NHS Reform: It’s Social Care Stupid!

 The current NHS crisis has spawned a flurry of proposed reforms to the National Health Service. They range from privatisation to the use of volunteers. However, most miss the point. The underlying problem facing the NHS across the UK is the failure to invest in social care.

The most obvious symptom of the NHS crisis is Accident and Emergency (A&E). Less than 68% of people were assessed, treated, admitted or discharged within the Scottish Government’s four-hour A&E target. More than 6,800 people spent more than 12 hours in A&E in October. While there is much in the Scottish Futures report to agree with, including patient-centred care, more volunteers doesn’t hack it. While the different NHS systems in the UK should cooperate, their emphasis on this is more political than practical. NHS Scotland is big enough to operate mainly on its own. More UK bureaucracy won't help.

The latest NHS Scotland delayed discharge statistics illustrate the need to focus on social care. A delayed discharge occurs when a hospital patient who is clinically ready for discharge from inpatient hospital care continues to occupy a hospital bed beyond the date they are ready for discharge. In October 2022, the average number of beds occupied per day due to delayed discharges was 1,898, the highest figure since the current guidance came into place in July 2016. To put this number in context, the Queen Elizabeth University Hospital in Glasgow has 1677 beds. So, delayed discharge is the equivalent of our largest hospital and then some. The chart below shows this is not a short-term blip.

There is also a human cost. In October 2022, there were 58,826 days spent in hospitals by people whose discharge was delayed. This is an increase of 17% compared with the number of delayed days in October 2021. No one wants to, or should, stay in a hospital any longer than they need to. This is on top of the financial cost, as hospital beds cost far more than social care provision.

The latest care inspectorate statistics showed that 60% of care services that employ nurses reported vacancies, creating a 16% vacancy rate. The staffing issues are not limited to social care. NHS district nurses play a crucial role in supporting people to return home from hospital. The vacancy rate for district nursing reached 16% last month. The Westminster Adult Social Committee has highlighted similar concerns in England.

The idea that more privatisation is the solution is risible. As Prem Sikka recently highlighted, social care companies are robbing the public purse, with profit margins of between 37% and 41.7%, and tax dodging is rife. This is the model that people like Karol Sikora want to expand! In addition, self-funding care home residents are now paying 40% more than publicly-funded residents, compared with 24% a decade ago.  

Sadly, the proposed National Care Service in Scotland will do nothing to challenge this, taking even more services from the public sector. Moreover, as the Scottish Parliament Finance Committee report highlighted, the costings of this over-centralised service are largely unknown. Still, we do know that it will divert much-needed resources from frontline services. Creating a National Care Service remains the right approach. However, its role should be to create a national framework, with services designed and delivered locally. Implementing organisational change of this magnitude will take a significant amount of time. In the meantime, we need to support the demoralised, tired, and financially stretched frontline staff who immediately need a break, decent pay and a vote of confidence. 

There has been a welcome initiative from former health ministers Alex Neil and Malcolm Chisholm to end zero-hours contracts. However, the response from Social Care Minister Kevin Stewart that companies bidding for government work are evaluated on their fair working practices "where it is relevant and proportionate to do so" - is not good enough.

Patients overwhelmingly access the NHS through GP services. However, patient surveys show this is becoming increasingly difficult despite GPs delivering more appointments (not all in person) than before the pandemic. Patient satisfaction is 12% down in the last year, with 10% saying it had become more difficult even to contact their GP practice. Some of the byzantine appointment systems don't help and put excessive pressure on reception staff, who take the brunt of patient dissatisfaction. 

This is primarily an issue for non-urgent treatment; charging better-off patients won’t help address this. While it may discourage some appointments, this short-term gain will result in long-term pain as conditions go undiagnosed, resulting in more severe conditions for the NHS to treat. The solution is recruiting more GPs and other health staff in primary care. GP numbers have fallen from 3,613 in 2019 to 3,494 in 2022. Scottish Government targets focus on headcount, which ignores the growing number of part-time staff. A BMA Scotland survey indicated that 75% are more likely to quit or reduce hours in the coming year due to ‘excessive workload’. Five years on, the deployment of multi-disciplinary teams has fallen short because of staffing shortages. 

Moving away from the expensive small-business model would also help in the longer term. Many more GPs, particularly younger staff, are coming to this view. For example, GPs at the Lothian LMC have recently said that the independent contractor model ‘is no longer fit for purpose.’

The NHS as an institution rightly attracts almost universal support, primarily because we all rely on it. That doesn't mean it is sacrosanct, and it is perfectly reasonable to debate reform. However, we must be wary of those who use reform as a trojan horse to promote their ideological agenda. The founding principles of an NHS free at the point of need, funded by general taxation, is the best way to organise healthcare. The NHS's main problem is the absence of adequately funded social care and primary care. That should be our focus right now. Anything else is a distraction.

Rebalancing the UK

 Big-picture reform may not be on everyone's list of priorities, but governments should be able to tackle big long-term projects while also addressing the immediate issues. Unfortunately, the short-termism of so many politicians has undermined the UK for far too long. In this context, we now have the long-awaited report of Gordon Brown's Commission on the UK's Future. 

The report starts with a persuasive case for change. The country was in crisis long before the pandemic and the economic consequences of Russia’s invasion of Ukraine. There are always excuses for not tackling the big issues, and successive governments have ducked them. Yes, we have an incompetent and ideologically driven government that has failed to deliver acceptable levels of investment, economic success and good-paying jobs. But, as the report says, the way our country is run is preventing us from making the changes we need for a better future.

Few could argue with the analysis in the paper of the challenges. These include the scourge of inequality, loss of trust in politics, and centralisation. Britain hasn’t taken back control as promised with Brexit – Westminster and Whitehall have. The same is true in Scotland by the Scottish Government. While there have been global factors, the UK has handled them less well, as this chart shows:

And while economic growth is not all we should be concerned about, at least on current definitions, our relative position has crashed.

