Health and care integration report card - could do better

Audit Scotland tries hard to use building language in their reports, but it was obviously a real challenge when it comes to health and care integration.

Audit Scotland has recently published their assessment of the progress with health and care integration in Scotland. Helpfully, as I was preparing a presentation for an English conference on how we tackle this issue in Scotland. You could be forgiven for missing this report as it came out on the day of the Brexit resignations.

As usual they introduce the report with a helpful infographic which captures the key challenges. Integration Authorities (IAs) manage a huge proportion of the Scottish budget (£9bn) and are supposed to achieve £222.5m of savings - an increase of 8.4%.

The positives are that IAs have started to introduce more collaborative ways of working and there are a number of case studies in the report that highlight best practice. This shows that the system can work, however, yes you knew there would be a but, “there is much more to be done”. 

The building language then starts to break down.

They main problem is that financial planning “is not integrated, long term or focused on providing the best outcomes for people who need support”. This is caused by the financial pressures on health boards and councils, compounded by health boards not including their acute services to the process of budget shift. Long term planning is difficult when budgets are set annually, with little medium term, let alone long term, strategic planning. However, an overall underspend by IAs of nearly £40m, does not inspire confidence either.

This doesn’t mean that there is no resource shift because the ISD cost data published yesterday shows a loss of 429 hospital beds. This data also shows that community services are getting more resources, with only a 0.1% increase in hospital spending as against 4.8% in the community sector. GPs have pointed to the fall in the amount devoted to GP services, but this may be related to service redesign. Either way, while there has been some shift from acute to community, progress is slow because of the overall financial position. 

The report also highlights a lack of collaborative leadership and strategic capacity, not helped by a high turnover in IA leadership teams and squabbles over governance arrangements. Cultural differences between partner organisations is another barrier to achieving collaborative working along with the necessary skills to work in partnership. This was predicted, and has been a problem all over the world (see Petch et al) with care integration.

Another lesson from the international evidence is that change cannot happen without meaningful engagement with staff, communities and politicians. Something the report says has not yet been achieved in Scotland. Honesty about the scale of change needed is indeed challenging, particularly when it can involve closing hospital services. Lengthy and technical IJB papers have not helped to engage members on these boards.

Workforce planning is crucial to the success of care integration. While the National Workforce Plans have now been published, they are still largely at the process stage, particularly in social care. There needs to be a better understanding of future demand, how this is likely to be met and what it will cost. Needless to say, Brexit looms large over this issue. Attempts by some IA leadership teams to promote the privatisation of services has not helped to build confidence. As UNISON surveys have shown, the procurement rules are not being followed properly. If they were, the two-tier workforce provisions (s52) would end this nonsense.

Data sharing and incompatible IT systems are another problem. There are too many local fixes rather than considering a single national solution. Interestingly, the report points to bringing staff together under one roof, rather than solely relying on IT. This is something that the Quality Care Commission recommended in 2015.

Many of the challenges facing care integration in Scotland can be fixed as local best practice shows. There are some national actions that can help, but there is nothing in this report that wasn’t predicted or points to unresolvable structural failure. The underlying problem is austerity - making big service change is doubly difficult when the budget simply isn’t keeping up with increased demand.

Commemorating the sacrifices of the First World War

This is a very special Armistice day, marking the centenary of the end of the First World War. It ends four years of anniversaries that commemorate the events of that terrible conflict.

There can be little doubt that we are more aware of the First World War as a consequence of the huge effort that has gone into events marking the centenary. Financial investment from the Lottery, Arts Council and governments have been supplemented by books, films, TV and radio programmes. But has that investment challenged some of the common myths, or done enough to recognise that the conflict didn’t just affect young white men on the western front? 

The Scottish Government’s Commemorations Programme has attempted to widen the subject with events covering the sinking of the SS Tuscania off Islay and the Quintinshill rail crash. A conference and exhibition celebrating the work of Dr. Elsie Inglis was an example of highlighting the role of women – the Serbian post office even produced commemorative stamps. However, despite these efforts, the abiding memory will be of Scots who died in the battles on the western front – important of course that those events were.

