Facing the vote

Alex Neil has been described as a political bruiser. Placed on what is thought of as the ‘fundamentalist’ wing of the SNP, he has cut a strident figure defending government policy and his own position.

Holyrood sits down with him only hours after a newspaper front page revealed a moment of potential conflict of interest between his role as Health Secretary and that of his constituency loyalties. As the local MSP,

Neil had vehemently and consistently been against a plan to remove acute mental health services from Monklands Hospital in Airdrie despite the health board’s consultation on the matter and recommendations to move towards community-based facilities.

However, a freedom of information request by Labour revealed that Neil had intervened shortly after becoming Health Secretary in 2012 to apply pressure on NHS Lanarkshire to reject the plan, but he later told parliament he had excused himself of the decision, passing responsibility to his deputy. The details of that timetable were to become the focus of a furious political row and a test of his ministerial integrity.

But if the question of whether Neil broke the Ministerial Code, which says he must keep his role separate from constituency issues, was troubling him on the day the story broke and Holyrood sat down with him, then it didn’t show.

In fact, Holyrood finds him in ebullient mood, unaware at that point the growing head of political steam would mean he would become the first minister to face a no confidence vote since Labour’s Sarah Boyack in February 2001, a vote he ultimately and inevitably survives, given the SNP overall majority.

“Petty,” he says of the accusations, with a grin. “It’s petty. I think the Labour Party needs to raise its game on health, and it’s got a long way to go to raise its game, quite frankly.”

The revelations have led his Labour counterpart, Neil Findlay, to question whether he is fit to be running the health service. Alex Neil dismisses this smartly. “When I’m bitten by a gnat, it hurts, when I’m bitten by a flea, it doesn’t. Gnat in this case is spelt with a ‘g’,” he jokes.

Once dubbed ‘minister for Newsnight’, Neil is clearly comfortable swatting criticism. However, his cabinet role has brought voices with a more emotional charge to his attention. The NHS, he points out, saved his own son’s life at 14. “In Scotland today, at any one time, half the population are engaged with the National Health Service. It might be for a repeat prescription, or it might be because they have a serious illness. I think it’s important to understand the scale of the NHS’ involvement with everybody,” he says.

Neil has made a point of making unannounced visits to hospitals to speak to patients, he says, an idea he hopes to extend to the primary sector, “because I think it’s important to keep in touch with what’s actually going on at the coalface, as it were.”

Learning through hearing about patients’ experiences is a vital part of the job for Neil.

“I recently went up to Dundee to visit a patient who has got PSP, which is a rare disease very similar to, but not the same as, Parkinson’s. Just learning [about] his experience, and the fact it took three years to diagnose this very rare disease. There are only 4,000 people in the whole of the UK who have got this disease,” he says.

A recent trip to Athens for a telehealth conference revealed a product which will help diagnose cancer earlier. “While they’re going to start with cancer, I made the point it could be particularly helpful in identifying rare diseases. Now if you could identify it much quicker, and had this patient identified it much quicker, the prognosis would have been much the same, but his journey for the last three or four years would have been much more comfortable. It’s important to hear firsthand from people.”

Visiting children and young people is particularly emotional, and Neil makes a point of visiting Yorkhill children’s hospital in Glasgow “on a regular basis”.

“I’m particularly keen to push as far as possible for cures, or at least for improving the prognosis of children and young people for what are currently terminal diseases, because there is nothing worse in the world than to lose a child, and for a child’s life to be snapped away at a very young age. If somebody like my age takes a terminal condition it’s very sad, and we must do everything we can to prolong their life and improve their quality of life for the time they have left, but at least we have lived a life. We’ve had a chance to do what we wanted to do. With children and young people, they haven’t had that chance.”

The pace of change in health has been considerable in recent years. Although he was once so vehemently opposed, the redesign of mental health services is something Neil is much more comfortable with now, given the Scottish Government’s 2020 vision is all about taking patients out of acute wards and into the communities. Indeed, he thinks other services can learn from the way mental health services have moved from the hospital setting. If this seems like a quick turnaround, it reflects a pace of change in health and social care which sees no signs of slowing down. Born in the 1950s, Neil remembers a health service in its younger years.

By the time he was 11 he had been in hospital four times. He was delivered by caesarean section, a much riskier procedure in those days. He had tonsillitis and appendicitis at a young age. “In those days, they just whipped you in and took them out, and I needed a correction on my right eye as well. Even although that happened when I was four, I vividly remember it because my eyes were bandaged for about two or three weeks.

Today it would probably be day surgery, but in those days, it was three weeks you were in hospital, and I remember being wheeled out, it was a lovely sunny day, being summer when I was in hospital, being wheeled out onto the balcony at Seafield Hospital in Ayr to enjoy the sun. I remember every one of those operations and experiences, and just how, as a child, you’re kind of frightened. Because in those days, they didn’t accommodate parents the way we do now. Visiting hours were very strict, so it was a wholly different experience, and quite frightening.”

