Hard-pressed doctors and nurses face an unprecedented challenge to deliver an NHS fit for the 21st century while working within the constraints of a limited budget.
For years Scotland has been unable to shake off its “sick man of Europe” tag. The issues caused by a rapidly ageing population seeking ever more expensive treatments, obesity, and health inequality are as acute today as they have ever been. Against this difficult backdrop, Scotland on Sunday sat down with the country’s four leading politicians specialising in health in an attempt to find how the key challenges the health service faces can be overcome.
Donald Cameron of the Conservatives, Labour’s Anas Sarwar, Alex Cole-Hamilton of the Lib Dems and Alison Johnstone of the Greens give their diagnoses of the problems and their suggestions for a cure.
Health Secretary Shona Robison declined an invitation to take part and limited her contribution to a written statement.
All four opposition health spokespeople were united in the view that patients deserve urgent action and the Scottish Government must devote more time to debating and improving Scotland’s most important and emotive public service.
Funding crisis – centralisation versus community hospitals
The Scottish Government has pledged to protect the health budget, which for 2016/17 came close to £13 billion. Nevertheless the question of where the cash is spent and how an ever increasing demand for healthcare is paid for is crucial to the health debate. In Scotland, all parties are wedded to the free at the point of delivery model, with Cameron rejecting the use of health insurance or privatisation.
“I think it is far more important to solve structural issues about the health service before turning to issues of privatisation. We have long since parted company with our colleagues in the south. The health service should be free at the point of delivery and based on need.” The Tories, however, differ from other parties in that they disagree with free prescriptions for all.
According to Cameron, other savings can be made. The Scottish Medicines Consortium should negotiate drug prices and efficiencies should be found when it comes to procurement and medical supplies.
Cole-Hamilton agreed: “We need to look at the Scottish Medicines Consortium and how doctors’ prescribing is one of the biggest drags on health care inflation.”
On the critical question of making savings by shutting small local hospitals and transferring services to large centralised facilities, all parties were reluctant to see community hospitals go.
Sarwar expressed concern at the reduced services planned for Lightburn, Vale of Leven and Inverclyde hospitals. Labour also had concerns about the performance of the flagship Queen Elizabeth super hospital in Glasgow, with reports of sick children and pregnant women having to be treated elsewhere.
For Sarwar and Johnstone income tax rises were key to meeting the ever increasing demand for more cash. Robison’s statement said the health budget was at its highest ever.
Cancelled ops and missed waiting targets
At the sharp end of the NHS crisis are the hospital patients whose operations are cancelled.
Last year almost 8,000 operations did not go ahead – an average of around 20 per day.
Waiting targets for 95 per cent of patients to be seen within four hours are regularly missed.
Cameron believes the targets-driven culture must be reviewed. Too many targets creates unnecessary pressure on NHS staff. Relieving that pressure would allow more resources to be devoted to high priority areas.
For Sarwar the key lies in taking pressure away from acute care, which is being squeezed by failures in primary care and an inability to clear beds blocked by elderly people.
“If we sort delayed discharge by adequately resourcing social care then that also relieves pressure on the acute sector and puts money into acute services,” said Sarwar.
Cole-Hamilton believes ring-fencing beds would prevent them being blocked. “We want the Cabinet Secretary to consider doing so,” the Lib Dem said. “If you ringfence beds and there are not physical beds for people to occupy or block then it really concentrates the mind about getting care pathways into the community.”
For Johnstone a fundamental problem is the fact that people who should be treated outside hospital are ending up at A and E.
“People are presenting at A and E with mental health issues,” she said. “The cash isn’t following the rhetoric in terms of this shift from care in hospitals to care in the community.”
Robison’s statement said that Scotland’s core A and E departments have been the best performing in the UK for the past 22 months.
Chronic staff shortages and the role of family doctors
For all opposition parties the staff shortages and recruitment crisis faced by all disciplines in the health services were of enormous concern. Solving this problem would be immensely challenging, but could alleviate many funding pressures.
The Royal College of Midwives has warned Scotland is facing a “retirement time bomb” with 41 per cent of midwives above the age of 50. The Royal College of GPs says Scotland will face a shortfall of 830 GPs by 2020. Overall consultant vacancies stand at 6.5 per cent, but in areas like psychotherapy they are as high as 22 per cent.
