The NHS in Scotland and the many men and women who work in it day-in-and-day-out perform admirably and are deserving of the praise they often receive.
However, that doesn’t mean those services could not be organised in a different way that better suited the public.
Last week the Health Consumer Powerhouse published the Euro Health Consumer Index 2014. As highlighted in last week’s Sunday Times, out of the 37 countries included, Scotland was ranked 16th with a score of 710 (just behind England at 14th with a score of 718). This was a fall from the 2013 index, where Scotland scored 719 and was ranked 13th.
One way Reform Scotland believes that we can improve the structure of healthcare in Scotland is to devolve it from health boards and give it to local authorities.
Health care in Scotland is dominated by 14 territorial NHS Boards, which are responsible for the planning and provision of health services for their local populations based on local need. Six of the NHS Boards are coterminous with one local authority while the other eight cover more than one council area. Money flows directly from the Scottish Government to the health boards on the basis of need. The boards are quangos with little, if any, direct accountability to the populations they serve.
Most non-executive lay members of the boards are appointed by Scottish Ministers; though a councillor from each of the local authorities covered also sits as a non-executive lay member.
Reform Scotland envisages that instead of having a parallel tier of government, whether it is directly-elected or appointed health boards, councils should take on board the responsibilities and expenditure of the health boards. We believe that the activities carried out by non-executive health board members should be carried out by accountable, elected individuals. While we appreciate that pilots have taken place of direct elections to health boards to increase accountability, turnout was very low so rather than having another parallel tier of government, this role should and could be far better done by integrating it into the role of local government.
This is not politicising the delivery of health care any more than any of the other local authority responsibilities, but creating a simpler and more transparent hierarchy.
Local authorities with a greater responsibility for the delivery of healthcare are not unique and many European countries have a far more localised health system. For example in Denmark, which has a population roughly the same size as Scotland and operates a similar health care system to ours based on the principle of free and equal access for all at the point of use, responsibility for healthcare services lies with the lowest administrative level so that services can be provided as close to the users as possible. Equally in Sweden, they operate a tax-payer funded system which is largely decentralized and in Norway, which again operates a tax-payer funded system, it is the country’s municipalities which are responsible for a large element of health care and social services. Norway, Denmark and Sweden were all ranked above Scotland in the consumer index.
Reform Scotland would also recommend giving patients greater choice – especially with regard to their GP. In August last year we published a survey of all GP practices in Scotland, focusing on their access arrangements. We found that only 67% had a website, only 51% allowed patients to order repeat prescriptions online, and only 10% allowed patients to book appointments online. This was despite the fact that four years ago the Scottish Government developed a toolkit in conjunction with the Royal College of General Practitioners which highlighted the use of the internet to improve access arrangements, including aspects such as ordering repeat prescriptions online/via email or booking appointments online. The Euro Health Consumer index also recognises the importance of the use of online facilities.
In addition to the main areas we examined, we also made some additional observations. For example, in some GP practices you could only get appointments for that day, whereas in others you could book appointments up to 6 weeks in advance. Some GP practices allowed you to request repeat prescriptions with a fax but not a computer!
What we also found was that there was no correlation between the size or location of a GP practice and whether it offered all the access arrangements we examined. There were practices of less than 1,000 which offered extended hours, online repeat prescriptions and bookable appointments online. If those practices could offer these services, why couldn’t larger ones?
Such variations in service provision are unacceptable when patients have little, if any, choice over the practice with which they register.
Reform Scotland believes that giving individuals greater choice over their GP practice would mean that people were able to easily walk away from GP practices they felt did not provide services that suited them. We don’t envisage that such a policy would lead to a mass exodus of patients from GP practices, but the potential that they could would help drive up standards.
I believe that introducing these policy recommendations would give patients more say over their health service and lead to a service that developed to meet their needs.
This article appeared in the Sunday Times on 1 February 2015