Vaccinations too are unrecognisable. “One of the great things now is just the number of vaccinations. I look at my grandchildren, and see them getting vaccinated. I’m very supportive of the new vaccination on meningitis, and the fact we’ve been able to deal with more than one form of meningitis.”

Although more effort is made these days to make children’s experiences as easy as possible, the transition to adulthood is still an issue for Neil, who wants to make sure young people are put in adult wards. “I was at the new cancer suite at the Western General last week with the Teenage Cancer Trust unit, and it’s fantastic what they’re doing there. One of the great things, having spoken to the patients, is the fact it’s all people of the same age group, from about 14 up to 25, and that’s important. They’re making new friends and sharing notes on their experience and how they’re dealing with the illness, and so on.”

The pace of change in clinical technique and technology has been “revolutionary”, according to Neil, improving people’s life chances considerably.

“My mother dropped down dead at 52, because basically, she had high cholesterol and high blood pressure. Today she would be on statins, and she would have had a substantially extended lifespan, because otherwise she was healthy. She died in 1977, so there’s been a revolution. The key thing is, and this is where people need to understand, we’re on the cusp of a massive revolution in terms of healthcare in Scotland, and indeed across the world, and the two things that are going to drive that revolution are personalised medicine, sometimes called stratified medicine, and also digital medicine. These two things are going to, in the next five to 10 years, completely change the way we treat people. And for the better,” he says.

Neil recognises treatment of long-term and chronic conditions has to be “a different way from always hospitalising people”. Hospital is not only more expensive, but has been proven to lead to poorer health outcomes. “Basically, what we’ve got to realise is ten or 20 or 30 years ago, if you were diagnosed with prostate cancer, say, the chances are there would be a period of two or three years between diagnosis and death. Nowadays, provided you detect it early enough, prostate cancer is essentially a long-term managed condition. That means instead of dealing with you for two or three years, the health service could be dealing with you for 30 or 40 years.”

The focus will be people over 70 with chronic conditions, dementia patients and diabetes, which Neil points out is often not diagnosed early enough. “Now we could probably actually pinpoint the people, from the data we have available, who are likely to develop diabetes 2. So I want to get to the stage where the GP can get their names and addresses and get them in and prevent it. Rather than early detection, I’d much rather we prevent it. That requires a degree of sophistication, and we’re just on the cusp of being able to deliver that.”

If strengthening primary care teams is necessary, it would require a shift in funding. Neil agrees, and points out he has asked every territorial health board to demonstrate they’re putting additional resources into primary care. “For too long, primary care has been the poor cousin in terms of allocation of resources within territorial health boards.”

Looking at the primary and acute sectors as separate is ‘old fashioned’, according to Neil. “We’ve got to make that shift from the acute sector into the community sector, and indeed treating acute illnesses in the primary sector and in the community. COPD very often can be far better treated in the community, but it might be a hospital consultant that’s doing it. It won’t necessarily be the GP. This is not about closing down hospitals; it’s about communitising the acute sector.”

It needn’t lead to cuts in the acute budget, according to Neil. Every territorial health board is to get a ‘real-time’ increase this year, he says, and so “it’s about giving primary care a bigger slice of the extra bit of cake, as a starter for ten.”

Technology will play an increased role in Neil’s ‘revolution’ in health. Remote monitoring pilots are reducing hospitalisation “by up to 70 per cent”, he says.

The other side of the coin, however, is social care. NHS Lothian’s chief executive, Tim Davison, told Holyrood recently there was real crisis in social care in Edinburgh, with high prices and too few beds, and a number of homes closed after inspections. Aren’t all the ambitious plans for getting people out of hospital being pinned on improvements in the social care system?

“That’s why we’ve issued the joint review report and recommendations with COSLA on the future of residential care, and I’m very committed to move forward as quickly as possible with COSLA in the implementation of those recommendations. In particular, the introduction of commissioning for residential care, recognising we also need, per patient, to put more resources in, because we can’t demand the quality and safety of care we need without resourcing it. Thirdly, I’m very keen we look at how we can take forward the proposal to introduce the living wage throughout the social care system in Scotland, and all the other recommendations. Again, we cannot achieve our ambitions for the health service without putting additional significant resource and reforming and modernising social care. It’s part of the jigsaw.”

Housing and housing support, too, must form part of the jigsaw, Neil says. “That’s why we wrote into the integration act the need for housing and housing support to be active partners in how we take forward the integration of health and social care.”

It remains uncertain whether people have grasped the urgency of the need for integrated services. Neil points to West Lothian as an example of how the benefits can be “enormous” after the local authority was one of the few in Scotland to pilot an integrated approach to health and social care, and all but eliminated delayed discharge.

