Scotland's Health Secretary on the challenges ahead

Scotland has a complicated relationship with its health. Long known as the sick man of Europe, in some parts of the country Scots still have lower mortality rates compared to areas south of the border and in many cases, patterns of ill-health remain ingrained.

For Scotland’s Health Secretary Shona Robison, the challenges facing her and her team are huge. Just days before Holyrood meets her, new statistics were released which showed there has been little shift in the balance of care from hospitals to the community in the last three years, despite it being a major stated aim of the Scottish Government.

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While the number of people delayed from leaving hospital has reduced over the past quarter, with figures now at the lowest level for almost two years, the statistics also showed that the number of beds unavailable due to delayed discharge was over 150,000 in the first quarter of 2015. Of the total £4.8bn spent on health and social care in 2013/14, £1.45bn was spent on unplanned admissions by people aged over 65 to hospital.

Royal College of Nursing (RCN) Scotland Director, Theresa Fyffe, said the NHS was struggling to deliver what was a key national policy as part of the Government’s 2020 vision for the NHS.

“Plans for integration of health and social care across Scotland may go some way to address this but in a situation where demands on hospital care absorb much of any additional money that may enter the NHS, the new integration authorities will certainly have their work cut out in rebalancing services between hospitals and communities or creating any meaningful shift of services to the community,” she said.

Robison said the Scottish Government was committed to a “whole system approach” which would lay the foundations for an arrangement where more people will be treated at home or in a homely setting.

When asked about this by Holyrood, she said: “Our groundbreaking legislation passed last year creates a solid platform for health and social care to be integrated more deeply than ever, making sure the right care is available in the right place, at the right time.

“We’re going in the right direction – but there is much more that can be done. Of course, the successful delivery of this reform will depend on partnership working, strong leadership and engagement and thinking and acting collectively about what we can do to shape and deliver this once in a generation reform agenda. The commissioning process set out in legislation and guidance is being worked through now. This must involve providers, service users and carers, the third sector and housing, so that the major steps to shift the balance of care can be taken.”

However, despite the size of the task Scotland faces, Robison is no stranger to the ministerial health brief. First elected to represent Dundee East in 2003, having been a list MSP for the North East region since 1999, Robison served as Minister for Public Health in 2007 and in 2009 was given the extra responsibility for sport. It was then decided the Government needed a dedicated minister for sport and the Commonwealth Games and Robison was the obvious choice. In 2014 she was promoted to Cabinet Secretary for the Commonwealth Games, Sport, Equalities and Pensioners’ Rights before being made Secretary for Health, Wellbeing and Sport in November the same year when Nicola Sturgeon – one of her predecessors in the Health Secretary role – became First Minister.

Speaking to Holyrood about the challenges Scotland faces in terms of health, she said: “The health service is always under increasing demand and when you look at the number of patients the health service treats, that’s always increasing. Although the health budget is around £12 billion for the first time this financial year, there are increasing demands upon it in the current financial climate with the squeeze on public services and austerity. 

“Although the health budget has been protected and there have been real-terms increases, demand continues to grow. So it is about being able to manage that and ensure the NHS continues to provide a good quality, accessible and quick service against a backdrop of a challenging financial climate. We have an ageing population, which is a good thing as we’re all living longer, but that brings challenges, [for example, there will be] more knee, hip and eye operations in the future. As well as the here and now, the challenge is to look ahead and to make sure that we have the capacity and the right workforce.”

In 2011, Nicola Sturgeon, then Cabinet Secretary for Health, Wellbeing and Cities Strategy, set out her strategic vision for achieving sustainable quality in the delivery of healthcare services across Scotland, in the face of the significant challenges of Scotland’s public health record, a changing demography and the economic environment. 

The Scottish Government’s vision is that by 2020 everyone will be able to live longer, healthier lives at home, or in a homely setting and, that Scots will have a healthcare system where there is integrated health and social care. 

There will be a focus on prevention, anticipation and supported self-management and where hospital treatment is required, and cannot be provided in a community setting, day case treatment will be the norm. Also, whatever the setting, care will be provided to the highest standards of quality and safety, with the person at the centre of all decisions; and finally, there will be a focus on ensuring that people get back into their home or community environment as soon as appropriate, with minimal risk of re-admission.

Robison said: “The piece of work we’re doing now on the back of 2020 Vision is to look beyond a five-year horizon to 10 or 15 years and to make sure that on capacity and on workforce we’re getting all the pieces of the jigsaw in place in plenty of time.

“Of course there are huge opportunities around not just the acute sector but also primary care. We’re in discussion with general practice about a sea change in primary care and looking at doing things very differently. General practice is where most people get their healthcare from and we think there are opportunities to do far more of that but with a broader range of health professionals to keep people well, at home and avoid acute admission where possible. 

