Rising pressure: How Scotland can tackle its health challenges

People are just tired, and I don’t mean they didn’t get enough sleep last night.”

Tom Waterson, chair of Unison Scotland’s health committee, has worked in the NHS for decades and describes the experience of staff in one word: exhausted. “Our staff are knackered by the time they are 60,” he warns.

There is no escaping the central problem faced by the modern NHS in Scotland: that there are not enough staff or resources to tackle growing demand, especially from an ageing population.

Jeane Freeman, the well-regarded former social security minister and one-time special adviser to Jack McConnell, moved to health in June 2018, and is seen very much as a steady hand on the tiller in one of the most challenging government portfolios. Resourcing challenges – particularly their impact on waiting times – have been front and centre for her, though there has been no shortage of other problems.

In January, it emerged that two patients, including a 10-year-old boy, had died after contracting an infection linked to pigeon droppings at the Queen Elizabeth University Hospital in Glasgow. The Crown Office announced investigations into the deaths and Freeman quickly ordered a review of the design, build, handover and maintenance of the flagship hospital, which opened in 2015.

Then in July, she took the last-minute decision to delay opening the much-anticipated Sick Kids in Edinburgh, after concerns were raised during final checks about its ventilation system. Freeman has ordered reviews of the ventilation, drainage and water systems, and of the governance of the project (due on 11 September), declaring herself “disappointed and deeply concerned” that the problem had not been identified earlier. With NHS Lothian paying £1.4m a month for the building, however, the health secretary has come under pressure to set an opening date. Publication of the reviews is unlikely to end the controversy.

It’s not all problems and challenges. There are positive changes afoot in health. Mental health services are undergoing a transformation, though the benefits of greater investment are yet to be seen. The integration of health and social care is continuing, with the aim of ensuring patients get the right care, in the right place, at the right time.

The Scottish Government, supported by the parliament, has embraced the prevention agenda, pursuing measures designed to curb unhealthy lifestyles. The implementation of minimum unit pricing for alcohol in May 2018 is expected to start reducing alcohol-related hospital admissions and deaths over the coming years, and ministers have signalled their intention to restrict the marketing and promotion of food and drink high in sugar, salt or fat, with a consultation on the proposals having closed in January.

There are also high hopes for Public Health Scotland, the new body being established to drive forward improvements in health.

Yet transformative change to Scotland’s health has been elusive, above all when it comes to gaping health inequalities. Overarching everything is the growing pressure on the health system and, according to health leaders, the need for a more involved conversation with the public about their expectations and responsibilities.

Dr Lewis Morrison, chairman of BMA Scotland, says: “You’re always running to catch up with a place you can never catch up with.”     He acknowledges that it’s been a difficult decade due to austerity but says there still needs to be an urgent debate about what the NHS should – and shouldn’t – spend money on, pointing to the “huge gap” between the resources the NHS will have and what it will need if spending continues on the current pattern.

Vacancy rates among senior doctors amount to the staff of a substantial district general hospital, says the BMA. This week, it was revealed that nearly nine per cent of medical and dental consultant posts are unfilled. Some specialisms, such as radiology, face international shortages, but doctors argue that better pay to address years of real-terms pay erosion could help tackle recruitment and retention.

Health: Jeane Freeman has spent the year fighting fires

The nursing and midwifery vacancy rate is at an all-time high, the latest figures show, with 6.3 per cent (4,000) posts unfilled. The nurse vacancy rate in the care home sector is estimated to be 20 per cent. The Royal College of Nursing welcomes a planned increase in the nurses’ bursary to £10,000 a year, but says that student numbers are only back to 2012 levels, before the Scottish Government cut them, and more are needed.

The Auditor General, Caroline Gardner, published her annual review of the NHS last October, concluding it was “not financially sustainable in its current form” and pointing to major workforce challenges, rising drug costs and a maintenance backlog.

Waiting times have been going up on several key measures. Ninety-five per cent of cancer patients are supposed to be treated within 31 days of decision to treat. The figure for the first quarter of 2019 was a respectable 94.5 per cent – up from the same quarter in 2018 – but the 62-day referral-to-treatment target was met in only 81.4 per cent of cases, down from 85 per cent the previous year.

The more general legally binding treatment time guarantee – that all patients should be treated within 12 weeks of decision to treat – was met in only 72.5 per cent of cases in the second quarter of this year, down from 74.5 per cent for the same period last year. The 18-week referral-to-treatment standard was met in 79.2 per cent of cases in the second quarter of 2019, compared to 82.8 per cent the previous year. Waiting times are also well short of target in mental health.

