Small country, big ideas

The term ‘sick man of Europe’ has been bandied around the continent since the Ottoman, or Turkish Empire was branded such in the mid-19th century. It often refers to economic circumstances as much as health outcomes. Post-unification Germany received the title in the 1990s, and recently the term has been used for Italy and Greece as they juggle debts and austerity.

When it comes to Scotland, however, the label has stuck, and is attached to a legacy of health records which have made grim reading for decades. Medical advances have meant people are living longer than ever, but mortality rates in Scotland have been a source of concern since the 1980s. While life expectancy has improved across Europe, Scotland’s figures have improved at a rate which now leaves it bottom of the pack.

Scottish males and females have the lowest life expectancy at birth in the United Kingdom. Male life expectancy is 2.3 years lower than the UK average and female life expectancy is 1.9 years lower. Broken down into localities, the figures look even worse.

For example, male life expectancy from birth in East Dunbartonshire is 80.1 years, compared with 72.6 in Glasgow city. Evidence points to widening health inequalities along a socioeconomic gradient, leaving many children facing significant hurdles to achieve their potential.

Dr Peter Cawston, a GP in Drumchapel told the recent ‘Scotland – Small country, big ideas’ health conference: “It’s as if we have a gold mine and we cover it in concrete and barbed wire.”

Overall cancer mortality rates in Scotland have decreased by 15.5 per cent in males and 5 per cent in females in the last 10 years, but are still far higher than elsewhere in the UK. Serious skin cancer in Scotland is increasing.

Diabetes, too, is a growing problem, with more people now living with diabetes in Scotland than with coronary heart disease. Two and a half times more people have diabetes than all cancers combined. As well as Type 2, which can be caused by diet and other external factors, Scotland also has the third highest incidence of Type 1 in children under 14 in the world.

Despite the decline of industry and a drop in smoking rates, Scotland also still has some of the highest rates of lung disease in the world.

On top of the traditional drivers of social inequality, and poor habits, Scotland’s poor mortality rates also have an additional, not yet known factor which leaves it trailing areas of similar demography and inequality in Europe. Broken down by cause of death, Scotland’s outlying mortality, particularly in Glasgow, is driven by what is known as ‘the diseases of despair’ – violence, drugs and alcohol.

Scotland, however, recognises its problems. The Information Services Division (ISD) is a division of National Services Scotland, part of NHS Scotland. It monitors health data for use in improvement science, and means Scotland now has some of the best health service data in the world. Healthcare Improvement Scotland uses the data to apply improvement science to scrutiny and safety.

Academic rigour is also at the forefront, with bodies like the Glasgow Centre of Population Health generating insights into the problems and gathering evidence to support future policy.

In NHS Health Scotland, charged with tackling health inequalities, there is recognition at the highest level problems cannot be solved by health agencies alone, and housing, education and employment impact on people’s life chances from the moment they are born.

And Scotland has world-respected clinical leaders who recognise a whole of government approach to improvement, and the importance of resilience in communities, such as former Chief Medical Officer Sir Harry Burns, who told the health and sport committee recently: “We are ahead of the game in Scotland. We have a long history in Scotland of concern for public health.

“The first study I can find of health inequalities anywhere in the world was carried out by the city treasurer of Glasgow in the mid-19th century, when he looked at infant mortality and measured affluence and deprivation. We also have a huge tradition of academic research into inequalities in health, so we know more about it than most places in the world. We have a good start in Scotland, and we really need to push on and fix it.”

The World Health Organisation (WHO) has often bypassed the UK CMO to speak directly to him, he added. Indeed, Professor Erio Ziglio, head of the WHO European Office for Investment for Health and Development told Holyrood last year he frequently uses Scotland as an exemplar to countries of a similar size around Europe when advocating an ‘all of government approach’.

“I can tell you there are very, very few countries that have that courage Scotland has now,” he said.

Alongside the longstanding and well publicised problems with Scotland’s health are new challenges which are shared with the rest of the developed world. As public budgets tighten, a combination of fast-developing innovations in medical science and quality practice and the resultant ageing population means treatment of the country’s population is unsustainable in its current form.

The rapid rise of dementia and older people increasingly suffering from multiple conditions at once means hospitals struggle to cope, while a lack of places in social care means transfers out of hospital are frequently delayed.

Although Audit Scotland has found NHS Scotland is managing its budgets well, it has warned there will be increased pressures ahead. Auditor General for Scotland, Caroline Gardner, said: “The NHS in Scotland’s financial performance was good in 2012/13, with all boards meeting their targets to break even and the service finishing the year with a small surplus.

“However, the health service needs to increase its focus on longer-term financial planning so it is prepared for the challenges it faces.”

Reshaping care for older people and joining up services has been a policy focus for several years but Audit Scotland warns progress has been slow, and says monitoring of its implementation and impact needs to improve.

The shift to treat more people at home or in a home setting isn’t purely driven by financial pressures, however. The Kerr report, published in 2005, proposed reform of the NHS and set a direction of travel to take healthcare into a more collaborative ethos. The subsequent quality strategy put some process into the suggested philosophy, and introduced the idea of person-centred care.

