Happy Birthday to our NHS

Happy Birthday to our National Health Service, one of Labour’s finest achievements in government. A brilliant socialist concept that shows the benefits of collective action to tackle the challenges facing our society.

There are a range of celebrations in the coming week to mark the 70^th anniversary of the NHS. I was pleased to be speaking at one of those today in Glasgow, organised with the new Scottish Labour Westminster candidate for Glasgow North, Pam Duncan-Clancy. One of a great group of UNISON women who will be contesting the next UK general election in Scotland.  

Some people, including NHS staff, can be a bit cynical about NHS anniversary celebrations. While they welcome the praise and celebrate the NHS they have dedicated their careers to, they wish politicians would also be thinking of those warm words when they are allocating budgets and funding their pay and conditions. A bit like Firefighters after Grenfell - warm words from the Prime Minister after she had slashed the fire budgets in the name of austerity.

None the less we should welcome these celebrations and I argued today that NHS 70 offers two broad opportunities.

Firstly, to remind everyone of the importance of the NHS - something we can take for granted. For most of us it has literally been there from the cradle to the grave. In a column in the Guardian this week – Emma Brockes coming back from the USA, compared the two approaches. She said:

"For all its faults and in spite of terrible under-investment, the very fact of the welfare state when seen from the US is nothing short of a miracle. I used to take it for granted, but that has gone. We are not supposed to think of the world in terms of us and them, yet it is impossible, moving between the two countries, not to see the welfare state, the NHS, and the philosophy that underpins them, as the greatest bulwarks between society in the UK and life as it is lived in the US. I know which side I’m on."

Most people in Scotland don't get to experience that comparison. However, on the train the other day I listened to two young women discussing an American medical drama - The Resident. This drama highlights the shocking profit driven approaches of a big US hospital. They concluded 'thank god we have the NHS'.

Well apologies to those of a religious persuasion, but the NHS isn't an act of God. It was campaigned for by organisations like the Socialist Health Association and delivered by a visionary health minister in a radical Labour Government. And it has been Labour government’s that have funded it better than any others.

We only have to look at the shambles of marketisation in NHS England to see how easy it is to drift into privatisation. So, we should also thank the Labour health ministers Susan Deacon and Malcolm Chisholm who took Scotland in a different direction in the early years of devolution.

Secondly, while we should celebrate achievements - should take the opportunity to recognise the challenges and look forward. These are set out in the SHA Scotland paper launched today, and Professor David Conway outlined these at today’s event. 

 It is important to emphasise that while the NHS does a lot of preventative work it is largely about patching and mending us when we get ill. So, preventing ill health requires action outwith the NHS.

With the exception of Asthma, you are more likely to suffer every other illness the lower your income group. That points to the fundamental challenge facing health of the nation - inequality. The research in the book the Spirit Level showed us how unequal societies are also unhealthy societies. Interestingly, it also showed that even the relatively affluent members of society also do worse in unequal societies.

And the NHS points the way towards the collective action we need to take to seriously tackle inequality. The NHS commands widespread support because we all use it. Even the rich understand that while they can buy a luxury room in a private hospital, it will be an NHS paramedic or the staff in an A&E dept who will save their lives in an emergency.

In Glasgow in the 19th century the council delivered many of the great projects that did so much to improve health in the city. It wasn't just hospitals. It was clean water from Loch Katrine and many other public health measures that made the difference. You can imagine one of those rich merchants saying to another on the council, why should I pay for these things. The answer was that disease knows no boundaries, even the rich couldn't inoculate themselves. 

It's that collective approach, yes socialism, that should drive our thinking as we move forward. In housing, social care, the economy and the broader welfare state. 

I may not make the 100th anniversary of the NHS, but if I do, I hope that we will have addressed the 21^st century challenges, which will reduce the demand on the NHS. By creating a more equal society that will honour the socialist giants, like Nye Bevan, on whose shoulders we stand.

Tory health policy with a difference

When a new Scottish Conservative health policy lands on my desk, I flick through it expecting to see the usual marketisation, ignoring health inequalities and blaming the poor for their unhealthy lifestyles.

 

However, this new paper, ‘Healthy Lifestyle Strategy’ from Brian Whittle MSP is somewhat different. It aims to set out a long term alternative strategy for health, welling being and sport.

So, why is it different?

 

For starters, the first chapter is entitled ‘Health inequality in Scotland’, and describes the difference in health inequality across Scotland and between income groups. Admittedly there is more emphasis on geography than income inequality, but this is real progress. I can remember the last Tory Chair of Greater Glasgow Health Board denying any link between inequality and health – well after the Black report had been published!

 

The next chapter describes two pillars of a healthy lifestyle, activity and nutrition. These are of course important and the paper argues for investment in early intervention - preventative spending as we would call it. It also recognises the importance of using procurement as lever to achieve change. Again something UNISON has long argued for.

