A long hard look at NHS Scotland
Scott Arthur takes a hard look at the NHS in Scotland, the claims made about it and the evidence we have for how well it is being looked after.
The NHS saved my life.
This did not involve blue flashing lights or lots of drama. After a series of consultations, I was diagnosed with “sick sinus syndrome” and a few weeks later I had a state-of-the-art pacemaker fitted. All the staff I interacted with between when I last saw my GP to when I was discharged from Edinburgh Royal Infirmary were utterly professional and I have huge respect for them all.
However, it was very clear that the staff and systems in the NHS were stressed. The nurse who took me to theatre did so in her lunch break. I saw a doctor offer to take casework off an overloaded ECG specialist. On discharge I was asked to make an appointment with my GP practice to have my dressing changed within 72 hours. On calling, I found that no appointment was available for two weeks and that I had to rely on good will to be seen. All this was in the space of a few hours.
These acts of good will typified my experience. Every member of NHS staff I met during my 24 hours in the ERI was absolutely dedicated to their job and willing to go the extra mile to help patients and colleagues, but it was clear that they were stretched. Indeed, two days after my operation I read the news that only around a quarter of nurses feel that their department is sufficiently staffed.
Based on this experience, I wanted to write about the NHS in Scotland and the challenges it faces.
Claim #1: The NHS is the best healthcare system in the world
Yes, it is certainly one of the best! The UK NHS has been declared the world’s best healthcare system by the Commonwealth Fund, a Washington-based foundation which is respected around the world, who rated its care superior to countries which spend far more on health.
Claim #2: The NHS in Scotland is better than the NHS in England
No! A comparative study in 2010 found that the NHS in England performed better than the devolved systems across the board. A similar independent study in 2014, which included a wider range of performance measures, revealed that while there are few indicators on which a devolved country does better than England, the performance gap between England and Scotland has narrowed in recent years, but is still significant. One thing that stands out in this study is that deaths considered avoidable due to medical intervention are 20% higher in Scotland (see charts below – NE England is included as its demographics are closest to Scotland/Wales/Northern Ireland).
On the positive side, waiting times have fallen in Scotland to the extent that they are now comparable to England’s (see chart below as an example).
It is important to note that the English system performs better than Scotland’s despite our system having extra funding.
Claim #3: The Tories in Westminster are starving the NHS in Scotland of cash
Nope, the NHS is devolved and Holyrood decides what Scotland spends on the NHS. During the independence referendum campaign the SNP’s Yes Scotland warned Scots that “more private money and less public funding” from Westminster on the health service would “automatically trigger cuts for Scotland”.
What the SNP didn’t say was that the Tories were increasing NHS spending and the SNP was not passing it on. The impartial IFS found that the Tories had increased NHS spending by 4.4% and, although this would have resulted in extra Barnett money, the SNP cut funding in Scotland by 1.2% (see table below).
Looking at spending per capita also raises questions (see chart below). In England spending on health has increased in recent years, but in Scotland it has fallen by £51 per person.
As recently as October 2015 Audit Scotland said that NHS funding in Scotland for day-to-day services and new hospital buildings had fallen by 0.7% in real terms over the last six years:
“Tightening budgets combined with rising costs, higher demand for services, increasingly demanding targets and standards, and growing staff vacancies mean the NHS will not be able to continue to provide services in the way it currently does. Together, these pressures signal that fundamental changes and new ways to deliver healthcare in Scotland are required now.”
Claim #4: The SNP have increased the number of nurses in NHS Scotland
Yes, but only after cutting them. When the SNP entered government, NHS Scotland had around 57,000 nurses and midwives (increased under the Labour/LibDem coalition from 53,000 in 2002 – a 7.5% rise). From 2008 to 2012, the SNP progressively cut the number of nurses to just over 56,000. It was not until 2013 that the number of nurses reached the level Labour had achieved. There are now ~59,000 nurses in Scotland – a 3.7% rise over 9 years (see chart below).
Claim #5: UK immigration policy is stopping Scotland recruiting the nurses it needs
Why does Scotland need to import nurses from outside the EU who have been trained at great expense to their own government?