“Finally, the big challenge is around tackling health inequalities and to make sure that in everything we do, we analyse our plans around the health inequality agenda.”

On a recent visit to the Wester Hailes Healthy Living Centre - a joint NHS Lothian and City of Edinburgh Council facility that provides a range of integrated health, social care and family support services – Robison announced that funding of £200m is to be allocated over two years to support the implementation of health and social care integration.

The investment will extend the current Integrated Care Fund into 2016/17 and 2017/18, and the money will be distributed among the 32 local NHS and social care partnerships that have been set up as part of the move towards integrated services. The fund forms part of over half a billion pounds of government investment over the next three years that will be used to support integration, including £30m over three years for telehealth.

On 1 April 2015, all integrated boards across the country were required by legislation to have their plans in place detailing how they will bring together health and local authority care services, to be fully implemented by 1 April 2016.

Robison said: “The integration of health and social care services is one of the most ambitious programmes of work this Government has undertaken, and one which we believe will deliver sustainable health and social care services for the future that are centred around the needs of patients. Only now are other parts of the UK waking up to the need for change, and the need for integrated services, which in Scotland we have been working towards for the last few years.

“Integration is about improving people’s quality of life, particularly those people with long-term conditions. We know the demographics of our society are changing. By 2037 we expect the number of people with a long-term condition to rise by 83 per cent and these people need help to manage their conditions at home and in the community.
“Integration will also help improve the effectiveness of the whole NHS and social care system, which can be disjointed at times. We know that people waiting to be discharged from hospital puts extra pressures on other areas of the NHS, such as Accident and Emergency.

“The new partnerships will manage almost £8 billion of health and social care resources, including the resources currently associated with 96 per cent of delayed discharge and 83 per cent of unplanned admission in the over-75s.

“We also now know that across Scotland, two per cent of the population account for around half of all hospital and prescribing resource. Partnerships will be focusing on making sure those people who have complex support needs are getting the care they need to support their independence for as long as possible.

“Health and social care integration is long-term change but it will also have immediate benefits. This vision, and our investment, will help to ensure that people across Scotland have access to the highest standards of care - in the right place and at the right time.”

Speaking about the facility at Wester Hailes, Robison continued: “The centre has a huge number of services under one roof. For example, you have the GPs involved in things like setting up walking groups and bringing young mums together to help them out of social isolation. They are really tackling some of the underlying causes of ill-health and people are getting support back into work, support around debt counselling and alcohol issues. It is, in a genuine sense, a holistic approach. As we move forward with reforms looking at primary care and how we deliver that in a more effective way, there’re some really good models which can also help us tackle some of the health inequalities which mean that [the] life expectancy gap is still too wide in Scotland.

“With the new world of integration this approach makes sense. Integration is a revolution of sorts, it is about bringing those two big systems together under one budget and one system. There is joint accountability for supporting people and that’s a big change. 

“A logical step is to house services under one roof or under one virtual roof where they should be working closely together. In Wester Hailes they are literally under one roof so people going in there will be able to see a whole range of health professionals but also social work, alcohol counsellors, as well as children’s services working on early years – for example, mums getting skills around healthy cooking and healthy eating. “It is really looking at the broader health of its people, not just ill-health but actually keeping people well. That is definitely the way of the future, ensuring we don’t just look at one part of a person’s life in isolation. 

“For me, we need to look at the scaling up of that. For example, how do we make sure that the new GP contract, which will be the first Scottish-only contract, taking place from 2017, how do we ensure it facilitates these ways of working and actually encourages and supports new ways of working around these models. I get the sense that general practice is very much up for that discussion and we will continue to talk to them.”

When asked about Scotland’s notorious ‘sick man of Europe’ title, Robison admitted the country has a “long way to go” but she believes it is changing.

She said: “If you look at some of the statistics around levels of activity, for example, also there are encouraging signs around alcohol use, although we still have major challenge there. We suffer the same health challenges as every other western European nation but we’re becoming less of a stand out. That’s due to some of the very good public health policies and a lot of the early intervention work. If you look at teenage pregnancy rates, they’re going in the right direction too. A lot of the work is being done by the early intervention family nurse partnerships who are working with young mums before the child is even born to give that generation a better start in life. I think we are turning the corner on some of our stand out statistics, which none of us were proud of, but we still have a long way to go. Within Scotland we still have far too big a gap in health inequalities in, not least, life expectancy.”

Robison cites the Penrose Inquiry as one of the biggest personal challenges she has faced since becoming Health Secretary. In March she apologised on behalf of the NHS and Government in Scotland to all patients and families affected by infected NHS blood and blood products in Scotland during the 1970s and 1980s.