 

As you might expect from a former athlete, Brian Whittle argues that activity should be at the core of health and education. He is right, although the emphasis should be on activity, not just sport. The health benefits are undeniable, but what’s different about this policy is that it recognises at least some of the barriers to participation – not just blaming the poor. It also recognises the importance of early years childcare and learning to achieving change and the need to invest in these services. Most policies in this field focus solely on teachers, but this policy also recognises the role of early years practitioners, which is very welcome.

 

Somewhat surprisingly the paper highlights the difference in participation opportunities between state and private education, and even highlights the fact that a third of the British Olympic Team was made up from 7% of the population that was privately educated. It also quotes extensively from the CPAG Scotland report on the hidden costs that hamper participation in extra-curricular activity. It is similarly opposed to some council charges, which have been caused by the council tax freeze.

 

It is of course true that many school facilities are closed out of school hours. However, some recognition that this is often caused by PFI contracts would have been welcome. UNISON Scotland’s ‘Combating Austerity’ toolkit shows how we could tackle this.

 

The chapter of the importance of good nutrition emphasises the role of procurement in ensuring food in our schools and hospitals is of high quality and locally sourced. Almost word for word from UNISON Scotland’s Food for Good Charter - even quoting the groundbreaking work of our members in East Ayrshire Council. No ‘nanny state’ lectures here, just maybe as Stephen Jardine argues in the Scotsman – the tide has turned in this debate.

 

The paper concludes with a long series of recommendations. These are very practical ideas, almost all of which we would have very little problem with. Several are not the sort of policy proposals you would expect to find in a Conservative policy paper.

 

It would be a fair criticism to say that the paper would have benefited from greater context on the impact of inequality on health and measures to address this including the importance of progressive taxation to create a more equal society. Practical programmes that ignore this reality are going to struggle.

 

So, this isn’t the ‘Spirit Level’ recognition that more equal societies are also healthier societies, but that was probably a step too far! However, it is a real step forward in Conservative thinking on this issue and should be welcomed for that.

Action on recruitment and retention of health and care staff

The health and care sector in Scotland is facing significant recruitment and retention problems at a time when we need to expand the workforce. We need to take action now.

Today, I was giving evidence to the Scottish Parliament Health Committee's inquiry into workforce recruitment and retention. It's a timely look at the issue given the problems the sector faces and the need to recruit thousands of extra staff to cope with growing demand. And that's before the uncertainties of Brexit, which understandably concerned MSPs as well.

We should start with the data. For the NHS we have pretty good workforce statistics because NHS Scotland uses a common payroll system and therefore ISD can publish a decent analysis of trends. For example, we know that nursing vacancy rates have been growing and currently stand at 2566 WTE. There are similar proportional problems with doctors and allied health professions, including Occupational Therapists.

The same is not true for the social care sector. This largely privatised sector is hugely fragmented and data is heavily reliant on registration with the SSSC. The problem with this is that not all staff are yet registered and some important groups, like PA's and childminders, don't have to register. The interaction with volunteers is another complication. We are therefore reliant on partial employer data and our surveys to plug the gap. We do know that many employers are holding high numbers of vacancies and have turnover rates that would make the worst outbound call centres blush.

This is also an ageing workforce. In social care the median age in all sectors is in the mid to late forties and younger staff are much more likely to be looking to get out of the sector. There is also gender segregation with men making up only 15% of the workforce. One of the barriers in attracting young men into the sector is the prevalence of part-time working. The data actually understates the problem because the SSSC defines full-time as more than 30 hours per week.

In preparation for today's session, I went back and looked at our member surveys in the last 18 months or so. What struck me was the similarity in the concerns of members from low paid home care workers, to professional posts such as district nurses and health visitors. They all point out that these are tough jobs, physically and emotionally, that are getting more complex. The job satisfaction that used to be a feature of the job has been undermined by cuts that leave them with not enough time to care. They also point to limited training and the loss of admin staff support and poor IT systems.

Pay and conditions are a big issue, particularly in the social care sector. In Living Wage Week we should be redoubling our efforts to ensure that care workers are getting at least that rate. We also need to tackle poor working practices such as insecure work, zero/nominal hours contracts and the treatment of travel time. As many staff have said to us, why should we work in such a tough job, with registration standards, when we can earn more stacking shelves.

Finally, let's look at some solutions.

We must start by valuing the care workforce. Paying them properly with fair work principles being delivered through procurement and sectoral bargaining. That will also help to address gender segregation.

Workforce planning is more of an art form than a science, but we could do better. Not least by widening the scope from the narrow group of professions currently included. We also need to recognise the scope for expanded roles and initiatives like UNISON Scotland's Skill Charter could contribute to this. 

