As part of the programme to mark 20 years since the creation of the Scottish Parliament, SPICe will publish twenty “20 year” blog posts on SPICe Spotlight over the course of 2019. This is the second in the series. Our earlier post sets out more information on the programme and the series of blogs.
It often feels like the NHS operates in a continual state of flux and politicians are often accused of inflicting change overload on the service. Given this, we thought it would be interesting to take stock of exactly what has changed in the NHS and Scotland’s health since 1999. This blog looks at the political focus on the NHS, the structure of the NHS, health strategy and public health.
The first legislative programme of the new Scottish Parliament did not announce any health bills. This was not a taste of things to come.
Since 1999 there have been over 30 pieces of primary health and social care legislation and considerably more secondary legislation. A timeline of key legislation the Parliament has delivered is set out below.
A review of parliamentary questions (PQs) in the first year of the Parliament shows that funding, workforce and waiting times topped the charts as the most frequently asked health questions. So far, so familiar. However, there were some other interesting front runners which provide a glimpse of what was topical at the time. Remember amnesic shellfish poisoning anyone? (pun intended) BSE? GM crops?
A similar look at PQs last year shows the top issues remain but the topical issues now include vaginal MESH and medicinal cannabis.
Interestingly, the first written parliamentary question on health was on the topic of Stracathro hospital and its long-term future. This is interesting because the future of Stracathro still features in the news. The controversy around the hospital could be seen as a microcosm of the issues that have dominated political debate around the NHS over the last 20 years. These are explored in more detail below (see Strategic direction).
Analysing changes in these perennial issues is frustrated by how the data has been collected. In some cases, core indicators such as waiting times were not really collected at all, and certainly not in a way that allows for comparisons. However, trends in staff and funding do give us an idea of how things have changed, with both showing a steady increase since 1999.
The number of whole time equivalent staff has increased from around 110,000 in 1999 to almost 140,000 today (ISD Scotland).
In addition, devolution kicked off at a time when the NHS was seen as suffering from chronic underfunding. In 1998/99, Scottish health spending as a percentage of GDP stood at 6%, compared to 8% today.
The following chart shows that health expenditure has steadily increased since 1999 and this growth has outstripped inflation.
As a proportion of overall expenditure, it has maintained a relatively consistent share over the years but now accounts for 30% of the Scottish total.
The structure of the NHS
Back in 1999, the NHS in Scotland was still shaking off the market system that had been introduced in the 1990s.
While mechanisms like GP fundholding had already stopped, the structure of the NHS was still divided into ‘purchasers’ and ‘providers’. This meant that, in addition to the 15 area health boards (the purchasers), there were also the primary care and acute hospital trusts (the providers).
The first Scottish Executive pledged to abolish ‘the last vestiges of the internal market’ and the NHS Trusts were subsequently dissolved in 2004. This created a ‘unified structure’ with health boards in charge of both planning and delivering health services.
At the time, this policy drive was the same across the UK. However, in later years, the NHS in England reintroduced some market mechanisms, which has led to a greater divergence in the UK’s health services. However, it is a structure which has largely persisted in Scotland with relatively minimal tweaks over the years, despite changes of Government.
The health boards remain, although there are now just 14 of them. The national ‘special’ health boards have also remained largely the same, give or take a few reorganisations.
Where there have been greater changes though, is around the structures which were created to facilitate greater integration between health services and social care.
At the start of devolution, we had the Local Health Care Cooperatives. These were then replaced by Community Health Partnerships, which were later replaced by Integration Authorities.
While the organisations and the powers available to them have changed, their aim of greater integration has remained the same.
Achieving that aim has remained rather elusive for successive Governments although.
Policies to facilitate integration increasingly became less voluntary and now local authorities and health boards are required to delegate functions and budgets to the new integration authorities.
Nevertheless, a recent report from Audit Scotland highlighted that challenges remain and a progress review by the Scottish Government stated that ‘the pace and effectiveness of integration need to improve’.
It is difficult to concisely sum up the strategic direction of such a complex organisation over 20 years. However, the phrase ‘shifting the balance of care’ perhaps comes closest to doing so.
What this means is that there has been a general aim of moving care out of acute hospitals and towards community settings.
This has been driven by a need to ensure the sustainability of a service struggling to keep up with the demands of an ageing population with increasingly complex health needs.
Although staff numbers and funding have increased, it is not enough to maintain the old service models while also ensuring good clinical outcomes.