This is particularly the case for workers. Pay and living standards for most people in Britain have not improved, and taxes have risen to pay for worse public services, making this a lost decade for British families. 

There are some broad solutions proposed to address these issues. Unsurprisingly, there is an emphasis on shared UK purpose and values while recognising that people in the nations of the UK feel morally and politically abandoned by the present UK government. So, the report argues that powers must be decentralised to the right place - in the nations, regions and communities. While there is more detail about local government in England, because this is devolved, many of the reforms proposed would also be welcomed in Scotland as an antidote to SNP centralisation. They reflect the arguments I made in a Reid Foundation paper a few years ago. My only exception is the obsession with directly elected Mayors. There is nothing democratic about centralising power in the hands of one person.

There are reforms proposed for Westminster, cleaning up the corruption that undermines trust in politics and Britain’s voice in the world. A long overdue plan to replace the House of Lords with a new second chamber of Parliament: an Assembly of the Nations and Regions. We should ignore the Lords who oppose this on spurious grounds, acting like Turkeys who don’t want to vote for Christmas. 

On Scottish devolution, the focus is on embedding the constitutional settlement, strengthening the Sewel Convention and introducing mechanisms to improve cooperation across the UK. While devolving powers is not the only way to enhance devolution, the principle of subsidiarity demands that powers be devolved to the lowest practical level. It is here that the report is weakest. Gordon's Treasury orthodoxy screams out of the pages, with the resistance to prudential borrowing powers that apply to local authorities but not the devolved administrations. New taxes can only be introduced by agreement with the UK government, which jars with the principles the paper claims to espouse. Today's STUC paper is much better on public finance issues.

On specific powers, devolving job centres is fine, but employment law is only to be shared. And what about drug policy and immigration? The Red Paper Collective has set out the case for devolving these powers clearly. Of course, all these should be exercised in cooperation when they can have implications for the rest of the UK. But the starting point is to recognise that not all parts of the UK have similar problems or require the same solutions. 

This report does offer a new approach that should appeal to the 40% of those living in Scotland who are not entrenched in either side of the national obsession. However, it could have been bolder in key areas, which also fall some way short of Scottish Labour’s policy positions on further devolution. Electoral reform is another issue that has been ducked, despite the recent UK conference decision.

Overall, we should thank Gordon Brown for embarking on this process because it takes someone of his stature to ensure this debate gets a hearing. While the report has weaknesses, the proposals would at least help rebalance the UK politically and economically.

From the national to the local

Yesterday, I was speaking at the book launch of 'A New Scotland: Building an Equal, Fair and Sustainable Society'. I have previously written about the themes in the book, which I picked up in my Afterword. These go beyond traditional economic thinking to include inequality, public services, and economic and political governance. While there is plenty of challenging analysis, there is also optimism that a better Scotland is possible.

My substantive contribution to the book was on local economics. There is plenty of commentary on macroeconomic policy in Scotland, not least within the confines of our interminable constitutional debate. However, there is far less analysis of how our over-centralised political and economic governance undermines the local economy. 

One of the issues I cover is the importance of ownership. This is a crucial issue with Community Wealth Building because local ownership is less likely to bolt when the cold economic winds blow. This week the Herald, in conjunction with The Ferret, ran a timely series of articles on ownership in Scotland. 

Their research looked at 23 major shopping centres in Glasgow, Edinburgh, Dundee, Aberdeen, Inverness, Perth, Stirling and Dunfermline, excluding retail parks. They found 18 involved ownership structures that made some use of companies registered to tax havens. In other words, more than three out of four of Scotland's largest city shopping centres are owned in or linked to tax havens. Tax dodging deprives governments of tax revenues, increases inequalities and undermines smaller and domestic businesses. As Paul Sweeney MSP said, “The levels of influence held by these multinational organisations is as unsustainable as it is unbelievable. For years, city centres and high streets have been left chasing their tails because large shopping centres have had carte-blanche to reconfigure the very fabric of our major cities.”

This isn’t just an issue for the retail sector. While the majority of cultural assets in Scotland’s cities remain in the hands of local councils and charities, others are not. These include venues such as the Edinburgh Playhouse, King Tut’s Wah Wah Hut, and Glasgow’s King’s Theatre, owned by global companies with links to offshore tax havens. In addition, cinemas and theatres are at risk of being taken over by tax haven-linked private equity companies.

The research also found that Scotland’s three largest airports and some major sea ports are linked to offshore entities and that a firm building Scotland’s digital infrastructure is ultimately owned by a private equity fund. One of the firms building broadband services across Scotland is backed by a state-owned Emirati company, which invested in an Israeli firm behind controversial spyware called Pegasus. The spyware is alleged to have been deployed by foreign governments against dissidents, journalists, diplomats and members of the clergy.

The Scottish Government has a welcome commitment to a 'wellbeing economy' and supports, in principle, Community Wealth Building. However, if this is to be more than just another glossy document full of ambition, it must be backed up by action. As IPPR Scotland puts it, “The Scottish Government has a stated ambition to create a ‘wellbeing economy’, built on inclusive growth and community wealth building. That needs to see wealth not just being created in our local economies but retained there, too.”

In the book, I highlight the local initiatives that could help to regenerate our town centres and High Streets. These include creating spaces for small businesses and cooperatives and 20-minute neighbourhoods that promote a circular economy. And most importantly, investing in the social infrastructure, like libraries and leisure facilities, which binds our communities together. All of these actions can be delivered under devolved powers. A better Scotland recognises that not all the solutions to our challenges can be dictated from the centre. They must be developed and organised from communities of interest and place because ownership matters.

Action on health inequalities

As the UK and Scottish Governments start the process towards another round of Austerity, we need to remember the impact this will have on health inequalities. Those in Scotland’s most deprived areas are 3.9 times more likely to die from an avoidable death than those in the least deprived areas. The leading causes of avoidable deaths were cancers, circulatory system diseases and alcohol and drug-related issues, and Covid-19. In addition, life expectancy in Scotland has been two years lower than in other UK countries for decades.