There has been an effort to acknowledge the role of the four million non-British soldiers that fought in the conflict – David Olusoga’s TV series and this week’s focus on the Indian Army are good examples. There has also been more about the home front and local histories. However, in the main, they have been drowned out - the western front, poppies and Tommies remain the most familiar iconography.

Other important fronts get very little coverage. I suspect very few people understand the role the Macedonian campaign played in ending the war, even though it involved two British Corps. With Serbian and French troops they advanced as far as Austria. Let alone the huge battles on the eastern front, Italy and the Middle East – and lesser-known campaigns in Africa and the Far East 

On many of these fronts, the war and its consequences didn’t end on Armistice Day. The crumbling of empires, the Russian Civil War and the related Polish-Soviet War went on until 1921. The Greek-Turkish War resulted in the ethnic cleansing of 1.6 million people. For many countries, November 1918 marks independence or the dismembering of their state. Hungary lost half its population and two-thirds of its territory. 

Many of these events have a bearing on the Europe we live in today. As Guardian columnist Natalie Nougayrede put it; 

“The point is not that a unified narrative should be imagined. Rather, it is that we would all gain from better awareness of the mosaic of European memories of 1918. The Europe we live in today still has its roots in that past.”

The same is true for the wider world. The British and French ended the war with even bigger empires in the Far East, Africa and the Middle East. These created the conditions for future conflicts and were certainly a poisoned chalice for Britain.

Our perspective of the First World War has changed over the years. In the 1920’s the monuments used the language of glory, honour, dominion and power. As the war poet, Wilfred Owen said: “The old lie: Dulce et decorum est; Pro patria mori”.

At the other end of the spectrum, I was brought up in the period of, ‘Oh What a Lovely War!’ and the ‘Lions led by donkeys’ view of WW1 generals. There have been some revisions of that view and lessons were learned as the war progressed and generals unlearned the lessons of the last war. The BBC ‘100 days to Victory’ series covers some of this.

The BBC History Magazine asked two historians of the conflict the question, Was it Worth It? 

As Professor Richard Evans says, it is not the job of historians to tell people in the past what they got wrong, but rather to explain how and why things happened. However, he reminds us that millions of British soldiers who fought in 1914 didn’t have the right to vote – so it wasn’t a war for democracy. He argues that it actually ended progress towards greater democracy in many countries and replaced it with brutal and corrupt dictatorships. Much of this was caused by the economic disaster that was another consequence of the war.

On the other hand, Professor Gary Sheffield argues that imperfect though the world undoubtedly was in 1919, it would have been much worse if there had been a German victory. Even if the Royal Navy kept Britain free from occupation, it would have faced the nightmare of a hostile continental Europe and the end of liberal democracies. 

Whatever view we take of the historical events, it remains the case that millions gave their lives in the conflict and afterward, for a cause that, at the time, most people supported. They made the ultimate sacrifice and it is right that we should remember them - red or white poppy, in the way we each deem to be appropriate.

Living Wage Week

This is Living Wage Week, another opportunity to promote the benefits of the real living wage and fair work more widely.

The week traditionally starts with the announcement of the new Living Wage rates, which this year have increased to £9 per hour and £10.55 in London. The Resolution Foundation has published a briefing on how the rate was calculated this year. Wider inflation was obviously a key factor in the increase. In addition, some policy changes act as a downward pressure on the rates, for instance, the increase in the personal tax allowance and additional childcare support. Other policy changes create upward pressure including the ongoing freeze in working-age benefits.

I was at the Living Wage Expo at the Tynecastle Stadium in Edinburgh yesterday. Peter Kelly from the Poverty Alliance reminded the audience of how much progress had been made with the Scottish Living Wage - £216m into workers pockets, 34,000 workers getting a pay rise and more than 1300 accredited employers. We should also remember that many other workers have benefitted outwith accredited employers, due to procurement and collective bargaining.

It was good to see a public sector employer (even if they try to hide the fact!), Scottish Water Business Stream, getting the employee choice award. The nomination included a positive statement from a worker who explained what fair wages meant to them and how it changed their perception of the employer. 

