Comment: Scotland’s NHS: a suitable case for treatment

THE move to bring health and social care together makes sense, but it won’t be as easy as it may sound, writes Jenny Stewart

With John Swinney publishing his draft budget and Alex Neil settling into his new role as health secretary, experts gathered in Edinburgh this week to discuss plans to integrate health and social care. However, a new study on how other countries’ health systems are dealing with the impact of the economic crisis makes for worrying reading. Will the NHS in Scotland suffer a similar fate?

The KPMG report Acute or chronic: the impact of economic crisis on healthcare and health looks at measures other countries are taking. The report raises concerns that some short-term cost-cutting may have a damaging impact on public health.

Healthcare spending has been increasing for many years at some 0.5-2.5 per cent above GDP growth rates. Most countries are now freezing or cutting spending. Some countries have cut health salaries by as much as 20 per cent; others have let waiting times rise; a number have asked patients to pay – or pay more – for individual services, and some have reduced entitlement to drug treatments or other services.

In the light of these findings, the KPMG report suggests a six-point plan to deliver quality healthcare to patients:

• Redesigning delivery models to lower dependence on institutional care and improving integration;

• Empowering patients to take more responsibility for their own wellbeing;

• Focusing on measuring and purchasing value for patients, not just on reducing costs;

• Making better use of technology to improve health management and reduce mistakes;

• Tackling corruption and fraud, where it exists, around payment and procurement;

• Focusing on prevention as a route to reduce admissions.

How does the NHS in Scotland compare internationally and can it make the changes necessary?

Work has begun in a number of areas. However, the pace of change needs to quicken considerably if the NHS in Scotland is not to be engulfed by increases in demand.

Scotland has made huge strides in recent years in increasing life expectancy – reducing death rates from major diseases and increasing the length of time people lead their lives in good health. But other European countries have made even greater improvements. We are still the comparative sick man – and woman – of Europe and spend more per head than many other countries.

The Scottish health budget is now some 42 per cent of the Scottish Government’s total departmental spend – more than £11 billion.

This time last year, John Swinney set out his financial plans to 2015 and promised “we will protect NHS spending” by passing on UK health budget increases to the Scottish health budget. Other budgets were cut to protect health. The prospect of any real-term growth in NHS spending in Scotland in the medium term looks nigh-on impossible – given the disproportionate cuts other, smaller programmes would suffer. Indeed, yesterday’s updated draft budget shows a £190 million per annum real terms reduction in health spending by 2014-15 through cuts in capital spending.

The debate over the next few years will be about how to direct that £11bn to deliver the maximum health benefit.

For some time, the NHS in Scotland has been grappling with how to treat increasing numbers of patients within financial constraints. It has had to absorb the very significant cost of providing free prescriptions for all and is already dealing with an ageing population and the increasing complexity of patient conditions.

In the past two years, the NHS in Scotland has coped with extra demand by focusing on delivering efficiency savings, implementing a pay freeze and reducing staffing. According to Scottish Government statistics, full-time equivalent staff numbers in the Scottish NHS have fallen by 4 per cent in the past two years (and by just over a 6 per cent in local government). In yesterday’s budget, John Swinney set out plans for a 1 per cent pay increase for public sector workers for 2013-14.

There is widespread recognition within the NHS that short-term solutions alone cannot meet the challenge and that some bold and radical measures are needed. Policymakers and healthcare professionals know they will have to rethink and redesign healthcare provision so it can be sustainable over the long-term. Nicola Sturgeon, at a recent conference, indicated that more than 1,800 new hospital beds would be needed by 2020 if models of care did not change.

Many countries have tried to shift funding from the hospital sector to community based health – Scotland is not alone in struggling to do so. The Scottish Government is therefore right to focus on redesigning models of care, with greater integration between health and social services. But plans are at an early stage and will take time to implement. KPMG has seen this at first hand, advising the States of Jersey to design a new integrated health and social care system, which is being implemented now. If implemented properly, integrating health and social care services could deliver huge benefits for patients in the medium term.

In the meantime, more rapid progress should be made in providing telehealth services – where technology allows long-term conditions to be monitored and care provided at home.

Scotland’s telehealth strategy has led the way in Europe and many small-scale initiatives are bringing real benefits to patients’ lives. But with more than one million people in Scotland with at least one long-term condition, only a small proportion have access at present to this type of service, which improves quality of life and reduces distressing visits to A&E or emergency admissions to hospital. The challenge is clear: we need to deploy the health workforce differently; use technology better to change established and, in some cases, outdated models of care; and we should treat and support more people outside hospitals.

We know from experience across the UK and the world that these approaches are clinically effective, financially efficient, more convenient for patients and therefore popular. This level of change requires boldness and leadership – managerially, clinically and politically. It isn’t easy, but it is essential.

• Jenny Stewart is the head of public sector at KPMG Scotland.