Mortality rates in higher-income countries have steadily improved for more than a century. However, these improvements started to stall after the last round of Austerity in 2012, actually increasing in the most deprived areas. In 2019, the UK ranked 24th in the OECD in life expectancy, behind all other English-speaking countries (except the US) and nearly all countries of Western Europe.

These trends were noticeable before the pandemic, which has exacerbated them, but there has been no return to pre-pandemic levels. As a GCPH/University of Glasgow report highlighted, ‘there has been a stalling of improvement overall, accompanied by increasing death rates among large sections of the population living in more socioeconomically deprived areas. This is hugely worrying. Put simply, we should not see such trends in a wealthy society such as the UK.’ Austerity is evidenced as making an important and substantial contribution to these trends.

While drug-related deaths, in Scotland in particular, are an important factor, they are not the sole or majority contributor to stalled mortality trends. Changes in rates can be observed even when drug-related deaths are excluded, and the increase in drug-related deaths is likely to have been partly caused by the same underlying factors associated with the overall mortality changes.

An independent review by the Health Foundation found large and sometimes widening health inequalities among children living in Scotland’s most and least deprived communities. They found that by 2016-18, infant mortality was 2.6 times higher for babies born to women in the most deprived areas compared to those of the least deprived, compared to a difference of 1.8 times in 2000-02. A key issue is obesity, which by 2019/20, was around 6% among the least deprived five-year-olds compared to roughly 13% in the most deprived. In 2001/2 there was no gap. This will not be resolved simply by targeting behaviours because there is no difference in physical activity by deprivation. There are differences in diet, and a healthy balanced diet is considerably more expensive calorie for calorie and therefore increasingly inaccessible to those on the lowest incomes.

Child poverty has long-term implications. People who experience deprivation as children are more likely to choose to do things that, although pleasurable in the short term, are unhealthy in the long run. This includes overeating, taking drugs, smoking cigarettes and gambling. This can help to explain why some people go on to become addicts while other people can avoid some of the more harmful effects of drugs and alcohol.

Politicians are failing to address the underlying causes of inequality. In Scotland, we have plenty of analysis but limited action. Audit Scotland recently reported that ‘the Scottish Government has not yet demonstrated a clear shift to preventing child poverty.’ Others, like Suella Braverman, seek to cover it up by focusing on immigration. Public anger at a lack of affordable housing and secure work, declining living standards and austerity has been redirected at the caricatured foreigner. Instead, we should be focusing on the economy and public services with actions such as those suggested in the GCPH report, including:

• Changing the economic structures that lead to immense wealth and income inequalities.

• Increase all benefits and tax credits in line with inflation every year, and put in place a one-off increase now to compensate for the loss of real income since 2010. Using devolved fiscal powers to top up reserved benefits and reverse UK cuts. Create new devolved benefits and increase existing benefits to support those in low-income households.

• Improve the availability of ‘good work’ by increasing in-work benefits, strengthening trade unions, minimising health and safety risks and increasing the statutory living wage to the Real Living Wage.

• Address tax evasion and avoidance and increase taxation of wealth, assets and corporate profits.

• Increase public sector funding for preventative services, and reinstate cuts in public services, particularly local government.

• Eliminate fuel poverty through action on housing insulation and heating and grow a social rented housing sector that is accessible, affordable and provides secure tenancies.

More than ten years ago, the visionary Christie Commission highlighted the impact of inequalities on the economy and our public services. They recommended more collaborative working, preventative spending, and building services around people and communities. Sadly, we see greater centralisation, silo working and little preventative spending. So, it was good to see the recent report of the Scottish Parliament’s Health Committee on health inequalities reference the report. What we now need is some focus on delivering its recommendations. Tackling health inequalities should be the priority of all governments.

 

I have always imagined that paradise will be a kind of library

 This is one of my favourite quotes about libraries, written by the Argentinian writer Jorge Luis Borges. It seems particularly appropriate during Libraries Week. Coincidentally, I contributed to a pan-European study this week on libraries, highlighting some of the challenges facing the public library service in Scotland and the UK.

I am very fortunate to own several thousand books in what I call my library and a frequent target for my wife's decluttering initiatives! However, it isn't a library. It is a collection of books, even if they are carefully organised and entered into a database. A public library is much more than a collection of books, more than a service; it is an integral part of the community. What I called in my Reid Foundation paper, Building Stronger Communities, social infrastructure.

Despite my 'significant' collection of books, I am a member of the British Library, the National Library of Scotland, the Mitchell Library in Glasgow, and arguably most importantly, my local library. I am not keen on the saying 'use it or lose it', although I understand the importance of demonstrating community support for public services. I always have a book on loan because even in my small local library, I can find a book that I wouldn't have bought, which stretches my thinking into new fields.

Under the Public Libraries Consolidation (Scotland) Act, as amended in schedule 21 of the Local Government (Scotland) Act 1973, local authorities in Scotland have a statutory duty to provide "adequate library facilities" for all residents in their area. The problem is that 'adequate' is not defined. I recall seeking counsel's opinion on a possible legal challenge some years ago, only to be told that the test could probably be met by one public library in the local authority area. There are some local acts on libraries, but they are no more substantial. Several local authorities have also outsourced their libraries to culture trusts, further blurring the statutory duty.

Like other local government services, libraries are under financial pressure. 83 public libraries have closed in Scotland since 2009/10, with spending cut by 30 per cent over the same period. This is despite yearly visitor numbers increasing by over 40 per cent. Many more libraries have cut their opening hours and reduced staff. Around 20% (700+) of all public libraries in the UK have no professional staff. They are spun as 'volunteer led', a euphemism for blackmailing communities into running libraries under the threat of closure. 

There has been a welcome move towards abolishing library book fines, although the data is limited. Glasgow Life has recently done this, arguing that it reflects a growing global movement to abolish late book fines, recognised as a barrier to participation, particularly for families from low-income households. A progressive move after they controversially closed several libraries, later reopened after great community campaigns.