This theme continued with a panel discussion involving Heart of Midlothian FC staff. They all described how the living wage meant they could afford what most of us regard as essentials, like holidays, transport etc. One young worker in the hospitality department highlighted the difference between £5.90 on the age-related minimum wage and £9 on the real living wage. The motivation of these workers was very apparent. Well done Hearts - time for other football clubs to follow!

The Minister for Business, Fair Work and Skills, Jamie Hepburn MSP set out the Scottish Government's aim of making Scotland a Fair Work nation. He rightly made the point that more equal societies do better on all tests, not just economically. He accepted that Scotland could do more as there are still one in five employees who are not yet receiving the living wage. I would point him to procurement, where policy has not always been matched by best practice.

The Outstanding Leadership Award went to Standard Life Aberdeen, who I would agree have been real private sector champions, not just with the living wage. They make the business case for the living wage, and in their sector, the wider benefits of trust and how it is a good measurement of company behaviour.

The living wage isn't just about big employers. One of the real successes of the living wage movement in Scotland has been the engagement from hundreds of small companies. Sarah Roberts from Healthy Nibbles is a good example of such a company and she set out the benefits for her firm and their workers. Importantly she emphasised the wider fair work agenda of her business. Other SMEs that have become accredited employers this year and were recognised in the awards as well.

As women are disproportionately represented in low pay workplaces, the living wage is also important in closing Scotland's gender pay gap. Anna Ritchie from Close the Gap pointed to the similarities in the business case for tackling the gender pay gap and the living wage.

Tess Lanning from the Living Wage Foundation reminded us that the living wage campaign started as a community campaign. This is something the campaign in Scotland is seeking to build on with the living wage place initiative. Including outsourced workers has also been important to the campaign, which has encouraged innovation in the workplace and extended the living wage beyond the core workforce. A good example is South Lanarkshire Council, who won the anchor institution award. They have increased the percentage of the workforce across the council area who are paid the living wage using the levers available to every local authority. I would also highlight North Ayrshire Council who were quick off the mark to commit to paying the new rate this week.

Dave Moxham from the STUC made the point that voluntary initiatives like the living wage are important in delivering real benefits to workers and promoting a different economic model. It supports the campaign for a higher statutory minimum wage and abolishing the age-related rates. Richard Leonard reiterated Scottish Labour’s commitment to a £10 per hour minimum wage this week.

Finally, I was very honoured to receive the Lifetime Achievement Award. It does seem like a lifetime since we kicked off the living wage campaign in Scotland, but actually, a lot has been achieved in a short time. Like others, I have burnt out a few PowerPoint projector bulbs pitching the case, but my role has often been to tear down fallacious legal barriers and find ways around EU and other procurement rules. There is still a lot to do, but the campaign is in good hands.

Let's make this the last major anniversary of rail privatisation

This week marks the 25^th anniversary of the legislation that privatised British Rail into a complex series of franchise arrangements. 

This is not an anniversary to celebrate. As Aslef’s Scottish Organiser Kevin Lindsay said; 

“Today is the 25th Anniversary of the great railway rip off, when John Majors Tory government rushed through the unnecessary, unwanted and plainly unworkable rail privatisation. It’s time for the UK and Scottish governments to take action and to return the railway to public ownership.”

Sadly, neither government appears to be heeding that call, which is supported by the other rail unions. A call that comes from the people who represent the workers who really understand the railway. The editorial in this month’s ‘Modern Railways’ paraphrases the Joni Mitchell song to say that the government has:

Looked at the railways from both sides now

From win and lose and still somehow

It’s life’s illusions they recall

They really don’t know railways at all.

The Scottish Government has the power to end this franchise early by using the break clause in 2020 which would see the franchise end in 2022. However, in a recent letter to the public sector bid stakeholder reference group, Transport Secretary Michael Matheson said he “fully expects the current franchise to continue to its planned expiry date of 2025”. 

The UK Government has commissioned the Williams Review - the Transport Secretary’s response to the fiasco of the May timetable changes. As the interim Glaister report concluded, ‘Nobody took charge’ – a clear recognition of the damage fragmentation has caused. The review will look at the ‘most appropriate organisational and commercial framework for the sector’.  

