On 5 July 2023 the NHS celebrates its 75-year anniversary. Between March and June 2023, the Health, Social Care and Sport Committee heard from all of the territorial health boards in Scotland to find out what the key issues facing the NHS are. This blog summarises some of the themes raised:
- population change;
- financial sustainability;
- redesign; staffing;
- prevention and;
- capital investment and infrastructure.
Population change: increasingly complex need and a demographic shift
A number of health board representatives spoke of the changing healthcare needs following the COVID-19 pandemic.
“Our system was designed to be effective for healthcare needs in 2019, but we need to acknowledge that healthcare needs have changed and are significantly different in 2023. That relates to complex care needs and our population coming forward with frailty issues and broader chronic condition issues”
Professor Jann Gardner, NHS Lanarkshire
Other areas spoke about changes in the age profile of the population.
“We are forecasting a significant demographic shift over the next decade […] a 35 per cent increase, between 2020 and 2035, in those over the age of 65. The number of people over the age of 85 will double, which is significant. We need to start not just solving the issues that we face now but planning for the future”
Laura Skaife-Knight, NHS Orkney
Financial sustainability
In its NHS in Scotland 2022 report, Audit Scotland noted “The financial position of the NHS in Scotland is concerning”. Three NHS Boards (Ayrshire and Arran, Borders and Highland) remain at Stage 3 of the Scottish Government’s performance escalation framework due to concerns around financial management.
Jeff Ace from NHS Dumfries and Galloway highlighted the scale of the challenge:
“Times are difficult and there are financial pressures […] all boards are reporting difficulties in breaking even as they look at forecasts for the next two to three years. That is not how things have been in Scotland over the past decade, when things have been difficult but have not been as they are now or as it seems they will be”.
Jeff Ace, NHS Dumfries and Galloway
Some of the smaller island Boards highlighted their concerns regarding the allocation of funding at a national level.
A recent NHS Highland Board paper referred to Scotland-wide analysis that suggested a financial gap of £940 million in 2023-24. The analysis suggested that, even after savings had been identified, the gap would remain at over £500 million.
Locum and agency staff
Many witnesses spoke of the financial impact of using agency and locum staff. According to the latest data on the NHS Scotland workforce, NHS Boards spent a total of £119.6 million on locum staff and £169.7 million on agency staff in 2022-23.
“From our core of 16 permanent consultants, about half are locum staff just now. Some of them have been locum staff for three or four years. It is very difficult to recruit permanent substantive consultants. Medicine and surgery are specific examples and mental health is another.”
Gordon Jamieson, NHS Eileanan Siar
Gordon Jamieson explained the current difficulties encouraging locums to apply for substantive posts. He said, “they want to continue indefinitely on locum terms and conditions and, therefore, we have locums who are with us for a very long time”.
Public Private Partnership costs
Some boards (NHS Fife and NHS Forth Valley) also cited challenges with the rising costs of some public private partnership contracts. This is partly due to the fact that the unitary charges associated with these contracts are linked to the Retail Prices Index (RPI):
“For health boards that have PFI [Private Finance Initiative] contracts, the inflationary uplift that is tied into those contractual agreements often runs much higher than the funding increases that we receive from the Government. For example, in NHS Fife, we see a 10 per cent cost pressure as a result of our PFI contract, over and above the funding that we have available.”
Carole Potter, NHS Fife
Other inflationary pressures
Other cost pressures include the rising cost of medicines and increased energy prices.
“There has been 12 per cent growth in the cost and volume of drugs […] people are living longer, which is fantastic, but there is an increased cost in medicine associated with that.”
Carol Potter, NHS Fife
Redesign
Linked to the themes of managing demand in a financially sustainable way, a key theme discussed by health board representatives was around service redesign.
“We will require a level of service redesign and really difficult decisions that we have not seen so far. Individual boards—particularly relatively small ones such as mine—will have to collaborate regionally and nationally in a way that we have not managed before, so that we have a once-for-Scotland programme to bring plans together.”
Jeff Ace, NHS Dumfries and Galloway)
Staffing
One of the most pressing issues for many of the NHS boards related to staffing. Ralph Roberts (NHS Borders) suggested that the fundamental issue is a lack of available staff:
“We talk about the financial challenge, but it is important to recognise that although there is no doubt that finances are challenging, the workforce position is equally challenging. The headline figure in our financial plan shows a projected overspend next year in the order of £22 million. However, the reality is that if you gave me an additional £22 million tomorrow, I could not spend it, because I would not be able to recruit the staff.”