The importance of professional staff is reflected in the wide range of services and activities in our libraries. It also provides an objective voice in selecting books and other resources. I am sure there would be no shortage of well-meaning middle-class people in my town who would be prepared to help run the library. However, they would have little idea of the wider community's needs. This is becoming a genuine concern in the USA as books are banned because some ideologue doesn't like the content. My experience as a UNISON official was that librarians made fearsome negotiators, always well prepared. A skill that even Donald Trump is discovering as he faces legal action for keeping files from US government librarians. I am also in awe of the work being done by "Crazy Ukrainian librarians" in the most difficult of circumstances.

The broader value of public libraries as a community resource is being recognised in the concept of 'warm banks' in response to the energy crisis. Librarians have always recognised this well before the current crisis. The consumer champion Martin Lewis has commissioned a best practice guide on this. A recent survey showed that 60% are actively considering participating in a "warm bank" scheme, offering heat and shelter to vulnerable people, as another way to help during the cost of living crisis.

In England, Baroness Elizabeth Sanderson has been appointed by the UK Government to help develop a new strategy to ensure public libraries provide the best possible service for their communities. There have been some understandably cynical responses to this initiative, but we will see. Almost one in five (18.6%) children in England between the ages of five and eight do not have access to books at home. Authors and publishers have urged the new prime minister to abolish "the last remaining tax on reading", and ensure schools have funding for author visits and invest in libraries.

So, please use Libraries Week to show your support for a vital public service. And challenge your elected representatives to strengthen the statutory duty, employ more library staff, invest in resources and keep our libraries open.

Governing With Purpose - a guide for charity trustees

 As someone who works with and serves on several third-sector boards, I have sometimes wondered why anyone does this. External criticism and internal squabbling are not unknown, and thanks are not always forthcoming. Moreover, when personal time has rarely been so squeezed, it isn't easy to get people to volunteer for this role, even if around a million people in the UK have risen to the challenge. Larger charities provide training when you become a trustee, but it can be limited for smaller ones, leaving the new trustee slightly overwhelmed.

In this context, a new book about governance in the charity sector should be welcomed. Brian Cavanagh, who has extensive experience in the public and third sectors, has written Governing with Purpose: How to lead a brilliant board – a guide for charity trustees. This is not a subject exactly brimming with previous publications. There are plenty of corporate governance books, but few focus on the charity sector.

Like Brian, I have seen examples of good governance and, sadly, some pretty poor ones. Charities have collapsed due to poor governance, and others grind on with little regard for their founding purpose. As many charities have become providers of services paid by the state, they sometimes lose their cutting edge as advocates for change, believing that they must acquiesce to government policy. It is not unheard of for a charity Chair or CEO to get a phone call from a Scottish Government minister after public criticism. As Jenny Starling said in an Open Democracy piece yesterday, 'Too fixated on doing ‘good’ and being polite, charities have stopped fighting for social justice.’

The book starts with first principles. What is good governance, and why it matters. Focusing on the big picture, vision, values and strategy rather than the minutiae of day-to-day operations. I have mentored a few senior staff in charities from other sectors, who have been surprised at the level of detail board members wanted to engage in. On the other hand, I have seen boards that nod through whatever is presented to them. Brian uses the concept of governing with purpose to suggest a different approach. He promotes the idea of governance as leadership, graphically portraying the interconnectedness as the governance square. 

This isn't just a theoretical concept. He goes on to give practical examples of how to develop good governance. The regulatory framework is not forgotten either. Something that could be stronger in Scotland. The chapter on strategy versus scrutiny is also helpful.

There are chapters on the roles of the Chair and CEO and the importance of the relationship between them. Again, in my experience, that can range between acquiescence and micro-management. I recently supported one charity when the Chair said, 'I could do her job better.' She might well have, but that was missing the point. This book has some good advice for both parties in this relationship and practical tips on how to Chair a meeting and related duties. Getting the board to focus on the 'why' of the charity is good advice.

The final section of the book is entitled ‘Re-imagining purpose’. As Brian puts it, ‘It includes bringing energy and dynamism to drive the charity forward. It is also about ensuring the ethos and purpose are not just words, but are put into practice, across the board and the rest of the charity.’ This includes stating uncomfortable truths, particularly when there needs to be alignment between what the organisation says it stands for and how it puts that into practice. The strength of trustees is that they can bring a diverse range of lived experience and expertise to the role. The final chapter in this section highlights the importance of recruitment, succession planning and board renewal. We can probably all think of the board member, or Chair, who has been there too long and recruits more people like them.

I found very little in this book that I disagreed with, and I tried! You might find some concepts a bit theoretical, but they are backed up with practical examples. Hopefully, it will spur some focus on governance in these difficult times for the sector. Unfortunately, I noticed the Scottish Government-backed 'Good Governance Award' had attracted very few takers.

For all the sage advice in this book, we should remember that being a trustee on a board should also be an enjoyable and rewarding experience. This book should help you achieve that goal and do some good on the way.

Tackling drug deaths - Scotland's national disgrace

Scotland's drug-related death statistics are a national disgrace. In 2021, 1,330 people in Scotland died due to a drug overdose. That was more than three times the rate of the rest of the UK and the highest in Europe. As the chart below shows, this isn't a new problem.

This month I was looking at drugs policy when drafting a response to Paul Sweeney MSP's proposal for a Drug Death Prevention Bill. This will enable the establishment of overdose prevention centres, including establishing a licensing framework for centres to prevent death due to drug overdose; and create a new body for the oversight of drug policy development and implementation to improve health by preventing and reducing drug use, harm and related death. He argues that preventable death due to drug overdose has become one of Scotland's major public health emergencies. Urgent practical action is required to address this health crisis, and this Bill is intended to be part of the solution, one contribution to a multi-faceted effort to tackle the problem.

Drug use is inextricably linked to poverty; it is not simply a 'lifestyle choice'. People living in the most deprived communities in Scotland are around 18 times more likely to experience problem drug use compared to people in the least deprived communities. As the Poverty Alliance argues, "That means redesigning our economy so that people are able to access decent work, and investing in our social security system and public services, so that people have the income they need to live in dignity and security."