The answer is simple – Nicola Sturgeon cut nurse training in Scotland when she was the Scottish Health Secretary. She cut the number of nurses entering training over three years from 3,400 to just 2,700 in 2012/13 (see chart below), claiming that her cuts reflected “emerging employment trends in NHS Scotland”. Indeed, when challenged by the RCN in 2012, Ms Sturgeon claimed her cuts were the “sensible way forward”. At the time, the RCN was clear that the cuts would result in a real risk that there would “not be enough professionally qualified nurses graduating” between 2015-18.
Events have shown that Ms Sturgeon should have listened to the RCN. In Scotland 75% of nurses think that wards are understaffed and 10% can’t take time away from their ward to undertake mandatory training. In January 2015 it was found that stress-related sick days among nurses in Scotland had risen by 34%. We have also seen that understaffing is at the heart of the failure of the A&E service to meet waiting time targets in Scotland.
Claim #6: The Scottish Government has a strategy to cut healthcare inequality
Yes, it has a strategy! This is how Audit Scotland described it in 2012:
“National strategies which aim to improve health and reduce health inequalities have so far shown limited evidence of impact”.
Audit Scotland said health inequalities were “long-standing and entrenched” throughout the country, and that “resources should be better targeted at those who require them most”. In response to the report the BMA urged the SNP Government to “use the unique relationship that GPs have with their patients and in their communities to target healthcare to those who need it most”.
In response to this damning criticism the SNP established a “taskforce”. Although this was welcome, it is clear that the most basic recommendation made by Audit Scotland has not been delivered 3 years later – healthcare resources are still not being targeted where they are needed most.
In late 2015 Audit Scotland noted that GP practices in deprived areas had less funding than their colleagues providing healthcare to middle class Scots. The difference in funding equates to around 2000 fewer appointment slots per year in each practice serving deprived communities.
Claim #7: PFI/PPP was bad for the NHS and it is good that the SNP abandoned it
The SNP don’t like to admit it, but they are big fans of PFI. They know it is controversial, so they call it “Non-Profit Distribution” – don’t be fooled by the name, it is PFI. In Edinburgh, the new Sick Kids Hospital and the Scottish National Blood Transfusion Service facility are being procured by the SNP using NPD/PFI. Indeed, just a few weeks ago John Swinney announced a new batch of projects which will be procured via NPD/PFI.
Claim #8: The SNP have stopped the backdoor privatisation of the NHS
This is bonkers. We know that about £82 million was spent by the SNP Government on private health firms last year, compared with £75.9 million the year before and £58m in 2006-7 when the SNP came to power. This increase comes after the First Minister Nicola Sturgeon’s pledge to save Scotland from the “creeping privatisation” of the NHS south of the border.
This does not include the involvement of the private sector in social care. One business which has benefited from this is Balhousie Care Group, Scotland’s largest private residential care home provider. The Chairman and founder is Tony Banks, a millionaire who is a key player in the independence movement.
Claim #9: A&E Waiting times are being reduced
Correct, but the waiting time target target is still being missed. At the beginning of 2015 is was clear that the SNP had lost control of A&E waiting times. After sustained pressure from Scottish Labour, the SNP started taking the issue seriously. Nonetheless, the most recent data shows that only 93.7% of patients were seen within 4 hours – the target is 95% (see chart below). In England the situation is marginally better with 93.3% (although there may be differences in how the data is collected/presented).
Personally, I find the obsession the Scottish establishment has with A&E waiting times unhelpful. It is a really important benchmark, but focussing solely on it is distracting. For example, is it not worse that so many children & young people that have had to wait more than 18 weeks to see a mental health specialist? The 18 week target is intolerably long and failing to hit it is unacceptable (see chart below).
Claim #10: By tackling delayed discharge, there will be fewer cancelled operations
Correct, but the SNP are not delivering the progress they promised. Cancelled NHS Scotland operations were in the news recently – there were thousands of cancellations in 2015 (see chart below). Whilst this makes a change from reports of A&E waiting time targets being missed, the two issues are related. Both are linked to “delayed discharge” (AKA bed blocking).
Delayed discharge is where a patient is judged clinically ready to go home but continues to occupy a hospital bed while plans are made for appropriate follow-up care. These plans can be complex, but can also be as trivial as fitting a handrail on someone’s bath at home. At any one time hundreds of patients can be waiting weeks for discharge. This is bad for them and bad for the NHS.