The Commission on the Future Delivery of Public Services was published in 2011, chaired by Dr Campbell Christie CBE. This coincided with the Scottish Government’s 2020 vision which provided a strategic narrative and laid more solid groundwork for many of the structural shifts Scotland has seen since to ensure long-term sustainability of health services for its citizens.

Integration of services has been at the heart of the strategy. This culminated in The Public Bodies (Joint Working) Bill 2014, which has legally underpinned the integration of health and social services by forcing health boards and local authorities to work together in the future.

The Children and Young People Bill 2014 has seen the start of a shift of resource into prevention, focusing on the potential health implications of a child’s environment in the first moments in life, and attachment to its parents.

Technological solutions will increasingly be sought, with the new Digital Health Institute in Edinburgh spearheading innovative ideas and NHS24 exploring more remote monitoring and high-tech clinical aids to ease pressure on traditional systems.

The involvement of third sector organisations has been an integral part of the transforming landscape. The Health and Social Care Alliance Scotland has grown into a prominent voice on behalf of over 600 member organisations, from large national support providers to individuals with long-term conditions and disability campaigners.

Former Labour politician Ian Welsh is their Chief Executive, and feels they have provided a “solid bedrock” for philosophical discourse. “We focused very strongly around the meta language that was around, and our input to the Christie Commission in particular focused around a range of issues like co-production, like personal outcomes for people, like developing a more responsive and collaborative commissioning context,” he says.

Self-directed support, which was designed to empower people to design their own services, has received a mixed response. Henry Simmons, Chief Executive of Alzheimer Scotland, feels there is an issue of cultural resistance to integration.

“We’re missing a significant opportunity to achieve this because of the way many areas view the development and introduction of self-directed support as a sideline, rather than a central issue of integration,” he says.

Human rights can fill the “values void”, says Simmons, and indeed a human rights-based approach has been at the centre of the Alliance’s priorities.

Although not everything they lobbied for has made it into legislation, Welsh feels they have been influential in what he describes as sweeping winds of change. “I would argue, I don’t think altogether immodestly as a small organisation representing a huge constituency, we’ve been able to, and been given permission to be very influential in how we prompt that kind of change,” he says.

The Alliance provides infrastructural support for its third sector members in health and social care to ensure people are at the centre of services. Increasingly, too, professional bodies are getting involved. This week it will join forces with the Scottish Government, the Royal College of General Practitioners and the Scottish Association for Mental Health to launch a links workers’ programme which will support GP practices in ‘deep-end’ areas of high levels of health inequalities.

For Cawston, inequalities hold back person-centred care. “There are thousands of people who get lost in our system. They’re the people who live in the most deprived areas, the people most in need of those systems,” he says. A community links practitioner will help the GP practices to build closer links with their communities so they can point patients towards the assets in their own communities such as a gym, a women’s refuge or children’s rights project.

Cawston’s practice has joined others in breaking with the national GP contract “to try and write a contract based on compassion, community and care planning.”

The NHS spends in one year on a GP practice what it spends on one appointment with a specialist, Cawston told the Alliance-led ‘Small country, big ideas’ conference. “Please insist we spend NHS resources not in leafy suburbs but in communities drowning under their social and health needs. And not in shiny hospitals,” he said, to rapturous applause.

Scottish Labour’s Health spokesman Neil Findlay has argued for a system-wide review, entitled ‘Beveridge 21’ to identify pressure points and long-term solutions. “GPs are being asked to do more without additional resources for competing needs. Yet the Scottish Government expects more people to be cared for at home which heaps pressure on doctors in communities, and as our elderly population continues to grow these pressures will become more acute,” he says.

As more people are living into old age and dying with multiple conditions, Marie Curie Cancer Care has urged the Government to improve the wider experiences of death, dying and bereavement for the people of Scotland. This starts with having more open and frank conversations about death, the organisation argues.

Cawston agrees. “If there’s one thing I could change, it’s our approach to death as a society. I think if we can see death as being a natural part of the life course then we have many more people thinking ahead and being empowered to make their own choices,” he says.

Despite the challenges, Welsh says there are reasons for optimism. When exemplifying some of the work done in Scotland during a recent visit to the University of Washington and Seattle, the largest global health faculty in the world, it became clear: “It was pretty much at the cutting-edge end of progressive activity. I think it’s really important for us all to be reminding ourselves that’s the situation.

“Although we have a challenging task in relation to health inequalities, we also have a full raft of very significant sunk investment now in things like self-management, and now increasingly in co-productive asset-based approaches locally, and digital innovation and so on, that makes us [a] pretty powerful prospect for good results in social care integration.”

While Scotland has invested in a collaborative and co-produced route to health, England has largely opted for one rooted in the concept of competition. The Health and Social Care Act 2012 resulted in the most extensive structural reform of England’s National Health Service since it was created.

The widening gap in structure and ethos between the health services in the countries has led inevitably to health being on the constitutional agenda, but whether as an independent country or not, Scotland’s health and social care landscape will be ‘unrecognisable’ in five to ten years time, according to Health Secretary Alex Neil.

The Government’s Director of Public Health Science, Dr Andrew Fraser, told the Alliance conference Scotland should be “ambitious and full of heart” when dealing with health inequalities. “We are not a small country,” he said.