Ralph Roberts, NHS Borders
Representatives of NHS Tayside described the challenges faced in relation to the wider NHS workforce:
“At times we are challenged by other areas such as allied health professionals and radiodiagnostics. Beyond that, one of the challenges that I face at the moment is recruiting trained staff to my estates department.”
Professor Archibald, NHS Tayside
Actions to address workforce shortages
Examples of actions taken to address workforce gaps included working with universities to understand future vacancy projections and optimise training offers in specific areas (NHS Dumfries and Galloway and NHS Shetland). Gordon Jamieson (NHS Eileanan Siar) spoke of the work that was taking place in schools.
“We have a summer programme that involves offering multiple student posts to schools and communities, to bring people in and give them experience. We have also had a significant increase and movement forward in apprenticeships”.
Gordon Jamieson, NHS Eileanan Siar
Housing need
Michael Dickson (NHS Shetland) spoke about challenges around housing provision for staff and Jeff Ace (NHS Dumfries and Galloway) told the Committee:
“Help with housing was going to be my one ask from the Parliament […] Staff who try to move into the area experience significant difficulties in accessing convenient and affordable housing.”
Jeff Ace, NHS Dumfries and Galloway
Support for staff and sickness absence
Acknowledging the stressful elements of working in a pressured environment, a number of Boards have introduced peer support network (NHS Fife, the State Hospital).
Staff governance was also discussed in the context of whistleblowing, suggesting that whistleblowing policies are being implemented to encourage staff to raise concerns and access support.
“We are working on our culture, on creating the psychological safety for people to challenge poor behaviour when we see it in action and on supporting colleagues with education and training to give them confidence to challenge such behaviour.”
(Professor Hiscox, NHS Grampian)
Prevention
Another key theme related to prevention and population health. Pamela Dudek (NHS Highland) argued that NHS boards had been active in ‘the prevention space’ for a long time but that it may not have been at a consistency or scale that is required:
“The conversations that chief executives have, both nationally and locally, are very much about how to have a reasonable amount of sustained investment in prevention, because we all know that investing in early years and in primary prevention will help us in the long term. There is a commitment to that, but budget pressures and competing demands in the here and now mean that following that through can be very difficult.”
Pamela Dudek, NHS Highland.
NHS Forth Valley stated that a key focus of their 3-year financial plan would be inequalities and a shift to primary and secondary preventative care. They envisaged that this transformation would be the key to financial sustainability in the long-term. However, it is worth noting that this has been a policy objective of the Scottish Government since at least 2007 but has a much earlier basis.
Capital investment and infrastructure
The importance of investment in the infrastructure of the NHS estate was also raised. The Scottish Government’s Medium Term Financial Strategy (May 2023) highlights significant pressures on the capital budget due to a combination of supply chain issues and inflation.
NHS Lothian highlighted that a funding gap of £15 million has created what it terms a ‘care deficit’ because of an inability to invest in improving the infrastructure within the board area:
“Our sites are full and our infrastructure is ageing, so we are struggling to meet the demands of the population.”
Calum Campbell, NHS Lothian
The issue of maintenance backlogs was raised repeatedly in the evidence sessions. NHS Highland detailed an £80m maintenance backlog. NHS Greater Glasgow & Clyde also had extensive backlogs, including £100m at Inverclyde Royal Hospital and £80m at the Royal Alexandra Hospital. Jane Grant explained how NHS Greater Glasgow and Clyde takes a risk-based assessment approach to spending so that sites are prioritised where it is felt the benefit to patients will be maximised.
Capital investment was also highlighted as a potentially effective tool to drive revenue savings. Examples included reducing energy costs through the use of electric vehicles, district heating systems and solar energy.
These issues and many others were discussed with the Cabinet Secretary for NHS Recovery, Health and Sport at a meeting of the Health, Social Care and Sport Committee on 27 June 2023. 75 years on from the establishment of the NHS the issues facing the NHS Boards are pervasive and longstanding and how these are addressed will determine the future success of the NHS in Scotland.
Health and Social Care team and Financial Scrutiny Unit, SPICe Research
Image: Glasgow, Royal Infirmary Centre Block [05.03.2017]” by b16aug is licensed under CC BY-NC 2.0