Today is officially the start of the 'election period' for the Scottish Parliament – although it will have escaped few Scots (even displaced ones like me) that politicians on all sides seem to have heard the starting gun some time ago. As Scotland’s biggest employer and the largest public service for which the Scottish Government is responsible, the NHS should be at the centre of this campaign: it has certainly been at the centre of political arguments in the opening rounds. So what do voters need to know, and where do they need to look, as they try to decide who has the best plans for it?
How well is Scotland’s NHS performing compared to the rest of the UK?
As the Nuffield Trust and the Health Foundation found in a major study of health care across the four UK countries two years ago, comparing performance across the National Health Services is very difficult. Surprisingly, and disappointingly from the point of view of holding governments to account, information about health outcomes is treated differently in each country. For example, there is no data that reliably compares cancer and heart attack survival rate on an equal basis.
However, some high-profile waiting times indicators can be compared. This tells us at least about how the services are performing in allowing people to access care – even if we are still in the dark about the relative standard of treatment once they get through the door.
Scotland, along with England, performs relatively well on these broad measures – like the proportion of people spending more than four hours waiting in A&E, as shown below. Wales and Northern Ireland, meanwhile, have struggled in recent years.
Since 2012, Scotland has had a target that 90 per cent of people referred to hospital by their GP should be seen within 18 weeks. This was initially largely achieved by Health Boards. However, since the summer of 2014 national performance has dipped below it, and is currently at 87.1 per cent. England has consistently had a slightly higher proportion of people being seen within this timeframe, although it has experienced similar recent struggles and is missing its (higher) targets. In Wales, meanwhile, only about 85 per cent of people over the last year have been treated within its less ambitious target that patients should not wait longer than 26 weeks.
A bigger question, raised by the Royal College of Nursing in Scotland and others across the UK, is whether it is right for these specific sets of heavily managed targets to so dominate the measurement of performance in future.
What could be improved about the Scottish NHS?
Scotland’s NHS has a strong set of institutions devoted to improving quality. Our earlier research suggests we should be cautious about how much difference even the biggest and glossiest of political reforms will make. Nonetheless, political leaders must keep looking for ways to continue and expand the systems that drive quality, efficiency and responsiveness in the health service. There have been several reports in the last year examining issues relating to the way the Scottish NHS is governed, and in particular how it tries to drive and support improvement in the standard of care and the way services work. These set down challenges for all parties in the election campaign.
At the end of 2014, the Scottish Academy, made up of many different colleges of doctors and dentists, published a report looking back on recent serious failures in standards of care at different hospitals, mostly in Scotland. Echoing concerns raised in England after the failings at Stafford Hospital, it called attention to cultural issues recurring where lapses in fundamental standards had occurred: defensiveness and a tendency to cover up mistakes rather than learning from them. Although various streams of work are under way aimed at addressing this, visible and unified political leadership on this point will be valuable.
Another theme discussed by the Academy was the importance of safe staffing levels. The Royal College of Physicians of Edinburgh has recently echoed this, asking all political parties to “commit to developing and implementing safe staffing levels for all professions within hospital settings, based upon best evidence”.
The Scottish Government has responded by emphasising overall staffing trends in the health service. At this national level Scotland has long had a high number of doctors per person compared to the rest of the UK – but future governments should keep looking to ensure doctors, nurses and other workers are present in safe numbers in each individual place where care is provided.
Audit Scotland recently released a report that looked at plans for health and social care partnerships. These come into effect this April and are due to pool £8 billion in funding. They will be perhaps the most ambitious of programmes across the UK to encourage NHS and social care services to work together.
The report concluded that although the goal was right, new ways of working were still small-scale and patchy, and change was not likely to happen quickly enough to address rising pressures of patient need and a financial squeeze. These issues with speed and the realism of expectations will ring a bell with anybody who has looked at reports on England’s endless series of integrated care initiatives and plans.
In response, Audit Scotland called for stronger national leadership, with clearer numbers in a framework by the end of this year spelling out what was expected, how it would be measured and how much it would cost. This sets an immediate test for all political parties.
Lastly, the OECD released a report this February looking at how health systems across the UK were trying to improve the quality of care. It praised many aspects of Scotland’s quality system – which it saw overall as more 'bottom-up', as opposed to England’s more 'top-down' system.
However, it did suggest some changes – backing independent assessments of the quality of care, and a redesign of how key figures and statistics are recorded and published so that the public and clinicians can understand and use them. The Scottish Government has welcomed this report and pointed to ongoing scrutiny review, but it would be useful to hear more on the extent to which it accepts these points and plans to address them.
How much is being spent on the Scottish NHS?
Per person, Scotland has the highest spending on health care of any country in the UK. This has been the case for some time. Studies suggest it is probably necessary to reflect the higher health needs in Scotland due to factors like greater deprivation, and more people living in remote areas and on islands. However, in the five years from 2010 to 2015, health spending per person in Scotland was cut in real terms, by slightly more than £50 – as shown below. Why is this, and is it the right choice?
The reduction in spending per person is despite the fact that spending has risen by more than £50 in England, and despite the fact that the Scottish Government received uplifts to match this. Scotland would have been able to match English health spending growth if it had made the same spending decisions as Westminster.
However, this would not have been without costs. The total effect of the Barnett Formula during this period was to reduce Scotland’s block grant, meaning that substantial austerity was necessary overall. As the Nuffield Trust has seen in its work in England, Westminster’s decision to focus austerity away from the health service had serious consequences for other English public services. For example, personal social support for the elderly has been sharply cut south of the border, with concerns that this has pushed needy people out of the system – and increasing the burden on the English NHS. Meanwhile in Scotland (and Wales) personal social support for older people has risen since 2010.
But there is a twist: the 2016–17 Scottish Government budget appears to partially reverse course, with a 3.8 per cent increase in funding for the NHS and a 5.2 per cent cut in combined revenue and guaranteed rates for local government, which fund social care. However, some of the NHS money will be put back into social care services through the new partnerships – so the overall effect is difficult to determine. The election campaign should include a real debate over these important choices, both past and future.
Is it enough?
Looking at the bigger picture, are these levels of spending on health care enough? This is fundamentally a political question about how much we want to prioritise health care compared to spending on other public services, keeping borrowing down, or keeping taxes down. But to provide a benchmark, we can compare Scotland to other countries across the world by estimating the proportion of its national income that is spent on government-funded health care. Extrapolating Scotland’s proportion of UK GDP, this is around 8.6 per cent – considerably higher than the equivalent figure for the UK as a whole, and around the same level as comparable countries such as France or Germany.
However, remember that Scotland’s higher spending on health care compared to the UK as a whole appears to roughly reflect its higher need. Taking this and the UK’s low overall government health spending into account, we might guess that Scotland’s NHS still faces tighter purse strings than many other European health services relative to what it is being asked to do – as reflected in the increasing financial pressure found recently by Audit Scotland. With new powers over taxation being devolved over the period of the next Scottish Parliament, whether and when this might create an argument for a long-term commitment to start increasing health spending per person is an important question for voters.
Dayan M (2016) 'Health care and the Scottish election'. Nuffield Trust briefing, 24 March 2016. https://www.nuffieldtrust.org.uk/resource/health-care-and-the-scottish-election