NHS Finance

Moving Scotland forward

The dust may be beginning to settle after the Westminster poll but there is little let up for Scotland. We now have our sights trained on the 2011 election to the Scottish Parliament where health is again bound to be a focus for debate, says Dr Brian Keighley

Every five years or so the political football that is the National Health Service becomes a fierce battle for possession between the various teams that face up to one another in a general election. In the 2010 general election, however, the battle was complicated by not only the end of an unprecedented growth in NHS resources but also a crisis in public finances that threatens the significant increase in funding since Tony Blair promised to bring the UK’s health expenditure up to the European norm.

Scotland’s NHS has to cope with even more uncertainty as political control of its destiny and health policy will remain devolved to the Scottish Parliament no matter what transpires at a UK election.

What is more, whatever is delivered within Scotland is always constrained by NHS funding from within the Scottish block grant. This is determined, under the Barnett formula, by spending decisions in Westminster and is under increasing (hostile) scrutiny by UK party politicians which means it is likely to come up for debate in this next term.

I would caution those casting envious eyes across the border against a knee-jerk reaction. Future discussion of the block grant needs to be informed by Scotland's unique problems of dispersed population, challenging geography and existing pockets of health and social deprivation.

The biggest lesson UK politicians of all parties have yet to learn is that solutions predicated upon London and the Home Counties hold little relevance for more socially deprived areas of England and even less for the problems of the three devolved nations.

With health inflation, even a standstill in spending means a reduction and the NHS in Scotland (NHSiS) is standing on the cliff face of expected cuts in funding in 2011-12. In other words, it might be bad now but it is likely to get worse in the very near future.

The only certainty therefore is increasing anxiety over how we will be able to meet the major challenge of maintaining clinical services for patients at the 'front end' while making efficiencies in 'back office' functions.

But there will always be competing demands. For patients, the priority will be continued access to healthcare services. For clinicians, it will be about maintaining quality of services. And for managers it will also be about meeting targets and achieving efficiencies.

Depending on the scale and duration of the public spending squeeze, efficiency savings alone may not be sufficient, and current levels of provision are by no means guaranteed. Many more difficult decisions about spending priorities will need to be made.

Scottish patients will want to know how taxpayers’ money invested in the health service is performing. They will demand that funding decisions are not based upon ill-informed research, such as that recently published by the Nuffield Trust, which failed to compare like with like and which failed to measure health outcomes on the same basis, and focused entirely on hospital services. Instead, funding decisions should be informed by real, verifiable evidence so that it makes a difference to patient care.

Of course, Scotland’s NHS managers and clinicians will always seek to improve quality within whatever funding is available – and already work is going on to modify pathways of care to maximise effectiveness.

Just as elsewhere in the UK, all NHS functions, including so-called backroom or administrative areas, will be scrutinised to pare costs in order to preserve clinical services to patients – and major questions on service redesign will have to be asked. But these are matters for the Scottish Parliament and an acknowledgement of the reality of devolution as applied to health is a pre-requisite.

The health service will always need to be properly resourced. But that is far from the only contribution the UK government can make to health – and healthcare - in Scotland.

Arguably, implementing policies that will reduce poverty and the associated health inequalities could have the biggest impact of all. Health is determined by a complex interaction of social, economic and personal factors. Its causes are not straightforward. Health is marred by inequalities, for example, the type of housing and area people live in, household income and social expectations. Interventions likely to improve public health will require a combined package of social, economic and health policies.

Therefore, securing good health for the whole population means co-ordinating policy across and between government departments and also between the UK and devolved governments.

The NHSiS has one major attribute that UK politicians need to build upon. We have one less major tier of management (SHAs) but Scotland has the same mixed economy of clinicians, managers, medical royal colleges, civil servants and politicians. The main difference in Scotland is that all speak to, not at, one another in a spirit of cooperation.

Partly due to the size of the country, lines of communication are far shorter and, dare I say it, the relationships we have seem to be founded on a mutual respect derived from actually knowing each other. Creative tension is the norm – not a constant war of attrition from entrenched positions.

Yes, health policies are increasingly diverging across the UK - but this is an opportunity. By implementing different approaches in healthcare delivery we are in effect testing different models. Which delivery model is best for patients? Only time will tell.

There is one further aspect of this whole debate that I believe needs to be aired – and that is the position of professionalism within the NHS, whether that be in any of the four home nations.

I have seen enormous changes during my 36 year career as a rural general practitioner – the job I do now is far more challenging than the one I started as a young doctor. I have been through the 1990 contract, trusts, unitary health boards, markets, fundholding, purchasers, providers, local health care co-operatives, community health partnerships, areas, divisions, units and many other passing enthusiasms of fashionable health pundits. But one enduring building block remains – the one-to-one relationship between members of my clinical team and individual patients.

Above all I want a generation of politicians that will recognise that fundamental relationship – and seek to cherish and foster it and to realise that what drives clinicians is not targets, rules, sanctions or contracts – but the professionalism that underpins the doctor/patient relationship.

If we achieve that in the life of the next parliaments – at Westminster and at Holyrood - we will have done more for Scotland’s patients than we ever dreamed possible.

Dr Brian Keighley is chairman of the BMA in Scotland and a practising GP in Balfron

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