Reform Scotland

Can Scotland deliver NHS reform in 2023? – Dr Alastair Noble

When I spoke to the Chief Executives of the NHS Boards back in 2014, I challenged them to stop commissioning  600,000 occupied bed days of Delayed Discharges. Nothing significant changed, in fact it is still increasing. I was told I had been too gentle! This is the equivalent of 2 District General Hospitals and approaching the 800,000 occupied bed days for all elective care

This time I will be very blunt. The Status Quo is not available.

Good Consultants and good General Practitioners want to deliver the highest quality of clinical care to meet the needs of our current population.

To achieve this now we must change our commissioning decisions. We must accept that there is no such thing as separate health and social care. We must now have integrated health and social care and we need to adopt, and implement, the following basic principles:

  • Treat Consultants and General Practitioners as equals.
  • Prioritise localities and their Integrated Care Teams.
  • Each Patient must have access to good home care, good nursing home care, good community hospital care including hospice/terminal care and good consultant hospital care
  • Allocate Fair Share Budget for health and social care to each locality.
  • Better use of the excellent DATA sets we have, especially around the over sixty-five population alongside Community Empowerment to enable localities to accept and deliver the accountability and responsibility for their own outcomes.

Every time I have had the public discussion about the clinical variations in activity and the increasing clinical activity in the least deprived quintiles, I hear the same clinical sign up to change.  So where is the resistance to improving the quality of clinical care coming from?

There is a danger that some within the sector pander to disease/age/drug company specific groups/influencers all with their own agenda. Opposition politicians can also be guilty of arguing for the status quo and we allow poor management to delay complex decisions.

The outlook is not all bad. We have the fittest, healthiest elderly population we have ever had. We should be proud of our achievements. But we  must get on the front foot and make the necessary clinical changes otherwise could lead to the end of the NHS.

We also have the clinical and financial DATA to show it is affordable within existing Fair Share Integrated Health and Social Care budgets.

We must prioritise the individual patient and their own locality team. This will inevitably mean a changing pattern of care in poorly performing areas. It clearly means the downsizing of Specialist Consultant care in those localities which do not have General Practitioner beds. The alternative is to continue to provide poor and unacceptable institutional care as clearly seen for example in the Mid -Staffordshire Model.

The following data highlights the scale of the challenge we face through delayed discharge:

 There are 6.4 m Occupied Bed Days (OBD) in NHS Scotland. Of these:

  • 0.8 m are scheduled/planned procedures-still (with big variations in day care and outpatient investigation rates)
  • 5.6 m are unscheduled/unplanned
  • 600,000 are delayed discharge. The equivalent of 50-55 wards or 2 district general hospitals.
  • 4m OBD are by patients aged over sixty-five
  • Two percent of all patients occupy 79% of OBD. Roughly 2.5 % of total population takes up 50% of spend on hospitals and prescribing.

Therefore, it is imperative that we concentrate on this small group and see what the alternatives can be.

I would suggest that we should be looking at about 2.5 million less occupied bed days in Specialist Consultant Hospitals and replacing them with about 1.5 million occupied bed days in Generalist Community Hospital beds/nursing homes and fully staffed home care. This is the right model for Scotland with our current and projected population changes. It is the existing pattern in the best performing parts of Scotland -so we know it is clinically and financially achievable.

In Aberdeenshire more than 60% of the OBD for the over 65 population are in GP led Community Hospitals Glasgow has none.  This just illustrates the massive variations from locality to locality. We need to be looking and learning from what is happening in different areas of Scotland. Being close to a big hospital doesn’t always equate to the right care options.

I have written before about the good practice that has been developed in Nairn. Reform can be incorporated into our NHS and we need a health system that can work for all areas of Scotland.  A system which can deliver the best current clinical care for each individual with an integrated health and social care team in each locality and have clinical agreement between the Specialist Consultants and the General Practitioners in all Professions about what is best for the individual patient at that particular point in their journey from birth to death.  This means an honest clinical discussion with the patient and their relatives, friends, and communities.  The alternative is in the news every day. We can do so much better if we change to current best practice.

Dr Alastair Noble worked as a GP in Nairn