Changing gears

In May, Health Secretary Alex Neil became the first cabinet minister in Scotland to face a vote of no confidence since Sarah Boyack in 2001, after a freedom of information request by Labour revealed he had intervened in strategic decisions by the health board in his constituency shortly after being appointed. This, critics argued, was a breach of the ministerial code. The SNP overall majority in the chamber meant Neil could brush off the challenge.

In fact, this was only a tip of an iceberg of challenges faced by the Cabinet Secretary and the NHS in Scotland this year. In October, Audit Scotland warned the health service to focus more on long-term financial planning. Auditor General Caroline Gardner said: “While budgets are getting tighter, demand for healthcare is rising due to an ageing population, more people with long-term conditions and the impact of factors such as increasing rates of obesity.”
The NHS staff survey in December revealed only 37 per cent of NHS staff felt they are being listened to by their employer, and less than half thought care of patients was their health board’s top priority. The Royal College of Nursing’s Scotland director, Theresa Fyffe, called it a “wake-up call” for health boards.
Even more surprising was a probe into an excessive hospital mortality rate in NHS Lanarkshire which revealed widespread failures in care. The review by Healthcare Improvement Scotland showed serious problems with understaffing, quality of care and patient record keeping. The then president of the Royal College of Physicians of Edinburgh, Dr Neil Dewhurst, said the findings of the review made “depressing, but not surprising reading. They are an indication of systems under severe pressure and prevalent in unscheduled care.”
Dewhurst stood down in February, but not before firing a parting shot at what he called “almost intolerable pressure” on doctors and nurses in the NHS. Lanarkshire’s bad report, he argued, could have happened anywhere. “We need to be honest about the challenges which we face, to step back from crisis management, to develop more sustainable strategies for managing hospital services and to improve the standards of acute medical care provided to patients. Our patients deserve nothing less,” he wrote, in an open letter.
In an interview with Holyrood in March, Labour’s Health Spokesman Neil Findlay said the Cabinet Secretary was “by nature a fixer. You can’t just keep fixing it because it’ll fall to pieces at some point.”
Findlay joined with the Royal College of Nursing in calling for a system-wide review of the NHS, one which he would go on to call ‘Beveridge 21’ at the Scottish Labour conference.
However, activity in health and social care throughout the year has shown neither the Scottish Government nor the health service has been standing still. Successes in the Reshaping Care for Older People initiative saw action on many of the aims of the Government’s quality strategy and 2020 vision for health and social care, specifically, the aim of having more people treated at home or in a home setting by services that coordinate.
The Public Bodies (Joint Working) Act 2014 was passed after lengthy engagement with professional and third sector bodies, and put the concept of the integration of health and social services on the statute books. This was backed up by publication of the Prescription for Excellence action plan, which looks for a greater integrated role for pharmacists to prescribe medicines and become the first point of call for patients. The Person-Centred Collaborative explored ways to put the patient at the centre of decision-making, and this has been supported by the recent publication of another action plan, ‘Making it Easy’, which hopes to tackle barriers in health literacy.
Buoyed by greater recognition of their potential contribution, the third sector was organised in contributing to the process this year. Ian Welsh, Chief Executive of the Health and Social Care Alliance Scotland, says: “A range of alliance activity this year has demonstrated how amplification of citizen voice can support better outcomes. Our Dementia Carer Voices, People Powered Health and Wellbeing and Link Worker programmes, for example, have continued to enable lived experience to be at the heart of influencing policy and practice.”
A large focus of the alliance’s work has been on the health and social care integration agenda and ensuring the prevalent focus is on people and not process.
“The launch of the Health and Social Care Academy in April demonstrates our commitment to ensuring that burgeoning relationships drive real change and we look forward to engaging with colleagues from across sectors to drive fundamental change in health and social care in Scotland,” says Welsh.
But while ambition for integrated cultural change is evident, budgets have remained tight.
In April, NHS Lothian Chief Executive Tim Davison told Holyrood there was “a chronic lack of capacity in both health and social care” in the region and in June, Dr Brian Keighley, chairman of the BMA in Scotland, told his organisation’s annual UK conference, while Scotland can be proud of the care it delivers, his tenure had been marked by “the continuing crisis management of the longest car crash in my memory – and it is time for our politicians to face up to some very hard questions”.
It could be argued the Health and Sport Committee has been doing just that, from consulting all stakeholders through the integration bill, to looking at the health legacy of this year’s Commonwealth Games in Glasgow. Convenor Duncan McNeil, of Labour, says he and his SNP vice-convenor Bob Doris were well prepared because of their previous work on the public sector interface while leading the Local Government and Communities Committee. Despite accusations of partisanship among some Holyrood committees this year, McNeil remains a strong advocate of the system. “I know there have been stresses and strains, and we’ve experienced some of those as well. There were some issues around older care but I think it was a very good inquiry, and I think we see results from that. The other one of course was access to new medicines, and I think we worked effectively as a committee and with government to address some of these difficult issues, not just the impact on individuals and what choice individuals have at the end of life, but also the health economy in Scotland and whether our brilliant consultants and surgeons here are able to work with cutting-edge technologies and new innovations in medicine.”
The next challenge for the committee, McNeil says, is linking discussion of the late Margo MacDonald’s Assisted Suicide Bill with a wider debate about end-of-life care. “Of course they’re connected, and also with the whole issue of the changing nature of how we provide care. We have an ambition shared by all parties that people should be, if at all possible, treated at home or close to home in an environment they feel they’ve got some control over. But how do we provide the standards and the quality of all of that in a home setting?”
For McNeil, committee business has moved from big inquiries to shorter investigations, but he remains committed to taking in a wider perspective. “I keep saying it, there’s never a ‘Columbo’ moment where the representative of government collapses before the committee in tears and admits guilt or whatever. But just as we’ve seen progress on older care in pieces of legislation being put down, initiatives and inspections, we’ve seen a bit of that on teenage pregnancy in certain areas – Fife, for instance – areas which were out of synch and the issue was clearly a significant issue against the rest of Scotland.”
Health inequality is an ongoing project for the committee. Wider evidence sessions led to two globally respected figures in public health giving evidence recently: Sir Michael Marmot, director of the Institute of Health Equity and Sir Harry Burns, who left his post as Chief Medical Officer for Scotland this year. McNeil believes it was one of the most significant evidence sessions in the parliament.
“When I meet people working in this field I refer them to that evidence,” he says, “That session from Harry about lack of compassion in society, Marmot’s principles and that local governments in England and tower hamlets in Birmingham are actually narrowing the gap with the same type of pressures that we face in Scotland. Some might say more significant pressures. So I think we’re going to be rattling that up and having a debate in the sessions after October on some of our findings there.”