The Scottish Drugs Death Taskforce has called for more resources to be spent fighting Scotland's drug-related deaths problem after calling current resource levels "woefully inadequate". Their report (21 July 2022) outlines ten key principles and 20 recommendations underpinned by 139 actions. These call for greater funding, efforts to tackle the stigma of drug addiction, and a higher degree of responsibility for drug-related deaths in both health boards and Scottish and UK governments. The report states, "The First Minister has publicly recognised that her government 'took their eye off the ball'. The question now is whether the government will provide targeted funding to enable services to deliver transformational change – not a return to the funding of the past, but an ambitious and radical commitment to making people's lives better."

While there is a case to review the UK Misuse of Drugs Act and for devolving the legislation, we must focus on what we can do in Scotland using devolved powers. As the former head of Scotland's drug deaths taskforce (Professor Catriona Morrison) has said, Scottish Government ministers should stop blaming Westminster legislation for the high number of people dying through drug misuse and focus on what can be done to address the problem. 

Scottish Government cuts in funding for Alcohol and Drug Partnerships in 2015 resulted from the pervasive stigma and the demonisation of people with a drug problem. Cutting  £15 million of funding for the most marginalised and vulnerable people in Scotland is a classic example of ignoring the benefits of preventative spending as recommended by the Christie Commission. Scotland's drug strategy should focus first on keeping people alive, but we also need to help not just to stabilise their drug use but get help with the wider aspects of people's lives.

Paul Sweeney's Bill is not a 'magic solution' but could help as part of a range of measures. Drug consumption facilities have been introduced in at least 14 countries across more than 130 sites. They provide a safe environment for the most vulnerable to use drugs under the supervision of trained professionals. A study in The Lancet shows fatal overdoses decreased in areas where overdose prevention centres were introduced alongside other beneficial outcomes, including reductions in self-reported high-risk injecting practices and increased engagement with drug treatment services. They may also help reduce drug use in public places.

This Bill will provide a necessary focus on the drug crisis that has sadly been missing in recent years. It also focuses on what we can do now, in Scotland, to address these issues - always recognising that the drugs crisis is part of wider inequalities in Scotland that also need to be tackled.

Lessons learned from the pandemic for social care

I was in Stockholm this week speaking at a workshop looking at Europe-wide experiences of the pandemic on social care. The On the corona frontline – Lessons learned, promises broken? event was hosted by Kommunal (UNISON’s sister union), Arena idé and the Friedrich Ebert Stiftung. It was a follow-up to the paper they published last year, and I wrote the Scotland paper in the series.

As the BBC reported just this week, increased demand and staff shortages mean at-home and care home services across Scotland are overstretched. But unfortunately, the pandemic isn't over, and social care challenges haven't gone away. This was reflected in all the presentations from across Europe at the workshop.

This was the case for our hosts in Sweden, which pre-pandemic had an undervalued, high turnover workforce and health and care that is not integrated. There is a mixed economy of care, although much less private sector involvement than in Scotland - there are 290 councils in Sweden! Their COVID-19 Inquiry has already reported and highlighted structural shortcomings in residential care, including staff training, sick pay (80% of salary after the first day), and precarious employment. However, in terms of action, it is business as usual, although they are hopeful of new legislation soon.

In Norway, social and primary health care is a local government responsibility, and only 10% of providers are in the private or charity sector. Moves to rationalise the numbers of councils (over 400) have been halted. They generally have good conditions, including full sick pay for one year, thanks to strict employment legislation and a strong union movement. However, they have skill shortages and had similar pandemic issues as us over infection control, PPE and testing. Overall, they appear to have managed the pandemic better than most.

My colleague in England described similar issues to Scotland, with all the previous challenges exacerbated by the pandemic. Staff shortages are getting worse and not helped by Brexit, with increased use of expensive agency staff. A significant increase in unpaid carers has taken more workers out of the economy.

Spain has a decentralised care system to the regional level and a mixed economy of care, with 70% of care homes in the private sector. As in Scotland, the pandemic hit bigger care homes harder, and the lack of official data makes analysis difficult. A Dependency Shock Plan has been agreed upon with the government and the unions to reform the long-term care system, including accreditation of residential homes, raising workforce standards, more funding and integration of health and care. However, structural implementation has been slow, while some workforce changes like reducing precarious work have made progress.

Portugal's system is similar to Spain's, with similar data issues. There is considerable reliance on families who get little financial or other support. When the family 'fails', institutions (often the church and charities) may step in, although state support meets less than 40% of residential costs. This has led to a growth in unlicensed nursing homes, which are often small (less than 20 beds) due to regulation thresholds. Their demographic challenges are even worse than Scotland's, leading to skill shortages. There is minimal social care and health integration and little unionisation, leaving most workers at minimum wage levels.

In Germany, the private insurance system couldn’t cope with the costs of the pandemic, so the government stepped in. There is now a debate around how the system should change with less privatisation. Residential care costs are doubling, partly because wages have increased by a third – raising the legal collective agreement in long-term care, with better leave and other conditions. However, church institutions (major care providers) are exempt from collective agreement laws. Mandatory staffing levels are increasing while the workforce is ageing, with 500,000 retiring in the next ten years.  

My presentation reflected the Scotland paper I wrote last year. I explained how social care is funded and organised in Scotland, focusing on the workforce and employment standards. I emphasised that Scotland faced significant challenges in delivering social care before the pandemic. Not least an ageing population, budget cuts and limited workforce planning. The pandemic highlighted these challenges and created some new ones. The transfer of untested patients from hospitals to care homes resulted in half the first wave of deaths being in care homes. Home care packages were abandoned or reduced, causing further excess deaths. For the workforce, there was poor PPE, and they were not routinely tested for four months. 