The closure of hospitals and the centralisation of services often angers local communities and so it has faced opposition from all political parties. However, key policy documents of the Labour/Lib Dem Executive and the SNP Government contain a remarkably similar approach to this issue. For example:
Our vision for the NHS is that it should deliver safe, high quality services that are as local as possible and as specialised as necessary – Kerr report (2005)
Where clinically appropriate we will continue to plan and deliver services at a local level. Where there is evidence that better outcomes could only be reliably and sustainably produced by planning services on a regional or national level, we will respond to this evidence to secure the best possible outcomes – National Clinical Strategy for Scotland (2016)
Both documents contain many other similarities, such as supporting patients to manage their own conditions, aiming for the greater integration of services and preventing emergency hospital admissions.
Despite the drive to shift the balance of care, the overall level of hospital activity has not decreased. However, the average length of stay has reduced and a higher proportion of hospital activity is now accounted for by day cases. Perhaps more notable however, is that an increasing proportion of hospital activity is now taken up by emergency inpatients i.e. care that has not been planned for.
Source: ISD Scotland
It is difficult to assess changes in healthcare quality over time and many indicators used only look at narrow aspects of quality e.g. Healthcare Associated Infection, emergency admission rates. Very few of them also allow us to monitor long term changes.
The NHS is clearly of great public and political interest, but its importance lies in how it can affect the health of the nation i.e. as a vehicle to improve public health.
Shortly before devolution, the Scottish Office published ‘Towards a Healthier Scotland’. This was a white paper on public health which had an overarching aim of tackling inequalities.
It is difficult to overstate the significance of this at the time. For the first time in a long time (some would say ‘ever’) the white paper signalled a new political recognition of the importance of the social determinants of health (e.g. employment, housing and education).
Before this, the focus of public health had been dominated by efforts to affect change in the individual. Towards a Healthier Scotland was different in that it acknowledged the importance of people’s life circumstances and not just their lifestyles.
This recognition has been retained and progressed by consecutive administrations in Scotland, most recently in ‘Scotland’s Public Health Priorities’.
The jury is still out on whether this has positively impacted on public health. A recent report by NHS Health Scotland found that Scotland’s life expectancy – perhaps the ultimate outcome measure for public health – has now stalled and health inequalities have worsened.
Between 1992 and 2011, it took 5.5 years to add a year of life expectancy for women and just 4 years for men. However, over the last 7 years, this improvement has slowed and if the trend continues it will take nearly 21 years to add a year of life expectancy for women and 11.5 years for men.
In addition, between 2012 and 2017, death rates increased in the poorest parts of Scotland meaning health inequalities have increased.
The authors suggest that policies aimed at bolstering the economy (e.g. welfare reform and reduced public spending) may have had a detrimental effect on the wider determinants of health. If correct then this perhaps indicates the importance of economic policies as a lever to improve public health.
Nevertheless, it is not all bad news and it is in the nation’s lifestyles that some significant improvements have been made.
Despite Scotland’s image as a nation of drinkers and smokers, the prevalence of smoking and harmful drinking has fallen over the last two decades:
Source: Scottish Health Survey
Some of this success could reasonably be attributed to key legislation passed by the Scottish Parliament, much of it ahead of the rest of the UK.
The NHS has changed significantly since 1999 and the divergence between the UK health services indicates that devolution has been significant in shaping the organisation we have today.
Changes to the structure and strategic direction have been modest and incremental, with the organisation following a gradual evolution along a path which was largely set in the early days of the Scottish Parliament.
The extent to which devolution has benefited the NHS however is difficult to know due to a lack of long-term, comparable quality data. It could be said however that the resources allocated to it have improved.
Perhaps where devolution has brought the most noticeable and radical changes, is in public health policy.
Scotland has maintained a focus on the social determinants of health and blazed a trail with some brave public health initiatives. These have included the smoking ban and minimum unit pricing and the Scottish Parliament has been at the centre of these.
However, over the next 20 years of the Parliament, perhaps greater public health gains could be had from making more use of economic levers and addressing spending on the wider determinants of health.
In terms of the NHS, contrary to the perception of continual change, the level of continuity over two decades has been remarkable. Nevertheless, in order to achieve the shift in care that is needed to ensure the sustainability of the service, it could maybe now benefit from some of the bravery seen in public health policies.
Kathleen Robson, SPICe researcher, health and social care