Reform Scotland

Ideas to Stimulate a National Discussion – David Rowland

Introduction

We need our NHS now more than ever. 

With more of us living longer and with increasing chronic conditions, we need a service that responds quickly, effectively, safely and in a way that helps individuals achieve their desired outcomes if we are to avoid worsening symptoms becoming acute exacerbations that result in debilitating and decompensating stays in hospital.

But we cannot look at NHS service provision in isolation. 

Rather, given their symbiotic relationship, we must jointly consider what the future shape of NHS and Social Care services is.  These services must be planned and delivered in a way where Social Care is seen and valued as an equal to NHS services, recognising the vital role it plays in supporting people to live well and independently at home, reducing the chance of admission to hospital and ensuring timely discharge when a hospital stay has been necessary.

In progressing this discussion and to plan effectively for a Health and Social Care system fit for the future, the following factors should be considered:

  1. What Health and Social Care Services should we provide and to who?

The range of services provided by the NHS has grown exponentially since its inception and the level and complexity of Social Care at Home services has grown significantly since the introduction of Free Personal Care.

The current levels of provision are not sustainable.  Nor is there scope for further growth and development in a sustainable way under the current system.

There is therefore a need to discuss openly and honestly what Health and Social Care services should be delivered in the future.

From an NHS perspective, General Medical Services as the source of the holistic assessment, advice and support necessary for condition management, as well as gateway to more specialist interventions when required, must be protected and properly funded as a core Health Service, free to all at the point of access.

Similarly, to ensure life and limb continue to be protected in emergency situations, Emergency Departments should continue to offer assessment, diagnosis and treatment, following an accident or where a person has a life-threatening condition, with onward transfer to a specialist emergency treatment facility where required.  This too should be free to all at the point of access, as should emergency ambulance response, treatment and transfer to hospital where this is required.  People who present to these services who have not experienced a significant injury from an accident or who have a life threatening condition should no longer be given any treatment within the Emergency Department and should be signposted to the service that can best meet their needs, where these exist.

There is also a strong argument, given the increasing incidence and prevalence, particularly among low income and disadvantaged individuals, to continue to provide a full range of appropriately resourced Mental Health services, free to all at the point of access.

There does, however, need to be a discussion about wider primary care services.  Should General Dental Services and General Ophthalmic Services continue to operate in a mixed economy basis with assessments free to all at the point of contact and grades of treatment based on an individual’s ability and willingness to pay? Or should there be means testing to ensure those on lower income can continue to access services as they do now, while those on higher incomes either pay as they go or enter into an insurance-based arrangement to cover costs when they use services?  Similarly, should we continue with free prescriptions for all and free access to consultative services offered under General Pharmaceutical Services through the Minor Ailments Service or should these too be means tested?

Turning to specialist out-patient, diagnostic, day-case and in-patient services, the current level of expectation and demand cannot be met and a discussion is required as to how we manage this.  Work was done previously by the King’s Fund, highlighting procedures of limited value – should these be removed from the range of services offered by the NHS? Alternatively, should we raise the thresholds for access to treatment, accepting that this may impact adversely on how people live their lives and contribute to society? Or, indeed going even further, should we consider not offering interventions where a condition is a result of a self-inflicted lifestyle choice, e.g. smoking, excessive alcohol consumption, excessive eating, abuse of illegal or prescription drugs, etc.?  None of these choices feel in any way palatable but these are precisely the difficult type of discussion that is required if we are to safeguard the NHS capacity for those who need it most.  There is, of course, also the question of whether access to out-patient, diagnostic, day-case and in-patient services should be means tested and free at the point of access for low-income families, while those who are better off make provision through an insurance scheme – we accept the need to insure our homes, our cars, our life and our travel, so why not our health? There may also be a case for contracting out some of the high volume, low complexity planned care work.  While this could help reduce waiting times for certain services, there is a risk that altering the case mix within certain services could lead to increased pressure on NHS Staff who would be dealing with the more complex and challenging cases all day, every day, which could lead to burnout and higher staff turnover.

Linked to this is the ongoing introduction of new and expensive drugs and medicines, underpinned by evidence from clinical trials.  While the evidence of the efficacy of such treatments may be strong, there is a need to consider the extent to which new drugs and medicines, along with those already available, simply offer symptom relief, which offer limited impact on life expectancy or quality of life, which offer increased life expectance but limited or no improvement in quality of life and which offer curative potential with or without improvement in quality of life.  Based on this, discussion should be had with the public about the financial impact of providing such drugs and medicines, with an aim to determine a more rationale and sustainable approach to providing those that offer greatest benefit to the most people, accepting that some of these decisions will prove to be difficult and highly unpopular with some groups.

In terms of social care, the disparity in the availability of provision across Scotland is significant.  Similarly, the disparity in the assessment practice of practitioners is evident with some areas identifying the need for face-to-face social care packages that are double the size of the Scottish average.  There is a need for standardisation and an approach that limits face-to-face care to those interventions that only professional care staff can offer.  The days of having sufficient capacity to offer ‘check-visits’, medication prompts, shopping support, housekeeping support, etc are no more.  There is a need to focus our limited social care capacity on the provision of personal care, and a discussion as to how the third sector, local communities and families can offer wider support.  Linked to this, there is a need for an honest and open conversation about how sustainable Free Personal Care is, particularly in light of a dwindling workforce, increasing demand and expectation, rising costs of delivery and continued budget pressures.