I outlined how trade unions had responded to the organising challenges with greater use of social media. Important campaigns on paying the Scottish Living Wage, sick pay, death benefits, COVID tests, better PPE and access to the vaccine demonstrated the importance of trade unions to the workforce. At this stage of the pandemic, it is essential that these lessons are incorporated, along with tackling the workforce shortages. Finally, I explained the proposed reforms to social care around a National Care Service, although delivery is still some way off. Therefore, there is a need to focus on a new workforce strategy, funding recovery plans and strengthening communities being undermined by council cuts. 

The Scottish COVID-19 Inquiry needs to examine the lack of preparedness and why the lessons learned from pre-pandemic exercises were not fully implemented. It also needs to consider the broader structural and systemic issues in relation to patterns of disadvantage and inequality as well as care system capacity and capability. The research papers prepared for the Scottish COVID-19 Inquiry are worth a read. 

A paper is being prepared after this event and that should contribute to that Inquiry. The pandemic highlighted similar issues across Europe. Poor preparedness, inadequate funding, and an undervalued workforce existed before the pandemic. The pandemic highlighted these issues and made them worse. We need to learn the lessons and take urgent action.

A New Scotland

In the book, A New Scotland, leading activists and academics lay out the blueprints for radical reform, showing how society can be transformed by embedding values of democracy, social justice and environmental sustainability into a coherent set of policy ideas.

This is not a conventional book on economic policy. The first theme that struck me is the breadth of the factors that make up the nation's wealth. When I first studied economics, we were taught a range of formulas that calculated everything from a nation's output to the money supply. In this book, the contributors demonstrate that the wealth of a nation depends on much more than mathematical calculations. 

More than anything else, it is inequality that holds back our economy. Equal societies do better on almost every measurement. Then we have arguably the most significant challenge facing our society, environmental and climate justice. This also reminds us that we live in an interconnected world, which involves action beyond our borders. Some chapters cover subjects that are not traditional economic concerns yet are essential to a functioning economy. These include housing, education, transport, land, health and decent work. Land ownership is a particularly Scottish concern, with a disproportionate share held in the hands of very few individuals and bodies. 

Then there are chapters on the structural factors that undermine our economy. These include the need for economic democracy that challenges the elite domination of wealth and economic decision-making. As well as addressing the weak forms of political governance. Several contributors highlight the development of a highly educated, socially unrepresentative professional-managerial class, which has banished all talk of ʻcapitalismʼ, ʻclassʼ and ‘exploitation’ as obsolete - leaving little appetite amongst the political elites for change. Chapters on culture, human rights, race and gender also point to complacency in what we like to think of as Radical Scotland. 

The second big theme for me is that a better Scotland is possible. If the analysis might depress us, the possibilities are also there in buckets, from a new approach to bottom-up public ownership and investment in worker-owned business to individual economic rights, public participation and deliberation of the economy itself. This wouldn't be a book about Scotland without referencing our national obsession, constitutional change, and the authors hold a range of views on this issue. Whatever constitutional path is taken, Scotland will remain embedded in a complex web of economic relationships across these islands, Europe and the world. 

My chapter moves away from traditional macroeconomics to focus on the local economy. Scotland has one of the democratic world's most centralised forms of government and one of the least 'local' local democracies. Economic development in Scotland has focused on attracting inward investment. This has resulted in the wealth generated by workers, local people, and businesses being extracted by often distant shareholders as profits and dividends in our communities of place. These firms are often the first to flee when the economic cycle shifts. Community Wealth Building seeks to address this by encouraging plural ownership of the local economy, increasing investment using fair employment, progressive procurement and the socially just use of land and property. 

I also argue that outsourcing of public services has fragmented delivery and extracted wealth from communities. I make a case for the collective provision of a wide range of local services based on plural forms of democratised and decentralised common ownership. The cooperative movement and other forms of community ownership could also play a much larger role in regenerating the local economy. The problems facing our high streets and town centres will not go away after the pandemic. Consequently, we need to rethink our town centres as places where people live and work, not just shop. This should include a level playing field on taxation. I listened to an interesting IFS debate last night about an Online Sales Tax to offset the business rates for high street retailers. There are always challenges in implementing a new tax, but this issue needs to be tackled now.

This book highlights some challenges for traditional thinking on the left in Scotland. We should be proud of our radical history while applying the lessons to a Scotland in thrall to a neo-liberal economic orthodoxy with weak governance systems. The solutions cannot be dictated from the top; they must be developed and organised from communities of interest and place. This book offers a different vision for Scotland and signposts new approaches to our enduring challenges.    

ScotRail - the start of a new journey

Today is a special day for rail campaigners who have been making a case for bringing Scotland's railways back into public ownership for the 25 years since privatisation. ScotRail is back as a public service. While this has been a long journey, with every Scottish Government since devolution, it is not the final destination. Public ownership is not enough on its own. What matters is what we do with it. And let's not forget that ScotRail is only part of Scotland's railway system; privatisation is still with us. Anglo-Scottish high-speed rail is still a pipe dream.

There have been the predictable doomsayers who claim ScotRail will "turn out to be CalMac on wheels". The ferry fiasco certainly hasn’t enhanced the Scottish Government’s reputation for running anything. However, those who argue that there is some magic formula for success that only applies to the private sector clearly haven't been following the P&O debacle or the costly absurdities of rail privatisation over the past 25 years. Even the Tories have called time on their privatisation model, although typically, their new model just tinkers around the edges.

If we are to avoid another CalMac, the First Minister needs to get serious about the promised 'national conversation for the future vision of the service. We also need some immediate action, not another long grass strategy. Fortunately, there are already some good contributions to get us started. For example, the rail unions have published their vision for Scotland's railways with help from Unity Consulting. These proposals include expanding the service, introducing proper staffing levels, and improving industrial relations.

Railfuture Scotland has suggested a pretty good mission statement for ScotRail, ‘The trains need to go where people want, when people want and at a reasonable price’. Unfortunately, this will not be achieved through cuts in rail services and ticket office closures. Electronic ticketing is still unreliable, and many prefer or have no option but to use a paper ticket. I regretted using an electronic ticket last year when I had a long battle with Avanti, only resolved by going to the Rail Ombudsman. A closed ticket office is also a closed waiting room and toilets.

