Lesley Riddoch: The epidemic hospitals can't cure

Pouring money into A&Es stops the NHS tackling chronic problems that are sure to worsen

WAS Labour right the first time round? Should Monklands Accident and Emergency Department close to release cash for community care? Last week Labour leader Iain Gray announced he would guarantee the future of a service his party tried to close in 2007. It was recognition of electoral reality - and part of a cross-party refusal to face reality.

In a country with some of the worst health outcomes in the developed world, the proximity of top-notch hospital-based emergency care is still regarded by the public as the acme of health provision. It's not. When Labour's Lewis Macdonald, then a health minister, endorsed NHS Lanarkshire's decision to close Monklands' A&E, he said: "The service needs to look after people on a continuing and preventative basis, rather than isolated episodes of acute emergency inpatient care." He was right.

Pouring money into hospitals stops the NHS tackling health problems before they become emergencies. And we are pouring money in. In 2009-10, the NHS in Scotland spent almost 1.5 billion pounds on emergency admissions of old people - the majority of whom had no serious clinical problem. Some had a minor fall, or felt unwell or in pain. Without support in their own locality, they were taken to hospital - to be on the safe side.

Even without the current rates of hospital-acquired infection, that's a terrible admission of social failure. Once in a hospital bed, those old people stay. Health will find the cash to keep them - housing cannot find the cash for adaptations to let them go home. Community care cannot fund the professionals needed to drop by. Children cannot afford the time to do the job themselves. Our money is trapped in silos. And no-one can find a way to break those funding barriers down.

This will get worse. Health professionals estimate our ageing population requires the construction of a new hospital every 18 months. That cannot be afforded - and it should not even be contemplated. Margaret Thatcher once said money in the NHS should follow the patient. 40 years later the patient still follows the money. And the money is locked up in hospitals. It's a terrible Catch 22 - the same kind that kept people with mental illness inside institutions or locked up in jail.

In 2005 the Kerr Report tried to break out of this vicious circle by switching cash from hospital provision to ambulatory care centres - local outpatient units. Lanarkshire was one of the first to attempt the switch and to fund it, one of three fully staffed A&Es in the area would be closed. But which one? The choice was coloured by a political reality.Wishaw and Hairmyres were PPP hospitals - which made change difficult. The easiest candidate for A&E closure was Monklands and yet the population of Airdrie was most likely to use emergency services.

The impulse to rationalise was undoubtedly right. The choice of hospital to close was probably wrong. The result was that Labour lost a crucial seat in the 2007 Holyrood elections - and learned a hard lesson about public priorities. But whoever wins on 6 May, what next? If Lanarkshire couldn't afford three A&E departments in 2007 - can it afford them now?

If voluntary organisations helping people live with arthritis, COPD, chronic back pain, asthma, diabetes, cancer, heart disease, ME and mental health problems needed more cash four years ago, how much more do they need cash now? And yet almost every group delivering low-key, non-emergency care outside hospitals has had a budget cut.

Senior health professionals agree funding needs to be turned on its head. But which politician has the courage to remove 800 million from hospital budgets and risk the wrath of local voters to make local health care investments which may not visibly yield dividends for a decade? Hospitals are tangible. Services that help diabetics stay out of hospital are not. And yet 40 per cent of people aged 75 or over live with at least two such long term conditions. Audit Scotland projects a rise in the over-75 age group of 75 per cent by 2031, a rise in COPD (respiratory problems) sufferers of 33 per cent and a rise in patients with dementia of 75 per cent.

How will society cope? A solution may lie in housing and community care - not in health. Take Whitlawburn. In 1988, Glasgow Council was given 6.6 million to refurbish this run-down estate on its southern outskirts. West Whitlawburn had hard-to-fix high rise flats. So the council spent the repair money instead on the easier-to-fix low-rise blocks of East Whitlawburn. Outraged, the tenants' association in the West opted out and set up a co-operative to own, improve and manage their 540 homes. Phil Welsh MBE chaired the first Co-operative; "People fae miles away sit on a Housing Association Board. Only folk fae the neighbourhood sit on a Housing Co-operative. It was an opportunity to do things for ourselves."

Personal contact replaced distant bureaucracy. Dampness, security and renovation were made priorities. All homes were refurbished, an old school was turned into a healthy living centre and a team of concierges was hired to monitor 28 external and 185 internal CCTV cameras and 70 homes fitted with alarms. Elderly, disabled or vulnerable tenants can buzz down to the concierge base if they're lonely, frightened or ill, and can have a chat, a basic health check or a cup of tea with company - even in the middle of the night.

Eleven deaths have been averted by swift responses from the camera/concierge team. The Co-op refuses to turn its health success into cash savings.But they know higher-than-average management costs must be defended in straitened times. So they've produced social accounts instead which list the ways in which a well managed, self regulating community protects dignity and saves cash.

The West Whitlawburn Housing Co-operative is the salvation of its tenants and the envy of its council neighbours. It's also the saviour of local A&E departments - including Monklands. And yet healthcare is not a formal part of housing's remit.

Two reports will land on the new health minister's desk in June demanding change. Campbell Christie and Sir John Arbuthnot will both report on better delivery of public services. It's likely both will back self-management against hospitalisation - and hospital wards will have to close to finance such a shift.

Scottish politicians have just six weeks left to tell voters otherwise. Prepare for U-turns aplenty.