Is NHS Scotland the model for restoring a public service NHS in England?

People often refer to Scotland as the UK model for restoring public service and ask us to look at it as possible example of what we could achieve in England without the NHS internal market.

But what kind of NHS and social care service has Scotland come up with since 2001?

That was when the Scottish government legislated for NHS Scotland to abolish and reverse the NHS internal market and reintegrate services into 15 new area health boards, based on the existing 15 ‘local health systems’.

999 Call for the NHS has done our best to find out from online searches. If we have got the wrong end of the stick, we are happy to be set right.

Our takeaways are that:

  • The NHS in Scotland seems to be following the same global model for health service transformation advocated by the big management consultancy companies
    and the World Economic Forum, that NHS England’s 5 year Forward View replicates. (This “global model” is described in Deloitte’s 2018 Global Health Care Sector Outlook.)
  • Legislation to renationalise the  English NHS is necessary but not sufficient to stop and reverse the imposition of this model of healthcare – which is driven by a neoliberal, neoconservative agenda that undermines the core principles of the NHS as a comprehensive, universal service that is free at the point of clinical need.
  • For that to happen will require a commitment on the part of the public and government to abandon this neoliberal, neoconservative model of health and social care and come up with one that restores the NHS’s core principles of universal, comprehensive care for all on the basis of clinical need not ability to pay, in the changed context of today’s society.
NHS Scotland legislation timeline

A 2001 article on the development of integrated health care models in Scotland points out that New Labour’s ‘Third way” ideology underlay Scotland’s moves to remove “managed competition” from the NHS and to integrate NHS and social care services. And that globally such moves attempt “to reconcile increasing demands with limited resources.”

Following the 2001 legislation, in 2004 GPs were told to evolve from earlier forms of cooperation into community health partnerships (CHPs). These took responsibility for all out-of-hospital care and the promotion of good health, and for improving working with local government and the services it ran (including social care).

Legislation in 2014 replaced community health partnerships with 31 integration authorities across Scotland. These went live in 2016.  A 2017 Nuffield Trust study, Learning from Scotland’s NHS, likened them to English Sustainability and Transformation Partnerships:

“The 2014 legislation gives integration authorities a much firmer legal standing and a clearer role for local government than English STPs, which have a similar remit in bringing together the organisations responsible for health and social care.”

In each locality, Integration Joint Boards are jointly run by the NHS and local authority and are accountable to them as well as to the health secretary. All but one are ‘integration joint boards’ working across health and social care.

The establishment in Scotland of Integration Joint Boards was accompanied by a Health and Social Care Delivery Plan – which was:

“…designed to help address the rising demand being faced by health and care services, and the changing needs of an ageing population.”

Where have we heard that before?

National Clinical Strategy like NHS England’s 5 Year Forward View

In 2015 the Scottish government announced the need for transformational change in the Scottish NHS by 2020; and in 2016 it produced a National Clinical Strategy which aimed to provide “clarity on the provisions of that reform.”

The National Clinical Strategy seems similar to NHS England’s 5 year forward view in many ways – particularly the emphasis on “value based healthcare” as “a sustainable financial strategy” – something also stressed in Deloitte’s 2018 Global Health Care Sector Outlook .

Screen Shot 2018-11-05 at 14.57.06

Value based healthcare is behind moves in the English NHS to restrict GP referrals of patients to a range of elective surgical procedures. These restrictions are already in place in West Yorkshire and Harrogate Integrated Care System, South Yorkshire and Bassetlaw Integrated Care System, and nationally NHS England ran a poorly-publicised consultation over the summer on applying national restrictions to patients’ access to 17 elective surgical procedures.
The National Clinical Strategy summarises the financial considerations that drive it, “within the context of the toughest public expenditure conditions we have faced”:

  • a 1%/year increase in the volume of demand for healthcare equating to increased costs of up to £120m/year because more people are living longer
  • a 5-10% increase on current spending/year because of increased costs of medicines
  • increased staff costs (which are about 65% of total costs) because of pay structures, National Insurance and Pension changes.
Similarities between STPs in England and the Scottish Health and Social Care Delivery Plan, as carried out by Integration Joint Boards

The Nuffield Trust’s ‘Learning from Scotland’s NHS’ report shows the similarities between Sustainability and Transformation Plans in England and the Scottish Health and Social Care Delivery Plan, as carried out by Integration Joint Boards – with similar problems. For example (p27) lack of evidence about whether shifting care out of hospital saves money.

Other similarities include underfunding, with Scotland’s Health Boards having to make even higher levels of “savings” – ie cuts – than NHS England’s target of £22bn “savings” over 5 years.

The proposed remedies for this lack of funding seem identical: moving patients, services and resources out of hospitals; centralisation of services, including trauma hospitals; encouraging patients with long term illnesses or disabilities to “live independently” and new ways to deploy staff.

A new (2018) GP contract “refocusses” the GP role in order to support this agenda.

The contract specifies that the GPs’ role is now as an Expert Medical Generalist supported by and overseeing an expanded multidisciplinary team of clinicians and allied healthcare professionals. This means GPs will now only see patients with “undifferentiated presentation” (meaning that the receptionists’ triage/signposting has not identified who else to send them to) and patients with long term ailments who need “complex care”.

Under the contract, many GP services will transfer from GP practices to Health Boards in order to reduce practice workload and improve practice “sustainability.” Out of hours provision is removed from the GP contract.