Cutting admin support is a false economy, leaving front line staff to perform these functions, usually not as competently. Investment in IT systems and equipment that actually works would also help.

Structurally, in social care at least, fragmentation of providers has to be addressed. Does a country the size of Scotland really need a thousand adult care providers? 

With a growing demand for health and care workers we need to take action now if the workforce is going to be there when demographic change impacts on many more people living in Scotland. We can make some structural changes and coordinate workforce planning. However, none of that will work unless we value the workforce.

Why trade agreements are bad for our health

Our understanding of trade deals is limited because they have largely been a matter for the EU. Post-Brexit, we should be concerned about what's happening in Europe, as well as what sort of trade deals are being negotiated by our government worldwide.

Most people will be aware of the Transatlantic Trade and Investment Partnership (TTIP) between the USA and the EU, but less aware of the Comprehensive Economic and Trade Agreement (CETA) between Canada and the EU. Initial votes on this are imminent and the deal has many similarities with TTIP. Boris Johnson is also record as saying that CETA is a good model for future trade deals.

Yesterday, I was speaking at an event looking at the health impact of trade deals.  While the risks to the NHS are recognised, the wider impact on health policy has not been given the attention it deserves.

Even with the inclusion of health on the 'negative list' in CETA, the definitions are likely to be narrow and this still leaves open a range of other public services that impact on health. The aim of trade deals is to create a globalised market in public services and the 'negative list' approach is too weak. There is also a 'ratchet clause' in CETA that locks in privatisation, even when democratically elected governments want to bring them into public ownership.

There is no protection for public services in the investment chapter that allows private corporations to by-pass governments and domestic courts in favour of tribunals (ISDS), run by private trade lawyers. This exposes a wide range of Scottish public services to challenge because they all have elements of private provision already. Examples include Scottish Water and procurement initiatives like the Scottish Living Wage.

Another aim of trade deals is to reduce the supposed ‘regulatory barriers’ to trade, through ‘mutual recognition’ of regulatory standards. In effect a race to the bottom that ignores the precautionary principle in favour of lower safeguards, commonly found in the USA. In practice, this requires little direct action because ISDS creates a ‘regulatory chill’ factor that stays hand of governments.

The specific health impact of CETA and other trade deals include broadening and extending intellectual property rights which could delay the availability of cheaper generic drugs. All public procurement is covered and this could curtail buy- local food purchasing programs in Scotland as promoted in UNISON Scotland's Food for Good Charter. There is a sustainable development chapter, but like the ILO clause, these are aspirational with no effective citizens right to challenge. Regulation restrictions include licensing procedures that are “as simple as possible”, which means as weak as possible! There is also inadequate protection for public water services and on the ILO Convention right to organise, there is only a weak call on Canada to ratify.

If, as seems increasingly likely, the UK government goes for hard Brexit, trade deals will have to be negotiated across the world. So we need to take the debate away from darkened rooms of international trade lawyers and into wider public debate. This means not just saying what we don't like about them, but also to debate what a progressive trade deal might look like. 

There are few international models to copy. The possible exception is the South American APP agreement. However, that is based on a unique barter arrangement that it would be difficult to replicate in Europe.

A progressive trade deal would not build in a comparative advantage that locks in poor countries to a system that makes the global South produce goods that are paid for by speculation economy in the North. To illustrate this, the average EU cow is subsidised by $800, while the average annual income in Ethiopa is $100. Neither do we want the Singapore model, where the UK seeks to out-compete the EU through lower regulation and wages.

It ought to be possible to negotiate trade deals that include enforceable environmental and human rights commitments that control transnational corporations, with a citizen rights to challenge. Warm words in a trade deal are not enough - there has to be an effective remedy for everyone, not just the corporations. A progressive trade deal would encourage the  transfer of skills and technologies, not monopolise them. Trade should contribute to social goals, not limit them. From a health perspective they should include a health impact assessment as standard. 

We need to do much more to flesh out these ideas, before the UK government goes away and negotiates in secret. The Trade Justice Movement's, Alternative Trade Mandate 10 Point Plan is a good starting point.

The secrecy and complexity of trade agreements has resulted in very little public debate over their contents. That has to change because they impinge on almost every aspect of public policy, particularly health. The very best public health strategies are useless if they are struck down by private corporations. Modern trade deals are almost an alternative constitution. We wouldn't leave that simply to the lawyers and neither should we with trade.

P.S.

You can join the campaign against CETA by emailing your MEP here. The Scottish campaign will be lobbying the SNP conference on Saturday.

Impact of Brexit of Scotland's health and care sector

At this morning’s Holyrood Brexit and Health seminar, I was asked what my immediate response to the Brexit vote was. Well of course I was elated at the thought of the promised £350m extra spending on the NHS. I had quickly calculated the Barnett consequentials and drafted UNISON’s shopping list to the health minister. Then I woke up and realised that this pig had not flown by my window!