The key to the future of our railways and climate change is to get us out of our cars and onto the train. It has been estimated that we need to double pre-covid passenger numbers to achieve net-zero. Quite a challenge when commuting numbers are likely to fall with greater use of flexible working. There will be more focus on leisure travel and ensuring rail is the first choice for long-distance journeys. As there were twice as many seats provided each day as passengers travelling pre-Covid, rail is in a unique position to accommodate transfer away from the car without further increases in cost to the taxpayer.  

Railfuture has also produced a list of 50 new stations for reopening on existing lines that would generate significant numbers of new passengers. The same applies to rail freight. I recently did a paper for a European think tank on this issue, highlighting how far behind we are. In countries like Switzerland and Austria bus and rail use has been rising every year. Several bids for freeports or greenports don’t even have a rail link, suggesting they will be served by even more lorries on our roads. While all this will require significant investment, the costs of not doing it could be considerably more.

The railways also need to be part of an integrated transport system, which policymakers have discussed for many years and some cities have delivered. Sadly, not in Scotland, where it took the Scottish Government years just to establish a forum. We need a coherent network of interconnecting bus and rail services across the country. One break in that service and the car becomes the default means of travel for many. For example, I am flying from Edinburgh Airport on Monday and I would have preferred to go by rail and tram. However, my recent experience of cancelled trains means I will probably have to drive to be sure of catching my early morning flight. I will not be alone in that, looking at airport car parks.

Today is a cause for celebration, but it's just the start of the journey. The end destination must be ensuring the Scottish Government delivers a model of public ownership for ScotRail that is genuinely world-class. 

Putting the local into reducing health inequalities

While national strategies are essential in reducing health inequalities, we need to emphasise local action. 

This week the Scottish Government statistics division published its long-term monitoring of health inequalities. Spoiler alert, it doesn’t make happy reading. Male Healthy Life Expectancy at birth was 46.8 years for those living in the most deprived areas, 23.7 years lower than those living in the least deprived areas (70.4 years), and it’s getting worse. For women, the gap was almost identical at 23.6 years. Moreover, in 2020 the premature mortality rate in the most deprived areas was four times higher than the rate in the least deprived areas.

So, what is the Scottish Government doing about it? Well, there was a public health ‘review’ in 2015. There are many glossy documents and websites that say they are ‘working towards’ reducing health inequalities, ‘defining’ their priorities, and a lot of similar guff. What’s missing is any sense of urgency to actually implement these plans.

Let me give just one small example. The Scottish Government rightly says that Fair Work is an important tool in reducing health inequalities, and procurement is an important lever. Last year, SHA Scotland spotted that NHS Education for Scotland (a health quango) had awarded a contract to Amazon. Given Amazon’s notorious employment practices, they wondered how they passed the Scottish Government’s Fair Work criteria that are supposed to be applied to the evaluation of contract bids. So, they sent off an FoI request and were told that the Fair Work Criteria wasn’t applied to this contract. Here we have a government health quango who couldn’t even be bothered to apply the policy. It is no wonder that there is a considerable gap between rhetoric and policy delivery.

Important though national action is, many of the services and actions required to reduce health inequalities need to happen locally. No serious plan to tackle health inequalities in Scotland can ignore the pivotal role of local government. Councils make a vital contribution to weaving the social fabric of their areas and seeking to create and sustain healthy places for people to be born, grow, live, work and age. 

I drafted a paper that SHA Scotland launched this week, which sets out some of the ways that local government can make a difference. Planning, public spaces, leisure and cultural services all make up the vital social infrastructure that promotes wellbeing in our communities. This helps tackle poor mental health through stronger social cohesion and social support. They can also create sustainable communities tackling air pollution and food poverty. However, this cannot be achieved while the Scottish Government cuts councils' funding by nearly a billion pounds. Fair funding for local government is crucial to tackling health inequalities. In addition, centralising services in Edinburgh, as with the proposed National Care Service, is also the opposite of what is needed to reform social care.

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Local action on health inequalities requires councils to lead the way with a community health strategy that puts reducing health inequalities at the heart of everything they do. When we focus on the social determinants of health, we see that local government services are health services. Without local government, adults and children would die sooner, live in worse conditions, lead lives that made them ill more often, and experience less emotional, mental and physical wellbeing than they do now.

The Scottish Government should set the framework for reducing health inequalities and take appropriate actions at the national level. That doesn’t mean micromanaging from Edinburgh. They must also ensure that the local government is funded fairly, not just pass on Tory austerity to councils while protecting their budgets. Local communities understand what needs to be done in their area, and they need the leadership and resources to do it.

Time to reform sick pay

'Fixing the UK's broken sick pay regime would reduce the spread of infectious diseases – and be a small step towards a fairer country.' I read these words in a Guardian editorial just before a mentoring session with an HR colleague. She reminded me that I was surprised when we discussed reviewing sick pay as one of her initial goals after moving from a private-sector post to the care sector.

I probably shouldn't have been surprised as three out of four employers responding to a government consultation agreed that statutory sick pay should be extended, and small businesses were as supportive as large. Not that this consensus brought any action from the UK Government. The UK has the least generous statutory sick pay in Europe, worth just £96.35 per week, around 15 per cent of average earnings, compared to an OECD average of over 60 per cent. And it is only available to employees earning £120 per week or more – meaning two million workers nationwide, mostly women, do not qualify.

The pandemic ought to have been a wake-up call on sick pay. Too many workers in public-facing jobs are, in effect, incentivised to go to work when they are ill. If care workers suspect they are seriously ill but worry that £96 a week will leave them behind on rent and bills, they have a choice: fall into debt or risk patients getting ill – with potentially fatal consequences. More than 250,000 workers were self-isolating last month without decent sick pay or any sick pay at all. And it's not a problem that will go away when the pandemic is over. An estimated 1.3 million people (1.9% of the population) were experiencing self-reported long COVID as of October 2021.