  1. How do we promote and encourage individual responsibility for health and wellbeing?

The NHS has for too long been seen as a panacea to all our health-related ills.  It has become a paradoxical entity that is both treasured and valueless at the same time.  People recoil from any hint of change, modernisation or transformation of the health service that may change their relationship with it while at the same time, having no sense of the costs they incur when they access it.

This is perhaps a result of one of its greatest traits – a service that is free to all at the point of access.  But perhaps it is that trait that has resulted in a common belief that the NHS is there to support us regardless of what health needs we have.  And this, has perhaps, for some, led to an abdication of personal responsibility for one’s own health – for where is the incentive to change or adapt one’s lifestyle to live a healthier life or to take the steps that can help better manage a known condition and avoid acute exacerbation, when you have grown up knowing that the NHS will respond to your needs and, without cost to you at point of access, generally get you back home and living your life again?

We therefore need an honest conversation about our population’s health and the responsibility of every single citizen to take the steps they are able to in living the healthiest life they possibly can.

Similarly, with Social Care, the introduction of Free Personal Care has created an expectation that people will be supported at home with a four-times-per-day visiting service from trained, professional care staff fast becoming the norm.  This combined with the comparatively low value we as a society place on the elderly, when compared to other societies across the world, means that some individuals and families abdicate responsibility and seek to take no role in meeting people’s social care needs – even the non-personal care aspects.  This is neither sustainable nor particularly healthy for us a society and the impact on older people’s wellbeing cannot be underestimated.  There is therefore a need for discussion on how we see and value older people as vibrant contributors to our society and how we develop strengths based approaches to helping them understand how their assets, their families, their friends and their communities can support them in living the life they want while helping them connect them with a wider range of supports to help them achieve their desired outcomes.  Such an approach would enable us to focus our limited professional social care resources on ensuring people’s personal care needs can be met in an effective, efficient and timely way.

  1. How do we fund Health and Social Care Services for the future?

There is no question that the post-2010 austerity action has impacted greatly on the resources available to support the delivery of Health and Social Care and there is now a need to either significantly increase the budget for both or change the funding model for us as citizens.

We will not be able to sustain Health and Social Care services without change to the funding model and while it is difficult to engage people in a discussion about this, it must lie at the heart of our planning for 2048 and beyond.

Given there are little or no savings left to take, any increase in capacity needs to be funded and there are three ways to do that. 

First, to fund services we could introduce a new Health and Social Care tax.  A proportionate tax levied on income from individuals and ring-fenced for the purposes of Health and Social Care, with complete transparency in terms of a set of accounts that shows how much is being raised and what it is being spent on nationally.  This would have the added benefit of helping people understand the cost of these services and perhaps enhance the value they place on them.

Secondly, this levy could be made more proportionate by using the amount raised to fund General Medical Services, Mental Health Services and Emergency Services for all but only wider primary care services, planned care services and free personal care for low-income households, with higher earners required to make their own provision through an appropriate insurance system for health services and direct, personal payment of social care.

Thirdly, to raise capital funding to support new facilities or invest in new IT system development, windfall taxes should be raised on any excess profits (level to be determined) made by large utility companies, energy companies and pharmaceutical companies.  This would provide the one-off funding required for investment.

Discussion around the merits of these and other funding options is vital to considering the future of Health and Social Care.

  1. How do we create a vibrant, dynamic and committed workforce for the future?

We do not have enough trained staff in health and social care.  Practitioners leave both the NHS and Social Care because the terms and conditions are poor relative to other sectors in Scotland and, for those with greater mobility, other health sectors across the world. 

There is therefore a need to review and enhance the terms and conditions for staff.  This has to include the rates of pay, the hours they work and, of course the conditions they experience in the workplace.  If each day is a relentless, unfulfilling slog then even higher rates of pay and slightly shorter working weeks are not going to be appealing.

We should want a future workforce who are motivated to make a difference for the people they support, a workforce who want to help them achieve the life they want to lead and a workforce who take pride in achieving that.  More than that we should want a workforce who feel valued by those they support, but also by society as a whole.

For social care professionals in particular this is a massive issue.  They are not held in the same regard as NHS staff.  They experience much lower rates of pay than, for example Healthcare Support Workers, yet often carry much greater responsibility in terms of lone working, assessment and decision-making and, of course, administering medication.  This needs to be addressed as a matter of urgency and we need to promote a career in care in the same way as we promote a career in nursing or any other health profession.

We therefore need a discussion about how we achieve this.  It will take a change in how we portray Health and Social Care.  Pick up any newspaper, log on to any news outlet, listen to any opposition politician and they are all quick to tell you how bad Health and Social Care is right now – who would want to come to work in an industry that is getting such a bad reputation; who would want to stay in it.

