THERE IS NO MIRACLE CURE
Shocking life expectancy. Appalling heart disease and cancer rates. An obesity epidemic... and a chronic drink problem. The scale of Scotland’s health crisis is terrifying. And while the NHS works wonders every day, we need a genuine, radical and unflinch
It’s not often these days that politicians are in a position to boast about the day-to-day performance of the NHs. For all its many strengths, the story is often a gloomy one of strained budgets, missed targets, management shortcomings and allegedly overpaid doctors.
so it’s little surprise Nicola sturgeon seized the opportunity to be positive when it was presented to her this week. On the 69th birthday of the NHs, the Nuffield trust, a health research body, published a glowing report about the scottish system and suggested other parts of the UK could learn from it.
the study praised the ‘altruistic professional motivations’ of frontline staff ‘to do better’ at their jobs. It said scotland’s smaller size allowed for a more personalised service than in England: ‘Better ways of working are tested on a small scale, quickly changed, and then rolled out. this is overseen by a single organisation that both monitors the quality of care and also helps staff to improve it.’
this was contrasted with an English system ‘with a tendency towards too many shortterm, top-down initiatives that often fail to reach the front line’.
Further, scotland has had particular success addressing priorities such as reducing the numbers of stillbirths. Other parts of the UK could learn from pioneering initiatives to address unequal outcomes and the remoteness of some rural areas, the analysts found.
All good, and the First Minister, perhaps smarting from the severe bashing the Nats have recently taken over their management of the public services, was justifiably proud. ‘this is an overwhelmingly positive report into the performance of scotland’s NHs over the past decade,’ she tweeted.
However, the report came with a ‘but’. the researchers found that the service is in major financial trouble. ‘the need for savings is at least as great as for other UK countries, and health boards are struggling to find ways to deliver them. limited national planning for the next few years and a polarised, hostile political context make an honest national debate difficult.’
there are, it goes without saying, many clever and committed people working in the scottish NHs, and it performs wonders on a daily basis. But if a healthcare system is judged on its quality of service, its sustainability and the health of the population it serves, there are still far too many weak spots. And in the years ahead, the situation seems likely to deteriorate dangerously unless radical action is taken.
One of the main stresses was in fact identified by a noted French physician around 200 years ago. Philippe Pinel, known as a father of modern psychiatry, said: ‘It is an art of no little importance to administer medicines properly: but, it is an art of much greater and more difficult acquisition to know when to suspend or altogether omit them.’
the rising cost of drugs, increasing demand from pushy patients, an ageing population, and the over-medicalisation of some conditions have combined to exert extreme financial pressure on the NHs. there is, usually, a pill for whatever ails you, you’re determined to have it, and it costs.
scotland, the sick man (and woman) of the UK, has additional challenges all of its own. today, life expectancy for its males is 77, up from 73 since the turn of century, but trailing England’s 79. scotland’s women have seen their lifespan increase over the same period from 79 to 81 – south of the Border the figure is 83. You will live longer in Northern Ireland and Wales than in scotland.
Dig deeper and the stats don’t get much more cheering. ‘Healthy life expectancy’ in scotland is just 60 for men and 62.5 for women. While there has been a reduction of 36 per cent in premature mortality caused by illnesses such as cancer, heart disease and strokes between 1994 and 2015, 65 per cent of today’s adults are overweight, with 29 per cent classed as obese.
there has been almost no change to these figures since the start of the millennium, and there continues to be a clear link to deprivation. Eighteen per cent of pupils in the first year of primary school in scotland’s most deprived communities are overweight, obese or severely obese compared with around 11 per cent in the least deprived.
then, notoriously, there’s the booze. We scots still knock it back like there’s no tomorrow. Alcohol sales are a fifth higher in scotland than in England and Wales. they have also risen over the past two years, after a fall between 2009 and 2013. Alcohol-related harm is a serious problem: there are around 22 deaths each week due to alcohol misuse, and an average of 674 hospital admissions. the stats show, miserably, that both remain much higher than they were in the 1980s.
this gives some idea of the scale of the challenge faced by those seeking to improve public health. Whether you’re a politician, a medical professional or a civil servant, making any kind of real difference is a daunting prospect. Many innovative and expensive projects have been tried and fallen flat. Matters are only made worse by the infantile nature of the political debate and the repeated failure to confront what are often unpalatable choices.
I have spoken to a number of senior NHs figures over the past few months, and the same themes have emerged again and again. the overwhelming view is that a major crisis is looming and that a big, open debate is urgently needed about the system’s future.
OUR political leaders – not just the sNP, all of them – must tackle the hard questions, the serious financial restrictions, the demographic changes and the difficult decisions that are needed in a grown-up, non-partisan way. New priorities have to be set, but they must be based on as broad a consensus as is possible.