Lord Penrose chaired the inquiry, which looked in detail at how patients were infected with hepatitis C and HIV/AIDS through blood transfusions and other procedures carried out at NHS hospitals from 1974 onwards. Robison accepted the report’s recommendation – that steps should be taken to offer blood tests to anyone in Scotland who had a blood transfusion before 1991 and who has not already been tested for hepatitis C.

She said: “It is very difficult when you are sitting with families and people affected and you are listening to some heartbreaking stories. As I said at the time, we are determined to make sure we better support those affected and their families and I was very struck by the need and responsibility for us to do what we can to support those affected.”
In terms of other challenges, she said she likes to “roll my sleeves up and get into sorting out issues that are there”. 

She added: “Challenges are there to be overcome. I’d like to think that within the short months I’ve been cabinet secretary on delayed discharge, we’ve managed to get in a position where we can see the tide turning. We’ve had the lowest delayed discharge figures for two years, we can see them coming down and that’s due to the hard work of the team in here, led by Geoff Huggins, who have been working very closely with partnerships, NHS and councils to get them very focused on what they need to do. I can make any manner of statements but unless it’s then translated into what local partnerships do, it’s not going to matter one iota.”

In March, it was announced a further £100m over three years is to be invested in the NHS to help reduce the numbers of people waiting to be discharged from hospital. This funding will be used to support health boards and local authorities deliver good quality care and support for people at home or in a homely setting. This is aimed at preventing delays in discharge and preventing admissions to hospital and attendances at A&E.

“That work on the ground, the £100 million we identified to oil the wheels of that change, it’s good and satisfying to be able to begin to see the green shoots of recovery,” she said. 
“The reason it matters is that it has such a profound effect on all parts of the system, not least the acute system, from the front door of the hospital right the way through but also to ensure that at the back door of the hospital people are able to get out of hospital when they’re ready. For the individual concerned, being stuck in hospital is not a good thing, particularly for people with dementia, as well as the vulnerable or elderly. 

“I want to eradicate delayed discharge so we have a well-functioning, efficient system which utilises its bed capacity and provides the best service for those individuals.”
Taking on the Health Secretary role in November brought its own issues.

Robison said: “One of the other challenges was around A&E, we had a very challenging winter. I came in at the start of that and we needed to put some short-term additional support to help partners through that winter but I am determined that we get into a better position for the coming winter. We have also managed, through support, to help boards to improve their A&E performance which we’ve seen over the past few weeks through the weekly reporting. We’re not there yet, we’ve not hit the 95 per cent target but there have been significant improvements. My job is to ensure we keep a sharp focus on that and drive that forward.”

Last month representatives from the Royal Colleges, the NHS and Integrated Joint Board Chief Officers met with Robison to officially launch the new six essential actions approach to improving unscheduled care on a sustainable basis.

At the time, she said: “The Scottish Government is committed to sustainably improving A&E performance, which is why we are working with health boards, the Royal Colleges and councils to roll out essential actions which will ensure best practice across the country.

“Last winter was challenging for our health boards, despite the planning that went in to preparing for what is always a period of significant pressure.

“That is why all boards will be reviewing and refreshing their plans ahead of next winter and to ensure A&E performance improves across all 12 months of the year. I [met] with key experts to share learning and make sure we are driving forward that performance and ensure that patients get quick, high quality treatment, not just in all our emergency departments but across the whole system.”       

Speaking about getting people more involved in their own care, Robison said: “There needs to be a partnership with the patient. At the end of the day, self-management, patients playing their part and the public playing their part is critical to the health system. Without which you can have all manner of interventions, medical and pharmaceutical but if the advice isn’t followed then it is not going to have the effect it could have. 

“Whether it is diabetes or obesity or alcohol, patients and the public have an important role to play in self-management. What this health service can do is to assist them to be as well as possible and to keep as well as possible. That’s got to be a partnership and I think there is scope to do more on that.

“The self-management programmes where patients are provided with the tools to manage their condition better have been very successful. That then means people visiting their GP less, it means less admissions to hospital and we need to do more of that and across different conditions but we could also do a lot of preventative work. 

“For example, the brief interventions on alcohol where a health professional has a brief discussion with the person about their alcohol intake and for many people that can be a wake-up call. Also to make sure we are promoting and supporting people to keep themselves healthy, whether that’s through good advice from early years around healthy diet or physical activity. There’s been a lot of work from our clinicians and also from the health promotion people around the benefits of higher physical activity levels. 

“If you could be active for an hour a day, the benefits of that are tremendous and there’s growing evidence around that. Dr Andrew Murray was our lead when he was working in here and he has continued through the work he has done to really get a buy-in from the clinical community around some of those benefits. It is about more physical activity and better diet, less alcohol and if we can get the public to play their part in that it will help us as we sustain and improve our health services going forward. 

“The role of government in that is to have clear messages, help support our health professionals and others to deliver some of that and support the role of the third sector too.”