These changes are very like changes imposed as a result of NHS England’s GP Forward View, that are currently being implemented by Local Authority/Clinical Commissioning Group Integrated Commissioning Boards, which are due to turn into Integrated Care Systems from April 2019.

If the renationalised Scottish NHS is planning and providing a financially driven model based on denial of care, with care-closer-to-home as its principal driver for reduction of acute costs and shrinking the ‘NHS offer’, then we are left with the prospect of an ever growing market space being created for the private sector in what PWC calls the “UK healthcare and wellbeing market”. Leaving the NHS/public service model as the Medicare part of a two tier health care system.

Do we know even really what’s going on with the expansion of private health care?

The Scotsman reports:

“With packed NHS surgeries and well-documented shortages of family doctors, private GPs are expanding in Scotland with £100 appointments and late-night consultations.

More than 8,000 patients were seen at private practice Your GP in Edinburgh this year, with the company to launch its new surgery in Aberdeen next month and a third to follow in Glasgow in early 2016.

GP leaders have expressed concerns over a two-tier health system and claimed the core NHS value of care being provided on need – and not the ability to pay – is being put at risk.”

For the UK as a whole, a 2017 study of the UK private healthcare self-pay “market” by Private Healthcare UK  found that:

Providers and commentators report annual growth of 15% to 25% in the number of patients without health insurance who are using savings or loan finance to fund private operations.
The factors driving this growth are:

  • Lengthening NHS waiting times which are prompting more patients to consider the private option;
  • Demand management initiatives by Clinical Commissioning Groups (CCGs) which are reducing access to NHS care;
  • The increasing cost of private medical insurance which is encouraging older people to fund private healthcare from savings.
  • Marketing initiatives and financing schemes from the major providers.
  • Growth in self-pay treatment is being seen particularly in orthopaedics, ophthalmology, general surgery, vascular, ENT and cancer treatment.
  • Widely publicised restrictions on NHS funding for cancer drugs is fuelling the growth in self-pay oncology.

NHS Scotland’s policy is to develop the role of 3rd sector organisations in health and social care integration – soft privatisation. The intention is for the third sector to become an integral part of the new “landscape of health and social care”. Dumfries and Galloway Integration Programme Support Manager has blogged that:

“The Integration of Health and Social Care in Dumfries and Galloway offers us an exciting opportunity to work with a wide range of organisations from the public, private and third sectors.”

NHS Scotland uses private hospitals to cut waiting times. In 2015-16 it spent at least £38m on sending NHS patients for private treatment in order to help meet Scottish Government waiting time targets or to access specialist care in conditions such as dementia, anorexia and autism.  Audit Scotland warned that this did not offer value for money when used to meet targets.

Patient choice and the use of the private sector for hip surgery in Scotland has been found to be associated with a decrease in NHS provision and may have contributed to an increase in age-related and socio-economic treatment inequalities. This confirms concerns that the policy in England of contracting with private providers for NHS care, combined with NHS expenditure cuts, will accelerate the closure of local NHS hospitals and services and worsen health inequalities.

The Herald has reported that from April 2017 to February 2018, NHS Scotland spent nearly £4m sending Xrays and scans to private radiology companies in the UK and overseas.

NHS Scotland pays for privatised medical services in NHS hospitals. In March 2018 NHS National Services Scotland advertised a contract notice for a Dynamic Purchasing System (DPS) for Medical Services at NHS Hospitals. (A Dynamic Purchasing System is an electronic list of approved suppliers. When a contract is to be awarded, the buying authority invites all suppliers on the list to bid for it.)The Medical Services in question were:

  • medical services for adults and children to be performed by named qualified and competent consultants, with appropriate aftercare and follow-up.
  • diagnostic and other clinical services delivered by appropriately qualified medical and healthcare practitioners.

A 2016 PWC report “Capture the Growth”  on “opportunities” for new private company entrants into the “UK healthcare and wellbeing market” – introduced by Alan Milburn – predicts the “growth sector” is “in wellbeing (fitness and wellness), where no-one in the UK offers a mass market, comprehensive product.”

This is reiterated in the Deloitte 2018 Global health Care sector outlook report, which points to the rise of the “quantified self”, particularly in relation to the use of mobile communication devices for health services and information – wearable apps, smart devices and cyber networks. The Deloitte report ties this into the NHS agenda of value based commissioning and commissioning for population health outcomes.

PWC report_projected increase private health cos.jpg

So what exactly are we looking at in NHS Scotland? Is it the model we think it is? And what do we want in England, to replace the neoliberal, neoconservative model of health and social care that has been concocted by the big global consultancy companies and the World Economic Forum?

Update 20.11.22 The BBC reports that NHS bosses in Scotland appear to have discussed abandoning the founding principles of the service by having the wealthy pay for treatment:

“The discussion of a ‘two-tier’ health service is mentioned in draft minutes of a meeting of NHS Scotland health board chief executives in September. The minutes of the meeting seen by BBC News are marked ‘in confidence not for onward sharing’ and highlight the degree of official concern about the sustainability of Scotland’s NHS in its present form…

“The minutes of the NHS Scotland meeting summarise ‘themes, issues and ideas’ during 45 minutes of discussions on Wednesday, 21 September, about ‘what a transformed NHS could look like’.

“They ask ‘what can be done with the financial constraints that we have?’, and point out that some members of the public ‘are already making the choice to pay privately’ while the NHS is ‘picking up the cost for life enhancing not life-saving treatments’.

“It is in that context that the suggestion to ‘design in a two-tier system where the people who can afford to go private,’ appears.”

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