In the real world, health is like so many other sectors, avidly awaiting any semblance of a strategy from the UK government. It remains unclear if this is because of civil service unpreparedness or cabinet divisions. However, it shouldn’t stop us in Scotland, identifying the risks and the opportunities and preparing our own position.

An early priority should be the economy. There are some positive signs of recovery except for the currency, and crucially for health, the public finances. We should be concerned that the Autumn Statement does not use Brexit as an excuse for a new round of austerity in order to achieve the ideological goal of reducing the state. In the alternative, if the Chancellor accepts the need to boost the economy, we should be increasing revenue spending as well as capital. NHS Scotland needs revenue funding more than it needs capital.

The big issue that focused most minds at today’s seminar is migration.  A right to stay for EU nationals is crucial to health sector. It may be legally possible to deport people, but there would be huge political and practical difficulties. I suspect the UK government’s unwillingness to make a declaration on this, is more to avoid a pre-Brexit migration surge than as a realistic bargaining chip.

There are various estimates of how many EU nationals work in the health and care sector in Scotland, but none are reliable. Audit Scotland’s report today on the social care sector used a 2008 survey that showed 6.1% of the social care workforce in Scottish care homes for older people were EU – non-UK workers, and a further 7.3% were employed under work permits. Most of those employed from within the EU came from Poland and the Czech Republic and those from outside the EU were from the Philippines, India and China. The NHS staff survey on ethnicity is published annually, but is voluntary and equally unreliable.

What we do know is that staffing levels are already under pressure. NHS Scotland had 2207 nurse vacancies in March of this year and the social care sector is struggling to recruit and retain staff.  If we are struggling with EU nationals, we need to ask how we will recruit the additional 65,000 additional health and care staff the sector will need in Scotland by 2022.

Recruiting more care staff from the indigenous workforce is going to be challenging given the numbers involved. We will need to really value care workers for the great job they do. That means fair pay, training, and time to care. We also need to break down gender segregation in the sector. Unless significant numbers of male staff are attracted to the sector, something like one-third of all female school leavers will need to work in care – and that simply isn’t going to happen.

While these are the immediate concerns, we should start to plan for other issues that will impact on the health sector. These include the common EU standards in professional regulation and employment law, particularly the working time directive. There may also be some opportunities in Brexit to address the limitations European procurement law has had on the sector, in particular, state aid and the posted workers directive.

There are wider public health impacts of EU environment and food regulation. Not to mention the loss of research funding and opportunities for collaboration over research. We should also be concerned about a UK approach to trade deals given the lack of expertise and ideological approaches. If we think the EU has made a mess of TTIP, CETA etc. – imagine what ministers like Liam Fox will do! Private healthcare predators could have a field day in a post-Brexit environment.

In conclusion, Brexit creates a wide range of potential issues for the health and care sector. The threats are obvious, although we shouldn’t lose sight of opportunities. Most people at today’s seminar recognised that we should move on from despair at the outcome and focus on what we need to do to protect these crucial services.

The prospects for NHS Scotland and health policy

Improving the health of people living in Scotland ought to be a high priority for any government – so what might we expect from the next Scottish Parliament session?

Health inequalities remain Scotland’s most enduring problem as this week's GCHP report shows yet again. Life expectancy between the wealthiest and poorest areas remains stubbornly high. The SNP manifesto included a brief mention of health inequalities and that in the context of public health, with the promise of a new strategy on diet and obesity. Of much greater significance will be commitments to new housing and income support through devolved welfare powers. However, these measures will be constrained by the impact of austerity on public spending in Scotland and the limited use of new taxation powers.

One of the few SNP manifesto spending commitments is an increase in the NHS revenue budget by £500m ‘by the end of this parliament’. This is a modest increase over five years that should be funded from the Barnett consequential of English NHS spending. 

As we will be relying on these Barnett consequentials, we should take a closer interest in what is happening south of the border. Professor Andrew Street at the University of York points out that the claimed £8.4bn increase in English spending by 2020-21 is actually closer to £4.5bn. The chart below shows how this spending might be increased each year and the average 0.8% looks very low. The modest £500m increase promised for NHS Scotland therefore looks like John Swinney’s pragmatic assessment of the Barnet consequentials.

NHS England has highlighted a £30bn spending gap by 2020/21, of which the UK government claims to be providing £8bn. Wage and drug costs; a growing and ageing population; and a trend in activity demand, over and above the demographics, explains the gap. There are similar pressures in Scotland. Even if our population growth is slower than England, we have an older population and poorer health that drives up costs. NHS England’s ‘Five Year Forward View’ has some pretty optimistic solutions, including ‘a radical upgrade in prevention and public health’ and a shift to primary care.