“Just take the problem of delayed discharges alone. If we were able to eliminate delayed discharges throughout Scotland it would save the health and social care system £125 million a year. That £125 million would be available for reinvestment in other priorities, rather than being wasted as it effectively is at the moment. More important than that, the health outcomes of people whose discharge is delayed would be substantially improved,” says Neil, “our aim should be no gap between being medically fit for discharge and being discharged. It’s not good for your health.”

Could the traditional nostalgic view of Britain’s NHS be under threat? For Neil, a big factor is also the sweeping reforms of the NHS in England by the Coalition Government. “There are two fundamental mistakes they are making. One is privatising services, because the minute you add in a profit motive then you have a completely different animal from one driven by the needs of patients, and I very much welcome that Jackson Carlaw has made it clear in Scotland the Scottish Tories would not support that approach. The second big mistake is the fragmentation being caused by those reforms. I actually think now you could not describe the health service in England as a national health service as we imagine it. In terms of being an integrated service, it’s increasingly fragmented, and that’s very detrimental.”

Scotland can remain being run as a national service, he says. “A very good example is paediatric cardiology. The fact of life is we only really can have one paediatric cardiology centre of excellence in Scotland, because you need a minimum throughput to make sure it remains leading edge, but also it means the quality of care we get is internationally recognised as among the best. If you tried to recreate those services in small units across the country, you don’t attract the best surgeons, you don’t get the throughput that makes the surgery as safe as it should be, and also, you fragment the after care as well. I’m determined we’re not going to do that.

"Now it’s horses for courses. We’re now doing 35,000 cataract operations every year in Scotland, we’re doing over 7,000 knee replacements every year, and we’re doing over 7,000 hip replacements. So by definition, you need probably about ten centres to be able to deliver that service on a safe basis. We have to customise the design of services to meet the needs of the patients in a way that maximises the quality of treatment and the safety of the patient.”

But if Scotland is getting it so right, why has Neil frequently said Scotland’s NHS is under threat if the country votes No in the independence referendum?

“The decisions being made by London are having a negative impact on my ability to maximise the quality of delivery of health in Scotland,” he says.

Pension reforms are one example. “They’ve increased pension contributions at a time when wages are restrained. The extra contributions don’t go to an increased pension, they’re going to pay off the bankers’ deficit, and the pension that’s going to be paid out is to be reduced in real terms, and they’re going to have to wait longer to get it, because they’re extending the age. So the impact on morale has been very marked. Now they’re professionals, they get on with the job, but nevertheless, it’s a very good example of where bad decisions without consultation in a reserved matter are having a very detrimental impact on what is supposed to be a devolved service: health.”

Nevertheless, the NHS in Scotland is publicly run and publicly owned, and appears safe from the widespread reforms seen in England. Do we really need independence, rather than just more powers over, say, pensions?

“Another example is if they continue to privatise the health service down south, the budget for health is determined by the percentage increase the UK cabinet allocates to the health service in England. That’s no way for us in the long term to decide how much we want to spend in health without having to cut other things. We can only fund health to the right level when we have control over deciding how big the cake is and how the cake is sliced up, and how the service is to be funded. So there’s another example of where being part of the UK is bad for your health. It’s bad for your health being part of the UK.”

An even bigger point, he says, is good quality job opportunities. “Of course we believe fundamentally the job situation in Scotland will be far, far better than what it is as part of the UK. We’ve demonstrated with the limited powers we have how already we’ve managed to achieve a higher level of employment and a lower level of unemployment in Scotland.”
With all levers at Scotland’s disposal, Neil thinks of the country his grandchildren might grow up in, with leading-edge healthcare.

“I want the health service in Scotland to be the best in Europe. That’s my ambition. Now we’ve a way to go, obviously, but that’s my ambition, so no child in Scotland dies of any disease, or any young person dies prematurely of disease in Scotland. Now we rely on global medical research as well as what we do here in Scotland to achieve that, but that’s my ambition.”

He also aspires for them to have the opportunities and control that underpin good health, such as good job opportunities. “Where they’ve got the ability to travel, they’ve got the ability if they decide to study out with Scotland, they can do that. When they eventually start a family of their own, they can bring their kids up in Scotland knowing full well their kids will have the best education, the best health service, access to jobs, and even beat the Scandinavian countries, many of which do not have the same level of natural resources we have in Scotland.”

Whether or not Scotland becomes independent, Neil is as bullish about the future of the health service as he is with his political opponents. “It’s going to be much more about delivering at home, or in a community or home setting. The use of mobile technology, the use of apps, and also in terms of medical treatments, we’re on the cusp of a transformation where the medicine and the treatment people will get will be targeted at them as individuals, it will be targeted at their DNA, and at their specific type of illness, in a way that’s inconceivable, or would have been inconceivable five or ten years ago.”