To be fair to the SNP’s Health Secretary, Shona Robison, she said cutting the number of people stuck in hospital waiting for a care package to be arranged is an “absolute key priority” for the Scottish government. Indeed, she committed £100m to solving the problem (a few months earlier £5m was claimed to be enough). On the 25th of February in a BBC interview she said:
“I want over the course of this year to eradicate delayed discharge out of the system and I am absolutely determined to do that.”
Indeed, the seriousness of the issue led to Ms Robison invoking Nicola Sturgeon’s name a few weeks earlier:
“In presenting the Government’s programme for the year ahead, the First Minister made it clear that addressing delayed discharge is one of our key priorities and it is one to which I give my personal commitment.”
There we have it. With the support of Scotland’s First Minister and £100m in her pocket, Shona Robison gave a “personal commitment” to “eradicate delayed discharge” by the end of 2015. How did she do?
The situation up to October was pretty poor (see chart below). The official assessment:
“In October 2015, there were 50,945 days spent in hospital associated with delays in discharge. This is a 6% increase from September and a 9% decrease on the same period last year.”
So whilst the SNP’s apologists may want to suggest that cancelled operations can be attributed to “acts of god”, alert readers will perhaps argue that the SNP could be doing more to deal with the delayed discharge of patients.
Claim #11: OK, there are problems in NHS Scotland but at least it is better than when Labour ran it
Labour have not been in power since 2007. Over that time there have been real improvements in medical science, clinical processes and treatments. If nothing else, we now have a much better understanding of how to eliminate hospital acquired infections. We must give the SNP credit for taking advantage of these innovations, but we must also be willing to accept that other parties would have done the same.
We also must accept that the reforms Labour enacted as part of the National Health Service Reform (Scotland) Act 2004 led to some short-term problems with service delivery, but ultimately had NHS Scotland on a much stronger footing by the time the SNP took office. Indeed, in 2014 the Nuffield Foundation had this to say about the impact of these reforms on waiting times:
“In terms of whether Scotland’s greater emphasis since 2005 on targets and performance management has had an impact, it appears that Scotland’s hospital waiting times now match England’s, suggesting, but not proving, a positive effect.”
Claim #12: Yes, but no matter how bad NHS Scotland is it’s better than Labour’s NHS Wales
Firstly, the Welsh Assembly does not have the same range of powers as Scotland’s Parliament. Secondly, the Barnett formula ensures Scotland has higher per capita funding than Wales. Nonetheless, it is often claimed by the SNP that NHS Wales is inferior to NHS Scotland. Why is this?
I can’t answer this fully, but others have considered it. The Nuffield Foundation say:
“Across a number of measures of performance, since 2006” NHS Wales “has improved to a similar level as England”, however, “common procedures in Wales indicate a lengthening of waiting times after a period of improvement, contrary to trends in England and Scotland.”
This is because the Welsh Government has made different spending decisions and has placed greater emphasis on prevention (the chart below shows the number of GPs), public health and social care. The shift of money from healthcare to social care has meant that delayed discharge and A&E overload have not been the issue they have been elsewhere in the UK.
It appears that in Wales longer waiting times are accepted as a price worth paying for better social care and preventative healthcare. Accepting that, we can’t simply focus on waiting times when comparing NHS Scotland with the Welsh system. To emphasise this point, the chart below shows satisfaction ratings.
NHS Scotland is not perfect, but it is not a shambles either. However, if it is to be there when we need it, we all have a duty to be honest with ourselves about how it is performing. This means that problems must be neither exaggerated nor swept under the carpet. Simply ignoring failures or boasting that what we have is very marginally better than NHS England/Wales is not good enough. We all have to think about what kind of NHS we want and what level of funding it deserves.
When judging the performance of the NHS, we can’t simply focus on a single KPI (e.g. A&E waiting times), but look at healthcare in a much more holistic way. We have to understand the link between GP provision, bed blocking, social care and the demands placed on A&E services.
Labour have been clear that their priority would be to take the pressure off the NHS by investing in social care. The Public Bodies (Joint Working) (Scotland) Act 2014 is clearly a mechanism for doing this as it will demand our Local Authorities work closer with the NHS to deliver social care. However, as both are underfundedthere is concern that service delivery will actually be harmed. Nonetheless, there is huge potential to place much more emphasis on preventative healthcare in Scotland. A good start may be for the SNP Government to publish updated national social care standards and for all the parties in Scotland to bring forward proposals on how they can be delivered.