Des McNulty: Time for a healthy debate on NHS budget

INSISTING there can never be any cuts to the NHS in Scotland is a short-sighted view. We need to look at the bigger picture

As PUBLIC spending comes under yet further pressure, politicians from Scotland’s major parties continue to make commitments to “protect” the share of the total budget spent on health. But this idea that the NHS budget should be sacrosanct needs to be properly debated. We need to address two issues: first, the extent to which improvements in health are achieved through the NHS budget or other budgets, and second, whether the NHS budget is being used to best effect. The Christie Commission stated “irrespective of current economic challenges, a radical change in the design and delivery of public services is necessary to tackle the deep-rooted social problems that persist in communities across the country”. So what changes might be needed to achieve improvement in the nation’s health?

Scotland faces two overlapping health challenges. On average, people here live two years less than in England. We are not just behind England but every other country in western Europe. The factors that contribute to poorer health in Scotland are well known – diet, lack of exercise and consumption of alcohol amongst them. Strenuous attempts have been made to change behaviours, but much faster progress is being made in other countries – Finland, for example. Unless we can accelerate our efforts, we may fall further behind western European nations and in the near future fall behind eastern European countries also. This is not a competition, but we owe it to ourselves to do better.

Behind these averages lies a chilling fact. The health gap between better-off and worse-off communities in Scotland is growing rather than reducing. While dietary and lifestyle changes, earlier diagnosis and treatment of heart disease and other improvements are occurring, their impact is least amongst those living in vulnerable and marginalised communities. Our poorest communities have some of the worst health in Europe.

To meet the challenge of health inequality, the way we think about health has to change. In his 2009 report, the Chief Medical Officer suggested the way forward: community-led, asset-based approaches to health promotion. Sir Harry Burns’ proposal was that health disadvantage is best tackled not by focusing solely on health deficiencies in deprived communities but by building on the assets such communities have. Greater resilience will be achieved by drawing on the skills and knowledge of local people, on local networks and community organisations, and by giving people more say in determining the routes to healthier lifestyles. The essence of the approach is treating people as co-producers of their own health rather than as passive consumers of health services. The Chief Medical Officer’s advocacy of community-led, asset-based approaches stems from a profound reflection on both the causes of health inequalities affecting deprived communities in Scotland and the factors that help or hinder people in maintaining a healthy status. Simple things, such as more time for GP appointments in the most deprived areas, which would allow doctors to better engage patients with complex needs in improving their health, could make a huge difference.

Yet both the capacity of individuals to take more control of their lives and community assets are at increasing risk. In current economic circumstances, households in the most disadvantaged communities are the most likely to be affected by rising unemployment and benefits changes, leading to more stress on individuals and families. Cuts in education, social services and community development budgets will damage fragile assets, including the supportive social networks on which Dr Burns wants us to build. Reductions in financial support for housing providers and the voluntary sector will further impact on community resilience. And cuts in care budgets will result in more pressure on NHS services, which are much more expensive to provide than the services being withdrawn or pared back.

Two things need to happen. First, we need recognition of the importance of services provided by local authorities, housing associations and the voluntary sector in protecting and promoting the health of people living in poorer communities. If tackling health inequalities is truly a priority and building assets and strengths within the most deprived communities is the means to do it, joined-up thinking requires we are brave enough to abandon the “protect health” mantra. Spending on acute and primary care services will continue to be important – as will what is, in comparison, a very small health promotion budget. But health services should not be lifted above all other services: health and other services are interdependent.

Second, we need to find a willingness to accept that the health budget, whatever its size, might be used differently and so give us more for our money. All of us want good primary care services and a guarantee that if we are admitted to hospital, we will be treated by well-qualified medical specialists and nurses who have access to the necessary equipment and drugs.

But, of the four countries of the UK, we have the highest spending on, and the lowest productivity of, hospital clinical staff. We have been much slower in reducing waiting times for treatment. England got down to 18 weeks in 2008; Scotland’s aim was to reach 18 weeks by the end of 2011. These patterns are not due to any lack of capacity or effort from staff generally but to the way services are organised and delivered.

We know there is unjustified variation in costs of providing services. Yet there is a continuing reluctance to publish “star” ratings or to adopt incentive-based performance management – even though there is telling evidence that, elsewhere, these have provided a stimulus to greater cost-effectiveness.

We may not want every type of reform pursued elsewhere. Devolution allows us to make our own choices, and there is a very strong consensus in Scotland against going down the path Conservative ministers have proposed for the NHS in England. But that does not mean there is not room for managing resources more effectively. The measure of success is not the number of doctors and nurses employed by the NHS; it should be how quickly patients get the treatment they need and how good the outcomes of that treatment are.

The desire to retain a local hospital that apparently provides a full range of care is understandable and there is a good case for moving services closer to patients where it is safe and cost-effective to do so. But for some specialities, doctors are arguing on safety and quality grounds in favour of bigger units that can have a wider range of specialist staff on hand. The cost of specialist units at every local hospital has never been affordable. Yet, in Scotland, community resistance to rationalisation of provision and political party alignment with local campaigns have been a major barrier to change.

Health board proposals affecting accident and emergency units at Monklands and Ayr hospitals may not have been best conceived or well explained. But high-profile campaigns to save them, and campaigns to save smaller facilities or particular provision such as Lightburn Hospital in Glasgow, have made health boards increasingly reluctant to put forward proposals to rationalise provision. In the case of Lanarkshire, the retention of three accident and emergency units has placed a crippling strain on the health board’s ability to deliver other services. If health outcomes in Scotland were no worse than elsewhere in the UK, it might be justifiable to argue we could carry on as we are, avoiding hard decisions with inevitable political fall-out. But that is not the case.

There is a requirement to face up to Scotland’s appalling health inequalities and move us from the bottom of the league so far as life expectancy is concerned. To do that, we have to remove the boundary round health spending, focus on how we can use health resources more effectively and so free up money for the range of public services that can support those in greatest need to adopt healthier lifestyles. Doing so will involve real debate on what works – not a closing down of debate in fear of losing votes.

• Des McNulty is a former Labour MSP