It is not even clear that the Barnett consequentials will reach actual health board budgets, which are already under pressure. The SNP manifesto unhelpfully compounds the annual increase and claims it totals £2bn over the parliament. However, they are also committed to investing £1.3bn ‘from the NHS to integrated partnerships to build up social care capacity’. It is unclear if that is over and above the NHS revenue increase. It wasn’t in this year’s budget and it is hard to see where else this money is going to come from. 

As councils deliver social care, this is a big dent in the NHS spend, although few would dispute the priority given to social care that is in a state of crisis and the need to end the waste in bed blocking.  It will also help pay for the commitment to pay the living wage - an important first step in improving the recruitment and retention of staff in the sector. 

There are some other specific spending commitments. £150m has been identified for mental health services. This is welcome and there were similar commitments in all the party manifestos; demonstrating that the underfunding of these services, particularly for children, has attracted everyone’s attention. There is also £200m for five elective treatment services, although the adequacy of that budget has been questioned and it is a suspiciously round number!

The number of staff working for NHS Scotland recovered to its pre-crash levels last year and is likely to grow again. There is a commitment to an extra 500 health visitors, training for an additional 500 advanced nurse practitioners, 250 Community Link Workers and 1000 paramedics ‘working in the community’. There will be another 100 GP training places and £23m to increase the number of medical school places. Extra staff on the establishment will be welcome, but given the number of vacancies at present, it may be some time before actual bodies appear on the ground.

As in England, the Scottish Government is looking to reform to plug at least some of the financial gap. The SNP manifesto says “The number, structure and regulation of health boards – and their relationships with local councils – will be reviewed, with a view to reducing unnecessary backroom duplication and removing structural impediments to better care”.

Reducing the number of health boards is a practical proposition when it comes to acute services and could be built around three or four major trauma centres. It is much more challenging when it comes to community services. 

It is here that much will be expected from the new Integrated Joint Boards and it remains to be seen if these will continue as joint boards or morph into stand alone bodies. That will probably depend on how successful they are. Another option, as happens in other parts of Europe, is to move these services into local government. That option is unlikely in Scotland given the Scottish Government’s antipathy towards councils. The next GP contract could also be an opportunity to reform the antiquated small-business model, into something that is more integrated into the NHS or the IJBs.

What seems clear, is that the additional NHS staff and investment in social care are primarily focused on achieving what the SNP manifesto describes as “ensuring that our NHS develops as a Community Health Service”. Few would argue with that priority, as shifting resources from acute to primary care makes absolute sense. However, it has been an objective of many different governments over the years, in less challenging financial circumstances.

This is of course a minority government, but despite regular squabbling in parliament, there is a large degree of political consensus over health. Even the Tories are not immune from that consensus with little evidence of the market ideology that drives their counterparts in England. Labour and the Greens both put greater emphasis on tackling health inequalities and that also requires a shift from acute to preventative primary care services. If there is a difference in approach, it is structural - the opposition parties have a common preference for localism over centralisation.

On this basis, there appears to be a common understanding of the problems. The challenge remains to deliver the solutions in the context of austerity.

Health and social care funding pressures

The NHS and publicly funded adult social care will account for £157bn of public spending across the UK in 2015/16 – equivalent to 8.4% of gross domestic product (GDP) and accounting for around £1 in every £5 of government spending.

Economists at the Health Foundation and the Institute for Public Policy Research (IPPR) have published a report that looks at the scope for public funding to match these pressures and what the potential funding gap for health and social care looks like. They model the potential revenue that might be raised by different taxes to fill a health and social care funding gap, the distributional impact of the different tax options and how they compare to the profile of the ‘beneficiaries’ of additional health and social care spending.

While the analysis starts from English spending, they do try and extrapolate the numbers to paint a UK wide picture. The pressures in Scotland are in any case very similar. The solutions in Scotland may be different because of our different policy approaches, like 'free' care for the elderly.

The main findings are:

•Our analysis shows that despite government commitments to additional funding for the NHS in the UK, there is still likely to be a shortfall of £2bn in 2020/21, rising to £9bn (above inflation) by 2030/31.
•For adult social care the pressures are greater. We forecast a funding shortfall of £6bn by 2020/21, rising to £13bn in 2030/31, assuming there is no change in policy.
•The projected health funding gap of £9bn in 2030/31 is worth 5% of the projected budget that year; for adult social care the funding gap of £13bn is equivalent to 62% of the total expected budget for 2030/31.
•The combined pressures on health and social care funding will amount to an estimated shortfall of £8bn in 2020/21 and £22bn in 2030/31.
•The government has committed to eliminating the deficit in the national budget by 2019/20 and is planning to run a surplus of £10.5bn (0.5% of GDP) by 2020/21. If the planned fiscal surplus of 0.5% of GDP were spent on health and adult social care, it would close the combined funding gap in 2020/21, but leave an estimated shortfall of £8.4bn in 2030/31.
•One alternative to taxing income and employment is to tax consumption and in particular consumption that has a harmful effect on health – a so called ‘sin-tax’. The report looks at taxing sugar specifically.
•There are choices that need to be made about the medium to long term financing of health and adult social care. One option is to bridge some of the gap through a lower public finance surplus than currently planned; another is to increase taxes.
•While our analysis suggests that the NHS faces considerable pressures, it does not appear unsustainable. However, there must now be real doubts about the sustainability of the current financing system for adult social care.