The timetable for the review is as slow as our privatised railway – steam trains were quicker on some routes! (an excellent solution in my personal view 😊  – with CCS of course!). A white paper next autumn and an unlikely implementation ‘from 2020’, which points to a few cosmetic changes. There have been 30 such railway reviews since 2007. 

So how are our railways doing?

There was a small 3% increase in freight traffic last quarter, but that was mostly down to an increase in coal traffic caused by a spike in gas prices. Hardly a sustainable future for freight. Some innovative work is being done on promoting rail for log transport in Scotland and sidings for timber boards and mineral water, but overall there are few signs of a significant shift to rail freight. For example, the lack of long crossover loops on the Inverness line makes rail 30% less efficient than it should be. We should remember that rail generates around 30% of C02 emissions of road haulage per equivalent journey, nearly 90% less small particulate matter (PM10) and up to fifteen times less nitrogen oxide (NOx). 

Passenger demand for rail remains strong. 23.9m journeys were made on ScotRail in the last reported quarter, up 1.5%. Passenger journeys increased 3.1% nationally last quarter, despite the timetable issues, possibly driven by a 15% increase in the price of car fuel.

Scotrail’s poor performance is rarely out of the news with punctuality reaching breach level for the last two reporting periods and significant fines. Their management of rolling stock has been equally shambolic, with the new Hitachi trains delivered 10 months late and their new refurbished High Speed Trains expected to be introduced without Controlled Emissions Tanks, meaning effluence will be discharged directly on to the tracks. While services have plummeted, fares have spiralled. As of next year, commuters will be paying 10% more for their ticket than they did at the start of the franchise. 

In parts of the industry, Scotland’s attempts at integrating trains and track through the ScotRail Alliance is seen as a move in the right direction, if not quite a template. However, all is not well at senior levels as reported in today’s Scotsman. They report one industry source saying: “There is a lot of discomfort about how much control of the railway has been handed to the train operator [ScotRail].”

It does at least highlight one of the benefits of devolution and the Scottish Government is calling for the devolution of Network Rail. There is certainly a case for that, although integration requires more than just trains and track and this focus on powers avoids the bigger issues.

Which leaves us with the question of ownership. 

Many industry figures argue that only when you have created a working railway network should you consider ownership. I don’t dispute the importance of structure, but the idea that this can be done without addressing ownership and accountability is fanciful. We have the ludicrous situation where the majority of our railways are in foreign state ownership, sending profits back to support their domestic rail operations. We should also recognise the impact the short-term profit motive has on the management of any service. Management culture and accountability is an important issue that the ‘structure before ownership’ lobby ignores.

The TSSA/Common Weal report is a useful starting point for a debate on the merits and methodology of creating a publicly run railway in Scotland. There are some legislative barriers that could be circumvented to avoid a franchise bidding process, although that would be complex and legally challenging. Labour’s commitment to bringing railways into public ownership across the UK, provides the best platform to take this forward and that should include a discussion about further devolution. A policy that the polls show has widespread public support.

And then, inevitably, there is Brexit. Current EU rules would not allow a future Labour government to reinstate a national rail monopoly. The EU Commission’s Fourth Railway Package would astonishingly foist the UK model on the rest of the EU. There are also problems with EU Single Market rules on procurement and State Aid, which Mick Whelan of Aslef has outlined in the Scotsman and Scottish Left Review. 

Others argue that there are ways of introducing greater public ownership within EU rules as is done in Spain, Netherlands, Germany and Italy – using separate state-owned companies. Although even this retains the market framework. 

While more work is needed on the detailed structure and Brexit implications, the direction of travel towards an integrated railway under public ownership should be clear. Mick Whelan sums up the case this anniversary week when he said; 

“Privatisation has, demonstrably, failed to deliver. Fares have soared, rolling stock got older, and our trains are more crowded. Private companies talk about investment and risk. But there is no private investment – the money for investment comes from the taxpayer – and there is no risk because the companies hand back the keys when they can’t make the profits they want.”