Freeman announced £650m of extra funding last year to try and meet the targets, so far with limited success, and that continuing failure has become a major political sore point.

While stressing the importance of political scrutiny, Lewis Morrison finds it “unhelpful” when missed targets are used as a reason by opposition politicians to demand the cabinet secretary’s resignation. Health leaders would rather see a debate about reforming the targets.

Paul Gray was the chief executive of NHS Scotland until February. He says: “The cancer targets really do matter. The A&E ones matter, too, because there is clear clinical evidence that in most cases outcomes are better if you’re in A&E for no more than four hours.

“But there’s less clinical confidence in the 12-week treatment time guarantee, although everyone accepts that it is enshrined in law.

“What I’d like to see is a clinically led conversation with the public about prioritisation, drawing on the realistic medicine principles set out by the chief medical officer. For more serious conditions, an eight-week target (or even lower) might be better, whereas 12 weeks might remain the right answer for many conditions and 24 weeks might be better for others. But any change should be clinically led.”

Realistic medicine promotes shared decision-making between healthcare professionals and patients, and honesty from doctors about the benefits and downsides of different treatment options (including doing nothing).

A reform to waiting times would be a significant change, and would require the buy-in of other political parties, but is backed by the BMA, which favours a system that is more clinically nuanced.

The integration of health and social care should help relieve pressure on hospitals in the longer term, so how much progress has been made?

Gray says staff benefit from working together where they all feel part of the same team. “There are examples of excellent practice where I know that it’s no longer possible to tell who’s from the local authority and who’s from the health service or partner organisations, but there are some areas where the divisions are still too visible.”

An Audit Scotland review, published last November, found that the integration authorities, councils and health boards needed a stronger commitment to working collaboratively. The Ministerial Strategic Group for Health and Community Care subsequently accepted the recommendations, declaring: “The pace and effectiveness of integration need to increase.”

Meanwhile, health inequalities persist. Everyone agrees that the cost to the NHS, the economy and in sheer human misery is unacceptable. But like a troublesome disease, it has proved largely impervious to treatment.

Rates of obesity, anxiety, depression, alcohol-related deaths and smoking incidence are markedly higher in poor areas.

There have been some disappointing overall indicators of Scotland’s health in recent years, including worsening life expectancy figures between 2015 and 2017, but the effect is, as ever, more marked in deprived areas.

Scotland’s alarming return to the headlines for its rate of drug deaths also reflects health inequalities. Scotland has the highest rate of drug-related deaths in the EU, with 1,187 reported last year, up 27 per cent on the previous year.

Dr Pete Seaman, acting associate director of the Glasgow Centre for Population Health, says the health inequality figures are “disappointing”. Once again, he cites austerity and the impact of UK-wide welfare reform working against efforts to improve the wellbeing of those living in deprived communities.

Nevertheless, he is optimistic, particularly about the progress being made on prevention work, recognition of the causes of health inequalities – a lack of income, wealth and power – and an understanding that health services alone cannot eradicate them. He is also pleased that there is now a shared understanding among policymakers about what works: services that treat each person as an individual and empower them to live lifestyles that make them well.

The understanding that tackling health inequalities takes a multi-agency approach lies at the heart of the six priorities of the new body Public Health Scotland, launching in April 2020. Those priorities include having safe, healthy places to live, an inclusive economy and, crucially, good mental health.

Improving mental health in particular has shot up the political priority list for all parties over the last decade. The Scottish Government’s 10-year mental health strategy was launched in 2017 and envisages 800 additional mental health workers. A Suicide Prevention Action Plan has been published and new money is earmarked to boost mental health support for expectant and new mothers. Last September, Nicola Sturgeon announced funding for 250 school nurses and 350 school counsellors.

Even so, the targets are still being missed by a wide margin.

Meanwhile, the political background is volatile and Brexit looms. Civil servants have been preparing but not all the implications of Brexit can be anticipated. Any medicine shortages could have a knock-on effect on operations, with the possibility of cancellations, and there are worries about access to maintenance and spare parts for medical equipment sourced in Europe.

In the longer term, there are worries about Brexit acting as a deterrent to EU medical staff and students, and about the impact on the economy and public finances.

Against the challenging backdrop of Brexit and resource pressures on the service, health leaders believe that there needs to be a more honest debate with patients about what the NHS can realistically provide and what individuals can do to help themselves, particularly in relation to lifestyle.

Maintaining and promoting good health is a shared responsibility between professionals and patients, and if Scotland’s health profile is to change, the ways of the past must change too.