Social care funding in Scotland is already at crisis point. This report shows that funding pressures are not going to get any easier and some very tough political decisions will be required.

Can more legislation raise care standards?

Effectively tackling harm, abuse and neglect in health and care settings is vitally important, but is more legislation the best way to address this issue?

I was giving evidence to the Scottish Parliament Health Committee today on the Health (Tobacco, Nicotine etc. and Care) (Scotland) Bill. The Bill covers three distinct policy areas: controlling non-medicinal nicotine vapour products (NVPs); tobacco control and smoking on NHS hospital grounds; ill-treatment and wilful neglect; and duty of candour.

UNISON supports the regulation of NVPs on the precautionary principle as we can see the potential risks of these products becoming a gateway to tobacco smoking that has done so much damage to public health. We also support a ban on smoking in hospital grounds.The more controversial proposals relate to legislating for a duty of candour and new criminal offences for ill treatment and wilful neglect.

Care professions generally operate within culture of openness that supports an open discussion of potential harm and the management of risk. It is not clear that a new duty of candour on health and social care services is the best or only way of securing a culture of openness and transparency. It can be argued that consideration should be given to all other avenues for achieving this policy goal. The desired culture change could be secured through guidance, training and improvement support, rather than legislation.

The Bill will certainly create additional costs in excess of the optimistic assumptions in the Bill's financial memorandum. It will increase workload and probably add some bureaucracy that front line staff can do without. IT systems are generally not adequate or joined up to be of much assistance. There will need to be significant training and support.

This legislation could also have unintended consequences. Criminal offences can lead to defensive practice and even a culture of hiding bad practice, rather than the intended transparency. The development of a culture where open and transparent reporting is the norm requires employers to establish clear, no-blame incident reporting systems from which to learn and improve. It is also the case that some definitions in the Bill are less than clear and there is a risk for double or even triple jeopardy, with employment and regulatory procedures.

On the other hand we have to accept that there is inconsistently of approach. Observations made by Healthcare Improvement Scotland has shown that ethical and policy guidance has largely failed on its own to improve rates of disclosure. Research by the Professional Standards Authority outline the impact on health and social care professionals to exposure to stressful situations and heavy workloads, often linked with a requirement to process complicated information and focus on specific goals and targets. This 'stimulus overload‘ is cited as a potential contributor to unreliable implementation of best practice regarding a duty of candour. Normalisation of abnormal events becomes a way of coping with high risk situations.

Legislation can help to change culture although it rarely does so on its own. It will also need leadership, better staffing ratios and proper training and support for staff. All of these are likely to be in short supply with budgets stretched because of austerity. However, the Scottish Government's approach is inconsistent. When we made a similar case for new legislation to protect workers from violence at work, they produced similar arguments against legislation as those who are critical of this Bill. We are at least consistent in recognising the role of legislation!

While the evidence to support legislation in NHS Scotland is thin, it is somewhat stronger in the social care sector. The introduction of commercial contracts has put enormous pressure on staff and managers to cut corners in care. UNISON Scotland's 'It's Time to Care' report highlighted these pressures and they have if anything increased with the introduction of self-directed care. Staff reported that they were not encouraged to report safety or even carer abuse issues, because managers were concerned that they would lose the care package. A recent Employment Tribunal case involving a care manager showed that she was instructed to accept packages even when there were no staff to deliver them.

One reason to welcome the legislation is the emphasis on organisations and not individual practitioners. In remains to be seen how this will work in practice, but it should mean that organisations and their managers recognise their responsibility to provide the necessary support to staff. We have to improve organisational cultures rather than just create a monitoring tool. The remedial and publicity orders in the Bill are useful tools, although we should recognise the internal pressures within commercial organisations to suppress adverse reports.

On balance we believe that legislating for a duty of candour and the new offences could assist in achieving the stated aims. The Bill places important duties on organisations and managers, not just front line staff. However, care services have to be properly funded, otherwise there is a real risk that this Bill will simply result in staff being scapegoated for the system's failings.

 

Inflation busting registration fees for health workers

At a time of pay restraint it is not acceptable for regulators to impose inflation busting fee increases on health and care workers.