All were agreed that better workforce planning would cut down on the £175 million spent on agency staff last year. “An agency nurse costs the NHS £84,000 a year [in salary and agency costs] while an NHS nurse costs £38,000,” said Sarwar. “Finance is a big issue, but the workforce crisis is of more significance.”
Cameron believes there should be a “robust” national workforce plan which looks decades ahead. He also wants a “scorecard” system to check spending on locum doctors and agency staff.
There was consensus that much more should be done to support GPs, some of whom are seeing 100 patients a day during 12-hour shifts.
“We need to move to a system where GPs are surrounded by multi-disciplinary teams so there are fewer referrals to hospitals,” said Cameron, who, along with Labour, recommends an expansion of the minor ailment scheme which aims to put pharmacies at the heart of primary care. Sarwar and Cameron said physiotherapists and specialist nurses could take the pressure off GPs.
Cole-Hamilton believes recruitment has to be done on a long-term basis. “We need to recognise that this is a profession that’s on its knees,” he said. “We need to box clever and think about the needs of the next 30 years in terms of persuading primary school pupils to follow careers in the health service.”
Johnstone agreed, saying medical schools had a responsibility to sell working in a GP surgery as an attractive career. Robison’s statement said the government was developing a workforce plan.
Caring for an ageing population
The advances made in healthcare mean that people are living longer than ever before, which puts huge strains on the health service as older people present themselves to the NHS with complex illnesses that are expensive to treat.
The cost of the government’s flagship free care for the elderly policy has more than doubled in the past 12 years to around £500 million per year.
Similarly, opposition politicians have signed up to the SNP plans to merge health and social care. But, according to Cameron, the pace of integration must be accelerated.
“The damning thing is that we have been talking about this for ten years and the speed with which it is happening is farcical,” said Cameron.
With local authorities expecting cuts to their health and social care budgets, Sarwar believes the funding gap must be plugged.
“The local government budget cuts will have a direct impact on social care so you have to solve budget cuts,” he said.
Cole-Hamilton believes a radical shake-up of how we look after the elderly is required.
“The older style care home suited the smaller percentage of people who made it to a ripe old age. As living longer becomes the norm we are not going to have the capacity to look after people in that old style structure.”
Johnstone added: “We need to make sure that jobs in social care are seen as attractive, sustainable careers. We undervalue people who are in care work.”
Robison’s statement said: “People living longer must be viewed as an achievement for the clinical care and public health provided in Scotland.”
The sick man of Europe – obesity, inequality and preventative medicine
For too long Scotland has been labelled the sick man of Europe. Study after study has identified problems with obesity, low life expectation in poor areas and poor health outcomes for children growing up in poverty.
Last month a Royal College of Paediatrics and Child Health report said Scotland had one of the worst children’s health records in Western Europe with more than 210,000 children living in poverty.
It also found 27 per cent were overweight or obese and that 400 children die each year with a “significant number” potentially avoidable.
Tackling obesity is a priority for all parties. “Obesity is a real time bomb, every year Cabinet secretaries get embarrassing and disgraceful statistics about our physical health,” said Cole-Hamilton.
“It is time we got tough on that and legislate in the same way we have done with alcohol on things like the marketing of fatty foods, discounts and the way we dispense food in our hospitals and schools. It’s all very well having healthy options, but if you’ve got an unhealthy option kids tend to go for that.”
The Lib Dem also said more resources had to be devoted to treating mental health illnesses earlier and when patients are younger.
“There is a lot of rhetoric in political circles about early intervention, but we are fighting fires,” he said.
“Nowhere is that more exemplified than in mental health where the waiting times for children and adolescents is a national scandal.”
Sarwar said more GP resources were required in poorer communities.
“People in the poorest areas are in most need of time with a GP, but they have the least time. Extra hours from additional GPs are required in the poorest areas where there are more complex illnesses.”
For Cameron, more emphasis on preventing illness would make a difference.
“There is a huge issue about preventative health, which I don’t think we are gripping with the speed and seriousness required.
“My colleague Brian Whittle [the Tory MSP and former Olympic athlete] believes physical activity and nutrition for younger people has a very important effect on physical and mental health. We need comprehensive sport and obesity strategies.”
Johnstone was keen for action on food promotion in supermarkets and more work to tackle obesity and diabetes.
Robison’s statement said the government had published an obesity plan and measures were in place to tackle smoking and alcohol misuse.