There is no question that Health and Social Care is under pressure – I would not be writing this if it wasn’t.  But the staff within those services do brilliant things every day. They change lives every day. They are there making the best of times better and they are there making the worst of times as bearable as they can. Our staff are to be celebrated but we only hear about the bad.

The discussion on how we promote careers in health and social care and how we value the services and cherish the workforce needs to be driven by how we de-politicise these services.  Both have become the proverbial political football with those in government defending their policies and performance of service while setting unrealistic targets and goals and driving silo-based and at times contradictory service directives.  While those in opposition attack and seek to highlight and make the most of any weaknesses for political gain.  This needs to stop. We need to build a political consensus around what the professionals and the public tell us our Health and Social Care services should look like for 2048 and beyond.  This needs to managed and delivered on a cross-party basis, with appropriate but constructive challenge around those areas where improvement are needed.

  1. What Health and Social Care Structures do we need for the future?

Scotland is a large geographical area but with a small population.  Many of our more specialist services are not sustainable at current territorial health board levels due to limited staffing availability and budgetary challenge but more importantly insufficient population density to sustain skills and expertise.

We therefore need a new model of delivery where we agree what people can reasonably expect close to home – definitely General Medical Services and perhaps a ‘rural DGH’ offering immediate assessment and stabilisation of life-threatening conditions before transfer on to specialist sites; General Medical, Care of the Elderly and Rehabilitation / Repatriation for recovery from acute exacerbation; supported virtual out-patients; and a full range of diagnostics (reported remotely).

We also need to specify a new model of delivery that sees, as a norm, people traveling to regional centres for planned care, where capacity protected from unscheduled care activity, is maximised to reduce waiting times and from where people will be discharged at an earlier stage back to their local DGH for recovery.  Similarly, regional unscheduled care centres will be needed to provide the specialist interventions required before transfer back to a local DGH for recovery should become the norm.

This would require a very different Territorial Health Board structure and it is perhaps now time to move to the much talked about three-region model to plan and deliver these regional hubs, with local ‘rural’ DGHs being managed by a reformed Integration Joint Board structure that would ensure these services were planned and delivered in a way that is right for local needs and in a manner that interfaces seamlessly with the social care and community health delivery in the area.

These reformed Integration Joint Boards should be directly accountable to and funded by Scottish Ministers through the National Care Service.  All responsibility for Social Care should be removed from local councils to avoid disparity of standards and to ensure application of budget is not swayed by conflicting local priorities.

  1. What systems do we need for Health and Social Care services in the future?

For Health and Social Care services to operate effectively, safely and in a person-centred way, everyone involved in a person’s care should have access to the information they need.  Right now, there are a myriad of health systems and a myriad of social care systems that allow the flow of information to a greater or lesser degree.

This builds risk into the system, is frustrating for people providing care and support and exasperating for people accessing care and support as they have to tell their story time and time again.

We need to discuss what our information requirements are. We need to discuss how we want information to be shared in the future. And we need to use that to form a specification for our IT systems for the future.  We need to move away from individual NHS Boards and Councils having the ability to specify and procure their own systems and move to an NHS and NCS procurement that is led by Scottish Ministers on a once for Scotland basis, and rolled out consistently across all services.

Through the move to Vision for all GP Practices by 2026, we are seeing the first step towards this and we need to build on that momentum. 

It will take time, perhaps a decade or more, and it will be disruptive and painful but the long-term benefits far outweigh the short-term disadvantages.

Similarly, when it comes to applying new technologies, there needs to be a once for Scotland approach to ensure equity and avoid waste and duplication.  There are three key areas where discussion is required now to agree a national direction.

First, the use of Robotic Assisted Surgery, ensuring this is linked directly to service planning and the regionalisation of specialist services, as well as workforce planning and the training of our future surgical workforce.

Secondly, the implementation of Artificial Intelligence in Radiology to improve efficiency and effectiveness in the reading of images to support clinical decision-making.

Thirdly, Digital technologies to support independent living at home, deploying a pace and scale those technologies that can support the activities of daily living, those that can aid social interaction and those that can monitor changes in health and behaviour and escalate for early intervention to reduce the number and level of acute exacerbations.

Conclusion

There is no single or simple answer to how we create a more viable and sustainable Health and Social Care system for 2048 and beyond.

Rather, there is a need for an open, honest and challenging discussion with the public, with professionals and with politicians on how we radically transform our current arrangements into those that will be fit for the next hundred years.

Those discussions will need to cover the factors covered in this article, and indeed many others.

But there is a fundamental aspect that needs to be considered and that is the expectation of those who use these services.  That expectation has grown exponentially over the years since 1948 – perhaps even more so than the range and capacity of services that are now offered.

At its inception, the NHS issued a leaflet to every household detailing what their new health service would offer and how they should use it.  It may sound patronising and twee at this point in time but the truth is we have lost sight of this over time and whatever the design of our future Health and Social Care services looks like, we perhaps need to go back to that very direct, basic messaging to re-set expectations and people’s relationship with these services.

David Rowland has a Masters in Public Policy and Management and a lifelong interest in, and passion for, excellence in health and social care.

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