I was giving evidence today at the Scottish Parliament Health Committee on secondary legislation that increases registration fees for a range of health and care professions UNISON represents. The Health and Care Professions Council (HCPC) increased fees by 5% last year and indicated that they would not increase them again for two years. However, they have now come back for a further 12.5% increase after a perfunctory consultation while Westminster was in election purdah.

They claim this is because of a levy from the regulatory overview body, the PCA. However, only 30% of the increase relates to that with the balance reflecting new accommodation and IT systems. This looks opportunistic, particularly when there has no detailed costing was provided. The HCPC also generated a big operating surplus last year and is substantially increasing its reserves.

Needless to say health and care workers are not getting a 12.5% pay rise! The HCPC argue that they are the lowest cost regulator, but comparing paramedics, OTs and ODPs to doctors and dentists was, to put it mildly, insensitive. A UNISON survey of registrants indicates that many staff do not think they get value for money and that the HCPC could do more to reduce unnecessary hearing costs.

Scottish Labour MSP, Richard Simpson moved a motion of annulment, a very rare procedure in the Scottish Parliament. He made a very strong case pointing to the absence of an Equality Impact Assessment on what is a predominately female workforce. He also drew attention to the huge increase in the Chief Executive's pay, up by £26,000, more than the annual pay of many registrants. Also that the fee for Scottish social workers, regulated in Scotland, is only a third of the cost of their English counterparts who are regulated by the HCPC.

Predictably, SNP MSPs voted against the annulment as this increase is supported by the Scottish Government. We will look forward to the minister supporting a 12.5% pay rise next year!

In fairness MSPs did so with no great enthusiasm, they welcomed the fact that this debate took place and that the regulator was put under scrutiny for probably the first time. There is a case for wider reform of UK regulatory bodies and they might find it more difficult if they return for another increase next year.

Putting the increase under the spotlight was probably the best we could have achieved this year. Health and care workers have no choice but to pay these increases, so they look to their MSPs and MPs to scrutinise these costs vigorously.

Focus on social care to end bed blocking

With thousands of beds blocked this winter by patients healthy enough to return home, it's time for politicians to put as much focus on social care as they are on NHS Scotland.

Thanks to data obtained by BBC Scotland we know that over a four-week period, an average of 1,216 beds per day were unavailable to incoming patients in hospitals across the country. NHS England is also struggling with this problem and 139k patients were stuck in beds, unable to leave, in December. Scotland's comparative numbers are more than double, with 31,610 reported in Scotland for a population 10 times less.

Health Secretary Shona Robison said the figures "aren't good enough" but blamed the position the government inherited. Possibly the lamest excuse a minister could give when her party has been in government for nearly 8 years!

Scottish Labour's health spokeswoman Jenny Marra said: "Bed blocking has a real impact on our whole health service and the operation of our hospitals. It is something the government needs to get on top of soon". True, but Labour's policy announcements have been focused on the NHS and not on social care - where the real focus should be at present.

The last edition of Holyrood Magazine has a good analysis on how the NHS in Scotland is being used as an election issue. In fairness to the politicians, they are largely reflecting public perceptions and therefore, as I said in the article, we all need to do more to explain the interaction between health and social care. The ConDem austerity cuts in Scotland are largely being dumped on local government and councils are in no position to respond to the demands placed upon them.

Council social care budgets are to be merged with health budgets. This is aimed at forcing both to work closer together to move patients into the right care setting. The Scottish Government announced £100m in funding which, invested over three years, will be used to help health boards and councils provide support packages for people in their own homes. Welcome though this funding is, it is well short of what is required.

Firstly, we need to fund an increase in capacity. We know from our surveys of the staff involved that assessments are not being delivered in full. That's in addition to patients blocking beds - now the equivalent of the bed capacity in the new Southern General Hospital.

Secondly, it's about recruitment and retention of quality staff. We have a hopelessly fragmented delivery of home care that has been increasingly privatised. Many of the new providers cannot deliver the service because of high staff turnover and recruitment problems. There has been a race to the bottom in pay and conditions, and staff are voting with their feet.

For example, an authoritative new report from the Resolution Foundation revealed that at least 160,000 care workers were being collectively cheated out of £130m a year by virtue of being paid below the National Minimum Wage. How can we claim to be a civilised society when we allow the people entrusted to care for our elderly and disabled people to be treated so outrageously? The Save Care Now web site has a petition on this issue that I would urge everyone to sign.

In Scotland, this is reflected in UNISON Scotland's Time to Care report that highlighted some appalling working practices. The growth in zero and nominal hour contracts is another abuse that needs to end because it directly impacts on the quality of care. Workers on these contracts are simply unwilling to report even care abuse, because of the threat to their precarious jobs.