Part of the problem is structural. Because the sNP runs a minority government in Edinburgh, the party has found it
difficult to pursue policies that would prove controversial (pretty much everything when it comes to healthcare).
The opposition parties will often oppose for the sake of opposition. This makes it impossible to, say, close hospitals or wards, even if there is a strong clinical reason for doing so. One NHS manager says: ‘We should be asking questions like “will you accept fewer hospitals if they are of a higher quality?” and “do you want to be operated on by someone who has performed your specific operation hundreds of times or just occasionally?”.’
Then there is the Nationalist obsession with providing as many services for ‘free’ as they possibly can. Everyone living in Scotland gets free prescriptions, regardless of wealth or income. ‘Should this really be the case when you can buy paracetamol in the supermarket for 16p?’ says one doctor.
Eye tests are taxpayerfunded, too. In England, the Government has smartly asked providers such as Boots to pay for such tests as a loss leader, on the basis the patient/customer will then be likely to buy spectacles or contact lenses in the store.
The general practitioner system has problems of its own: a contract that has largely destroyed the patient-friendly out-of-hours system, on top of recruitment and retention problems. Around one in four surgeries has a vacancy for a family doctor, and a recent recruitment drive failed to attract enough candidates.
More than 70 per cent of empty posts have been vacant for more than six months. In part this is due to an increased workload in what is viewed as shortened hours.
One GP describes how, when he started out 30 years ago, the consultation rate per patient was around three visits a year. By 2016, it was running at six to seven visits per patient.
There are also the inevitable grumblings about management – overly powerful beancounters with little understanding of how to run a patient-facing service smoothly and efficiently without resort to a cold spreadsheet.
The tough choices required to free up the necessary cash to tackle the health service’s growing pressures will require a steel-willed leader, one who is willing to brave the fury of the unions and the medical profession where necessary.
But the ideas are out there, and, interestingly, many come from within the NHS. For example, with talk of lifting the public sector pay cap, some say the NHS should scrap its ‘no compulsory redundancies’ policy. With the state pension age scheduled to rise to 67 by 2028, others say the funding of free personal care for the elderly should no longer begin at 65. Both measures, though controversial, would save millions.
Tactical forms of intervention could save money in the longer term – some argue that a sugar tax could cut obesity levels, while transport policies could do more to support walking and cycling.
‘Should the A9 be dualled when the health record in our major cities is dreadful and the money could be spent there instead? It’s about priorities,’ says one health service policymaker. ‘Equally, we know that adverse childhood experiences have a massive impact on life prospects, so why not spend more money in areas such as early intervention rather than on free prescriptions?’
The SNP has shown a thirst for setting national targets, some of which are more useful than others. An analysis by the former chief medical officer Harry Burns of the plethora of ‘targets and indicators’ is due soon.
‘A number of them are not necessarily helping us, and are of questionable value,’ says a source. ‘The 12-week treatment guarantee, which has been turned into a law, is a case in point – if a clinician thinks 16 weeks is safe, why spend the money on making it 12 weeks? Scotland is the only country in the world with such a guarantee.
‘Then there’s a drug misuse target that 90 per cent of people should be seen within three weeks. Given the constraints placed on us, is that really necessary? Again, there’s no target in England. These all need to be more openly debated – do you really need them all?’
THERE will also need to be a discussion about charging for additional services. The precedent is dental treatment, where most people already pay a contribution. Also, co-payment would allow the better off to part-fund their treatment within the NHS, freeing funds to care for people from more deprived communities.
Some health workers raise the thorny issue of rare drugs and end-of-life care – should someone with no quality of life be kept alive for an extra two weeks at huge cost?
The first steps towards the serious conversation that is needed have already been taken by the current chief medical officer, the inspiring Dr Catherine Calderwood.
She promotes a strategy called Realistic Medicine, which would fundamentally change the relationship between doctor and patient.
Dr Calderwood says: ‘You should expect the doctor to explore and understand what matters to you personally and what your goals are, to explain to you the possible treatments or interventions available with a realistic explanation of their potential benefits and risks for you as an individual, and to discuss the option and implications of doing nothing.
‘You should expect to be given enough information and time to make up your mind. You should consider carefully the value to you of anything that is being proposed whether it be a treatment, consultation or diagnostic investigation and be prepared to offer challenge if you feel it appropriate.’
If we are asking patients to show this level of understanding and maturity, is it really impossible to expect the same from our politicians?
Given the awfulness of Scotland’s health record, there is surely no more serious issue facing the nation.
As they play their games, the pressures on the system grow, and patients are the victims. It’s time to talk, before the storm hits.