It is also discriminatory. A report from the IPPR and UCL found that households earning less than £25,000 were twice as likely to lack access to any sick pay compared to those earning more than £75,000. Similarly, workers over the age of 65 were five times more likely to lack access to sick pay compared to those aged 25 to 44. Workers aged 45 and 64 were also twice as likely as this younger age group to lack access to sick pay. And people from a South Asian background were 40 per cent more likely to lack access to sick pay than white workers.

Another tricky issue for her care organisation was vaccine mandates. Like most people, including me, her board found it difficult to understand why care workers wouldn't want to protect themselves and the people they care for by getting vaccinated. It wasn't mandatory in Scotland, but several organisations had decided to go down that route. We agreed that vaccine mandates could be ethical and legal, and staff should be encouraged to get vaccinated. However, mandates will only be necessary if there is no other way of preventing transmission to a similar degree. There is now good evidence that a vaccine mandate will not prevent healthcare workers from passing on the virus to vulnerable patients. The organisation also rejected the idea of cutting contractual sick pay for unvaccinated workers as, given the low level of SSP, that could encourage working when infected. This approach worked with only a handful of staff not voluntarily getting vaccinated.

TUC General Secretary Frances O'Grady said, 'No one should be forced to choose between doing the right thing and self-isolating or putting food on the table.' Employers should ensure that their sick pay arrangements don't force workers to make that decision. That approach needs to be underpinned by a statutory sick pay scheme that pays the real living wage to everyone.

A wake up call for a realistic energy policy

 This month, I returned to familiar territory when asked to write an overview of UK energy policy as part of a wider European project. Energy policy can be quite parochial, particularly in Scotland, so it was interesting listening to European colleagues who link the issue to broader strategic issues, such as the Russian gas pipeline.

The impact of rising energy prices is a common concern across Europe. UK customers have had some protection due to tariff caps, but these caps increased by 12% in October 2021 and are set to increase in April 2022. The Bank of England expects the cap to rise from its current level by 20% for electricity and 35% for gas, leading to year-on-year energy inflation rates of 31% and 58%, respectively, in April. Others, including energy specialists Cornwall Insight, have predicted even steeper increases. The £2000 plus annual energy bill looks inevitable.

As the IFS highlight, this would lead to a mildly regressive pattern of overall inflation because lower-income households spend almost three times as much of their budgets on gas and electricity as the highest-income tenth on average (11% versus 4%). To this, you can add the impact of benefit cuts and tax rises, all of which disproportionately hit the lower paid. So much for levelling up!

A failing energy market is also not unique to the UK. New entrants have been collapsing like flies, not least because they were ill-equipped to cope with rising gas prices. Even more prominent players like OVO Energy (the third biggest supplier) are in trouble. They announced 1700 job losses today, which is unlikely to do much for their customer service. Already tarnished by advising customers to keep their heating bills low by “having a cuddle with your pets”, eating “hearty bowls of porridge” and “doing a few star jumps”. Ovo took over SSE’s retail operation a couple of years ago.

Reliance on expensive gas imports is another common position, driven by the ‘dash for gas’ in the 1990s by the privatised energy companies. In Europe, that may be addressed by the Nord Stream 2 project, which will bring vast amounts of extra Russian gas into the European market. However, the implications for Ukraine and Russian power more generally is clearly a concern. Brian Wilson reminds us we are paying the price of action and inaction over the past 20 years, “Those whose mission in life was to get rid of nuclear power knew that gas was the realistic alternative, regardless of cost or where it came from. Those who preached renewables and pretended there was not a problem with intermittency that needed to be addressed with equal vigour made the same unspoken assumption.” 

This should all be a wake-up call for further renewable generation and energy efficiency. However, that won't address the immediate challenges. The energy industry has suggested a £20 billion fund to subsidise bills, repaid over ten years. This, of course, assumes prices will return to previous levels, which may be a gamble the Treasury is unwilling to take. Removing VAT and transferring 'green levies' from bills to the taxpayer would save £250 a year for the average householder. Helpful, but just a dent in the projected price rises. A windfall tax on energy producers profits could fund an expansion of the warm homes discount and the winter fuel allowance and reversing benefit cuts and tax increases.

Fossil fuel producers exploit the crisis to warn against a rapid move away from fossil fuels. For environmentalists, the situation highlights the need to accelerate the move away from expensive and volatile fossil fuels. This highlights the failure of COP26 to tackle the fossil fuel status quo. More green investment is required to ensure the future falling fossil fuel production is compensated for by improvements in energy efficiency and rapid growth in clean power generation. Despite some limited actions by the financial markets to discourage fossil fuel investment, producers do not believe demand will disappear. 

The Scottish Government continues to bury its head in the sand over nuclear power. It argues, “Significant growth in renewables, storage, hydrogen and in carbon capture are, in our view, the best way in which to secure Scotland’s future energy needs and to meet our net zero objectives.”. This might be a strategy, except that three out of four elements are some way off at best. Little is happening on storage, which is, in any case, expensive when the alternative is to import English gas and nuclear power when the wind isn't blowing. Hydrogen is not really an option for electricity, it's a better bet for heating and transport, but even that is small scale so far. Carbon capture is a sensible option for industrial processes, but again we have barely reached demonstrator projects.

Meanwhile, Hunterston is closing, leaving us with just one time-limited nuclear plant. Nuclear does have cost issues, but we subsidised other forms of renewables. I have given up explaining on Twitter (well, not quite!) the misleading energy statistics that are so often bandied about. Not least the First Minister claiming almost all electricity used in Scotland comes from renewables. In fact, in 2020, 56% of the electricity consumed in Scotland came from renewable sources, 30% from nuclear (which is also renewable) and 13% from fossil fuels. 

There is no shortage of energy issues to be tackled in Europe and the UK. The short-term solutions are all expensive and are the inevitable consequences of a failure to take a sensible long-term approach to energy policy. They are coupled with too much reliance on market solutions. We need a planned and balanced energy policy.