Under the provisions of s52 of the Local Government in Scotland Act, councils should not be using procurement to create a two tier workforce, but they are. The recent local government benchmarking report says that the 8% shift to outsourced providers has, "contributed to reduced costs through lower salary and pension costs". Progress on extending the living wage through procurement has also been painfully slow.

Getting patients out of hospital is essential for the NHS and the quality of life for people stuck in an inappropriate care setting. It requires greater home care capacity as well as a revitalised workforce using the plan in UNISON's Ethical Care Charter. That is where political parties ought to be focusing their attention.

 

Health Inequalities - We need an end to austerity

Austerity and what is wrong with it has been leading the news thanks to the Syriza victory in the Greek elections.

This blog regularly highlights our opposition to austerity and the damage being done to families and particularly young people and the most vulnerable members of our society.

One of the cruel scandals of the wide and unfair health impacts is that too often people in poverty struggling with ill-health are attacked for unhealthy lifestyles by the wealthy and the powerful suggesting these problems are simply self-inflicted.

But in New Scientist magazine Scotland’s former chief medical officer Dr Harry Burns has reiterated that job loss and social breakdown, NOT smoking and bad diet, is at the root of the country’s infamously high rate of premature death.

He points out that from 1950-1970 Scotland had one of the lowest rates of death from alcoholic liver disease, but by 2005 it had the highest.

Dr Burns said: “It may be that what we are seeing in Scotland is the consequence of austerity in the 1970s and 80s, when social change and joblessness led to a breakdown in family life and a cycle of alienation...What we have seen in Glasgow may become evident in southern Europe over the next two decades.”

NHS Scotland is under financial pressure and it's going to get worse

NHS in Scotland is facing significant pressures at the same time as having to make major changes to services to meet future needs. That's the key message from the latest Audit Scotland report on NHS finances.

This infographic sums up the pressures.

They also found evidence that NHS boards are finding it increasingly difficult to cope with these pressures. NHS boards’ revenue budgets increased by just over one per cent in real terms in 2013/14, and smaller real terms increases are planned from 2014/15 onwards. Cost pressures, such as the growing costs of drugs and other health technologies exacerbate this tight financial situation. This table shows that while spending overall has increased in cash terms, spending per head of population has decreased since 2009/10.

While resources are falling in real terms, the demands on the NHS are increasing. This is as a result of demographic change, particularly the growing population of elderly and very elderly people; the number of people with long-term health conditions; and people’s rising expectations of healthcare. Audit Scotland conclude that it will be challenging for the NHS to make the scale of changes required over the next few years to meet the 2020 Vision strategy. In particular, progress has been slow in moving more care into the community - a process not helped by council budget cuts. They point to pinch points in the complex health and care system with only three boards meeting the delayed discharge targets. It remains to be seen if health and care integration will tackle these.

While all NHS boards met their financial targets, several required additional funding from the Scottish Government or relied on non-recurring savings to break even. NHS Highland, NHS Orkney and NHS 24 had particular difficulties. Five boards are relying on non-recurring savings to meet efficiency targets. A classic indication of NHS cost pressures is the backlog of maintenance required to ensure that hospitals and other buildings are fit for purpose. In 2012, the Scottish Government forecast that the cost of this backlog would decrease by £174 million by 2013, from £948 million to £774 million. The actual reduction was £90 million, to £858 million.

The NHS capital budget available to boards fell by 21% between 2012/13 and 2013/14, from £605.5 million to £481.3 million. In a separate announcement the Scottish Government has announced a big PPP/PFI programme. This expensive form of finance is funded from revenue.

In addition, despite significant efforts, the NHS did not meet some key waiting time targets in 2013/14. The report highlights a range of pressures including a significant increase in outpatient appointments. Audit Scotland argue that the current level of focus on meeting waiting time targets may not be sustainable when combined with additional pressures of increasing demand and tightening budgets.

There has been a reduction in the number of hospital beds across Scotland. Between 2008/09 and 2012/13, the average number of available staffed beds in acute specialties reduced by 7% (1,144 beds); the number of acute surgical beds fell by 11% (596 beds); and the number of acute medical beds fell by 5% (313 beds). The main reason given for this reduction is the growth in day surgery.

The report highlights a range of staffing pressures, particularly amongst medical staff. NHS Scotland spent £128 million on bank and agency nursing and midwifery staff in 2013/14, an increase of 15% since 2012/13. Spending on agency staff increased by 46%, to £9.3 million. This follows a rise of 62% the previous year, reversing the trend of falls in spending on agency nurses since 2008/09. Agency staff are likely to be more expensive than bank nurses, and also pose a greater potential risk to patient safety and the quality of care.

Overall, this report gives a good overview of the financial state of NHS Scotland and its constituent boards, shorn of the usual spin. In short, it's tough now, but it's going to get a lot worse.