What is the future of the NHS in Scotland?

Health is always a key political battleground, it is perhaps no surprise, therefore, that this briefing should contain an article on the future of the NHS. However, the NHS is currently facing a number of crosswinds that makes now an important time to consider how it might develop over the course of the next Parliament.

Pressures on health and social care services, 2013-2030

Health

Source: SPICe, data from Audit Scotland 2016

The pressures facing the NHS and social care are all too familiar: an ageing population suffering from multiple chronic conditions, workforce shortages, financial constraints and cost pressures from technological and medical advances (to name but a few). All of this creates the conditions for a perfect storm in that demand for services is expected to increase significantly (Figure 8) at a time when the resource to deal with that demand is increasingly limited. This has applied pressure on successive Governments to implement a plan which will ensure a sustainable future for the NHS.

Relative to other departments, the NHS has fared rather well financially due to a Scottish Government commitment to protect the health budget. However, an examination of the key performance indicators for the NHS reveals some symptoms of the ills facing the service. According to Scotland Performs, of the 18 standards due for delivery by NHS Boards, 11 were not met. While some of these were narrowly missed (e.g. Clostridium Difficile InfectionsClostridium Difficile Infections), others were missed by larger margins (e.g. waiting times for child and adolescent mental health serviceswaiting times for child and adolescent mental health services) and others appear to be on a downward trajectory (e.g. outpatient waiting timesoutpatient waiting times).

Probably the most high profile of the standards is the A&E 4 hour waiting time target. This target was lowered from 98% to 95% in March 2013 as an interim measure but, despite this lower level, 95% has been reached in just 5 of the 35 months since then and the last time a 98% performance was achieved was in September 2009 (ISD Scotland 2016).

A recent report from Audit Scotland and the Accounts Commission presented estimates that, within current service models, health and social care services would need increased investment of between £422m and £625m per annum in order to keep pace with demand (Audit Scotland 2016). In the current financial climate this level of investment is unlikely.  Therefore, significant changes will need to take place to ensure the sustainability of services.

Much hope rests on the integration of health and social care which was legislated for in the last Session of Parliament. The 31 Integrated Joint Boards went live on April 1st but are still in their infancy and are not expected to be in a position to make a major impact during 2016/17 due to difficulties in agreeing budgets (Audit Scotland 2015). Even once they are fully up and running, the estimated efficiency savings from integration are estimated to be between £138m and £157m per annum, so some way off the funding that is believed to be needed to keep pace with demand. It is therefore clear that something else will need to happen to address the shortfall.

This ‘something’ may be the National Clinical Strategy for Scotland which was published prior to the election (Scottish Government 2016). The clinical strategy sets out the future of healthcare services in Scotland for the next 10-15 years. It envisages remodelling primary care so that it is delivered by multidisciplinary teams integrated with social services and where GPs focus on more complex cases. The Scottish Government is currently negotiating a new GP contract with the British Medical Association and it is expected to be in place by April 2017. Given that the contract will need to facilitate any future approach to primary care, reforms may happen early in the Parliamentary Session.

A key feature of any future reforms is also likely to include hospital care and how to ensure quality and access within workforce and financial pressures. This is an issue that previous Scottish Governments have grappled with and there is a clear message within the clinical strategy that some specialist services may be provided on fewer sites. Given previous experiences of centralising services, this could prove to be controversial.

Prior to the SNP Government coming to power in 2007, there was controversy surrounding the proposed closure of A&E units in Lanarkshire and Ayrshire, decisions that were justified as being in tune with the previous administration’s Kerr report and its message that services should be “as local as possible and as specialised as necessary” (Scottish Executive 2005), i.e. that some centralisation might be necessary.

Much of the ensuing debate centred on the evidence that linked improved patient outcomes with higher volumes of clinical work within a unit. The then incoming Government over-turned the decisions in Lanarkshire and Ayrshire and stated there should be a presumption against the centralisation of core hospital services. However, the recent clinical strategy highlights that there is now better evidence that the volume of clinical activity is linked to outcomes, particularly for highly specialised services, and it signals a clear commitment to providing certain services on fewer hospital sites:

“Where clinically appropriate we will continue to plan and deliver services at a local level. Where there is evidence that better outcomes could only be reliably and sustainably produced by planning services on a regional or national level, we will respond to this evidence to secure the best possible outcomes.” (Scottish Government 2005)

It will be interesting to see how this will play with the Scottish public and which services will be affected. It may be that there is greater acceptance of more specialist services being centralised (as opposed to services like A&E) but it is notable that centralisation was already in the news prior to the election. This was in relation to the decision on whether or not to locate a trauma centre in Aberdeen (BBC 2016).

In summary, the incoming Government has some tough challenges ahead, and it is likely that health and social care services will feature highly on the political agenda in the coming years, with potentially significant reforms to how services are delivered.

Kathleen Robson

Source:

Audit Scotland (2015) Health and social care integration, Health and social care series. Available at – http://www.audit-scotland.gov.uk/uploads/docs/report/2015/nr_151203_health_socialcare.pdf [Accessed 27 April 2016]

Audit Scotland (2016) Changing models of health and social care, Health and social care series. Available at – http://www.audit-scotland.gov.uk/uploads/docs/report/2016/nr_160310_changing_models_care.pdf [Accessed 27 April 2016]

BBC (2016) Aberdeen doctors criticise trauma care plans, 23 March 2016 Bradford, E. Available at – http://www.bbc.co.uk/news/uk-scotland-north-east-orkney-shetland-35882183 [Accessed 27 April 2016]

ISD Scotland (2016) Emergency department activity and waiting times. Available at – http://www.isdscotland.org/Health-Topics/Emergency-Care/Publications/2016-04-05/AE_activity_waiting_times_Apr16.xlsx [Accessed 27 April 2016]

Scottish Government (2005) Building a Health Service fit for the Future, A National Framework for Service Change in the NHS in Scotland, NHS Scotland. Available at – http://www.gov.scot/Resource/Doc/924/0012113.pdf [Accessed 27 April 2016]

Scottish Government (2016) A National Clinical Strategy for Scotland. Available at – http://www.gov.scot/Resource/0049/00494144.pdf [Accessed 27 April 2016]