It's health inequalities stupid!

Benjamin Franklin famously said that ‘nothing is certain except death and taxes’. Well, it used to be pretty certain that this generation would live longer than the last – but no more. Life expectancy was improving until 2011 when it started to decline in Scotland.

This was my opening pitch when moving the Socialist Health Association Scotland motion on health inequalities at the recent Scottish Labour Party conference. The key point is that as health inequalities underpin most of the challenges facing our health and care systems, political parties should put radical action on health inequalities at the heart of their manifestos.

Let's start with why we should be concerned that life expectancy in Scotland is no longer rising. While deaths relating to COVID-19 play a part in explaining recent falls, the deviation from the long-run trend dates back to the early 2010s. More people in Scotland are in relative poverty, more are likely to be inactive due to long-term illnesses, and food insecurity, homelessness, and fuel poverty are all higher than they were. The SHERU report found that key outcomes related to health and inequalities are not significantly improving and are, in some cases, worsening.  The biggest difference in female healthy life expectancy is between the Orkney Islands (77.5 years) and North Ayrshire (54.0 years) – over 23 years difference.  A gap that applies to almost all the leading causes of death.

This isn't an easy debate for political parties. The health debate in Scotland focuses almost entirely on the NHS, partially driven by a less than edifying parliamentary scrap each week, but it reflects how the public thinks about health. Health equals the NHS. It is of course vital that we continue to make the case for the NHS when you have Farage and his Reform private company arguing for privatisation. The US healthcare corporations who have created the most expensive and inefficient healthcare system in the world are rubbing their hands with glee – and they have Trump to press their case through trade deals.

However, the actual pressure on our health and social care system comes from poor health outcomes caused by inequalities. When household income is too low to afford essential goods and services like food and warm homes, participation in everyday social activities leads to greater social isolation. This is not about behavioural factors – it’s about the big issues like income support, wages, employment rights, housing, air pollution, crime and fuel poverty. I remember running a fuel poverty course for health visitors who vented their frustration at returning time and time again to the same families with the same health problems caused by cold, damp housing.

We have many strategies in Scotland, beautifully laid out in glossy documents. What we rarely have is measurable action and outcomes. We have some isolated initiatives, like the excellent Scottish Child Payment, but no comprehensive plan to fully meet the statutory target of 10% of children in relative poverty by 2030/31. As the SHERU report and others have highlighted, there is limited evidence that current policies have effectively reduced inequalities.

All of this was highlighted by the Christie Commission over 13 years ago. I was an expert advisor to that Commission, and we calculated that 40% of all public spending was related to failure demand - putting right the impact of inequality. So, when ministers and others talk about public service reform, the solution isn’t going to be found in efficiency targets and the like. It requires preventative spending that tackles inequality before creating the failure demand, which costs much more. I remember talking to a lecturer running a pilot course for single mothers, helping them to keep their children out of care. The course was successful, but no one could fund the £450 per head to continue it. It can cost over £5,000 per week to place a child in a private care home. How bonkers is that!

Despite our economic challenges, we are a rich country, but the investment in preventative spending has to be paid for. This is spending to save, so we need to look at ways of increasing current spending and how long-term investment can be financed. In the short to medium term, the work of Tax Justice Scotland is essential. In the longer term, we might look at what the EU, with the UK, is considering with bonds to pay for increased defence spending. Now, I am all for financing the defence of Ukraine and the rest of Europe against Putin and his useful idiot Trump. But if we can spend to save for that eventuality, we should be able to do the same for health inequalities. This is an investment in our country’s future.

Social Murder?: Austerity and Life Expectancy in the UK

Life expectancy has increased in the UK more or less constantly for more than a century. Around 2012, this all stopped, and among poorer populations, it actually went in reverse. In some parts of the UK, the change to premature mortality rates (death under the age of 65 years) has been nothing short of astonishing. This is the starting premise of David Walsh and Gerry McCartney's new book, Social Murder? Austerity and Life Expectancy in the UK. 

