REFORMING HEALTHCARE – Alison Payne

  

However, that doesn’t mean our health services could not be organised in a different way that better suited the public.

In February the Health Consumer Powerhouse published the Euro Health Consumer Index 2014. 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.

There are ways that Reform Scotland believes we can improve the structure of healthcare in Scotland to devolve it from health boards and allocate the responsibilities for overall organisation 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. This has now been abandoned.

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. Even these pilots have now been abandoned.

The attachment of such health responsibilities to councils 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 than we see here are common, and many European countries have a far more localised health system.

Local authorities with a greater responsibility for the delivery of healthcare than we see here are common, and many European countries have a far more localised health system. For example Denmark, which has a population roughly the same size as Scotland, operates a health care system built on the principle of universal, free and equal access to all. However, unlike in Scotland, responsibility for the funding, managing and operation of health care is devolved to councils and municipalities. Local taxes are supplemented by state subsidies and money is transferred between areas, through central government, on the basis of need. This can lead to differences in the health care delivered in different areas; however, this often takes into account different local priorities. Danes also have a wider choice over who acts as their GP. Denmark was ranked 5th in the Euro Health Consumer Index 2014 on 836.Similarly, in Sweden, with a population of roughly 9.5 million, they also operate a tax-payer funded health-care system. However, as with Denmark, the responsibility for providing health care is devolved to county councils. Sweden scored 761 points and was ranked 12th on the index.

Some may be concerned that such decentralisation would create a “postcode lottery” within healthcare and clearly the ‘Greater Manchester ‘ proposals raise this fear in some people .

This phrase is often used in the press to describe differing levels of service people receive depending on where they live. However, sometimes the phrase is unfairly used – for example when local authorities adopt different polices which can lead to a different type of service. This is not a postcode lottery because the public has the choice to vote out the politicians and elect other ones if they are not satisfied with their local services. As long as there is some sort of choice, whether that is being able to vote for different politicians or change provider, there is no lottery.

It is also important to remember that sometimes it is simply not possible, or preferable, to pursue the same type of service delivery across a country as diverse as Scotland. Rather, it is far better if local needs and circumstances are taken into account.

However, it is important to point out that we already have a postcode lottery within healthcare. As the Scottish Government has pointed out, most people’s first and only contact with the NHS is through their GP. Yet, the way in which people can access their GP practice and its services can vary considerably, as we found in our report, ‘Examining Access’. For example, some practices allow you to book an appointment up to 6 weeks in advance, while others only allow you to book an appointment for that day. Some offer extensive extended hours cover, while others offer none at all. Yet patients have little, if any choice in the practice they are registered with. A difference in service and no choice in provision mean that there is an existing postcode lottery in GP provision.

The attachment of such health responsibilities to councils 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.

So along with decentralising healthcare, Reform Scotland would also recommend that patients have a greater choice over their GP practice. While there are practical issues associated with carrying out home visits across too large a catchment area, consideration should be given to ensure that a greater choice is given to all patients. In practice, most patients will still probably prefer to join the practice closest to them. However, by enabling patients to move and go elsewhere if they are unhappy with the way they can access the service; this will place greater pressure on all GP practices to improve.We 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 online in Scottish Policy Now, published in April 2015