues required urgent action.

Rising vacancy rates have coincided with an ageing workforce and reported increases in workloads, particularly from nurses and midwives, with one in three NHS staff now over the age of 50.

In December, UNISON claimed lives were being put at risk because of “dangerously low staffing levels” in the ambulance service. 

The proposed legislation will place a duty on health boards to ensure appropriate numbers of trained staff are in place, irrespective of where care is received.

But the last 12 months have shown that health boards are struggling already with the duties and targets they currently face.

In fact, the last time the benchmark for 95 per cent of A&E patients to be transferred or discharged within four hours was July 2017.

Concerns about waiting times for cancer treatment last September led to the establishment of a new £1m clinical delivery group.

But by June 2018, the time patients had to wait for an urgent referral had slipped to its lowest ever level.

Just like last year, only three health boards met the standard to have 95 per cent of patients seen within 62 weeks. 

In 2017, Dumfries and Galloway, Orkney and Lanarkshire met that target. In 2018, it was the Borders, Lanarkshire and Shetland.

The story exemplified the wider struggles of the NHS as a whole in its 70th year, with record levels of funding failing to meet demand, and new approaches not making a noticeable impact.

The fact that, increasingly, health boards would struggle with demand had been predicted by Audit Scotland in October in a call for longer-term financial planning.

“A clear and long-term framework is needed that features how funding will be used differently to change services, alongside greater financial flexibility for NHS boards,” the report said.

While health boards are restricted by one-year budgets and made to make ‘efficiency savings’, it added, “Scotland’s health is not improving and significant inequalities remain”.

After a harder than predicted winter for departments, the ‘Beast from the East’ snowstorm in February didn’t help.

The first three months of 2018 saw 3,160 planned operations cancelled for non-clinical or capacity reasons, with the number rising by 4.1 per cent from February to March.

March also saw 42,628 days spent in hospital by people who were well enough to be discharged, an increase of three per cent on March 2017 and 11 per cent on February.

And the finances of the regional health boards came further under the spotlight. 

Shortfalls across the country were filled with ‘brokerage loans’ from the Scottish Government, and in the case of NHS Tayside, had been in place for a number of years and were being investigated by MSPs.

Then, in April, Health Secretary Shona Robison placed the board under special ministerial control after reports it had used funds from a charitable trust to pay for core services such as IT. The leadership of the board was quickly replaced, with the chief executive of NHS Grampian and the chair of NHS Greater Glasgow and Clyde stepping in.

Auditor General Caroline Gardner told MSPs that repeated warnings about the finances at NHS Tayside had not been heeded. After all, Audit Scotland had warned about the finances at NHS Tayside for three consecutive years.

“Internal auditors raised concerns about the retrospective transactions back in 2014 and it is included in the external auditors’ report as well,” Gardner told members of the Public Audit Committee.

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“There is a significant question about why, throughout the NHS system, warnings from auditors are not being taken seriously. The reason why is something you would need to ask of Scottish Government and of the board itself.”

Pressure mounted on Robison, not least because the health board was in her own backyard. 

As Holyrood exclusively revealed in May, as well as losing both parents in the space of 18 months, Robison had had a health scare of her own, and she cited this in her resignation letter ahead of Nicola Sturgeon’s reshuffle.

“This last year has been particularly challenging for me personally, losing both my parents, having a health scare of my own, and some big changes in my personal life,” she said.

But despite the mounting pressure on the NHS, and her, Robison had got some significant wins under her belt during her last year in post.

The new GP contract, which was approved by BMA members in January, is significant because it alters the very nature of the role within the NHS.

In the face of the modern challenges facing family doctors from an ageing population presenting with more complex issues, GPs approved relinquishing some of the autonomy the profession fought so fiercely for when the NHS was formed in favour of some guarantees over workload.

Instead, the GP will be a more integrated part of the NHS, leading a multidisciplinary primary care team.

As the Scottish Government softened its stance on organ donations, agreeing to bring forward legislation on a soft opt-out system such as that introduced in Wales, so did the general public, as the existing donation register swelled to over half the population.

And after years of legal challenges by the drinks industry, minimum unit pricing for alcohol was introduced in May.

The law set the price at 50p per unit, designed specifically to tackle cheap high-strength alcohol like white ciders and spirits, and was agreed by the Scottish Parliament in 2012.

Doctors hailed the move as “an important milestone” in harm reduction, with many other countries thought to be watching the impact of the policy in Scotland with great interest.

However, not all high-profile campaigns enjoyed the same success. The government’s commitment to tackling the obesity crisis was questioned after its new strategy appeared to be watered down from the consultation document. 

Instead of a strategy, the document was called a ‘delivery plan’. The consultation document had promised to legislate, but there was no such promise in the plan. Despite overwhelming support for restrictions on the promotion and advertising of food in the consultation, the delivery plan merely promised yet another consultation.

Perhaps more controversial was the inquiry into the use of transvaginal mesh implants, which was branded a “whitewash” by campaigners when it reported last year. 

In a debate in December, former health secretary Alex Neil said he had “not been told the whole truth” by civil servants when he went against their wishes and ordered the inquiry in the first place.
A further review by health academic Alison Britton was set up to look at the process of the independent inquiry, and why it was changed between drafts.

The new parliamentary year begins with a new cabinet secretary, but she, too, is faced with many challenges and may experience familiar 
frustrations.