The authors, from the University of Glasgow, demonstrate how evidence shows that these extraordinary changes to life expectancy and mortality rates have been mainly caused by UK government policies implemented in 2010 by the Conservative-Liberal Democrat coalition. This is all carefully evidenced, showing what happened, when it changed and who was most affected. While we often bandy around the word austerity, the scale of the cuts to UK government spending is poorly understood. By 2019, annual spending was down by around £91 billion compared to pre-austerity levels. To put that in context, that’s more than the GDP of entire countries like Croatia, Bulgaria and even Oman. Over the period 2010–19, the cuts add up to a total reduction of approximately £540 billion. These are changes on an extraordinary level.

While the authors provide a mass of statistical and other data to make a case that was downplayed by many public health organisations, they also tell the stories of how austerity impacted individuals through case studies. These also show how the coalition government introduced a policy of vilification and demonisation of people in receipt of social security benefits. One case study highlights the impact on so many, "Moira was now terminally ill. But even that was not enough to satisfy the DWP. One of her daughters, Nichole, was told in a ‘cruel and heartless’ phone call that they would not believe Moira was terminally ill unless they were told by a doctor that she only had a few weeks left to live. They had requested evidence from the general practitioner (GP), they said. The GP told Nichole they had received no such request. In August 2015, one month after her cancer diagnosis, Moira died. She was 61 years old."

There are also startling non-public health statistics that illustrate the arguments. For example, in 2010/11, the Trussell Trust, the largest food bank provider in the UK, had only 35 food banks across England; by 2019/20, they had almost 1,300.

They don't deny the impact of other factors on life expectancy, such as COVID-19, obesity, and inflation. However, they point out that the trends pre-dated COVID-19 and the cost-of-living crisis - austerity made them worse. As with the title from an apt Friedrich Engels quote, they don't mince words, "Put more bluntly, poverty kills. And austerity has increased poverty levels in the UK." Austerity kills through physical and mental illness, and children are impacted the most. The book also looks at the international evidence, showing that the greater the austerity implemented by those governments, the worse the life expectancy and mortality trends. They also criticise public health agencies – most notably PHE and the WHO, for not raising the alarm that austerity policies were causing life expectancy to stop improving overall and causing it to fall rapidly in the most deprived communities, which they argue 'is a dereliction of duty', and lessons need to be learned.

If mortality rates are to improve, the new UK Labour government and other governments worldwide must understand the evidence, quickly reverse the erosion of public services and social security systems and protect those at greatest risk. The authors conclude, "If poverty in a wealthy country is a political choice, as Philip Alston so eloquently pointed out, then so too is no poverty. It is not only within the gift of our political leaders to achieve this: it is surely their moral obligation." It is not just governments; we all have a responsibility: "To really change our politics we need to be active citizens: building campaigns and protests; creating and supporting institutions and organisations that can help."

The recent budget was a start, as the impact analysis below is the reverse of the austerity years. However, as I argued in my Budget blog, this direction change must be sustained. If you want the evidence, look no further than this excellent book.

Pharmanomics - How Big Pharma Destroys Global Health

If you read one book this year about the economics of health, Pharmanomics by Nick Dearden should be it. The Director of Global Justice unpicks the way Big Pharma does business and rips us all off. This may not be unique in a capitalist society, but in the health sector, it costs countless lives. 

The COVID pandemic started to open the eyes of governments to this particularly rapacious form of capitalism. As Nick puts it, ‘They got to dictate who lived and who died in the most serious public health emergency in living memory.’ They prolonged the pandemic and entrenched global inequality for a generation with a vaccine that was invented mainly using public money. Corporations like Pfizer, Johnson & Johnson and Moderna  – used taxpayer support to get the vaccines that bear their names ready. Then, they privatised the  know-how  behind these vital medicines and refused to share it with the many countries that could have  joined the global manufacturing effort. Even AstraZeneca, whose Oxford vaccine was almost entirely funded by the public purse, turned what should have been a 'People's Vaccine' with an open license into an exclusive license, which prioritised rich countries. A practice they had undertaken before when they closed down early research into tuberculosis and malaria in favour of drugs for diseases affecting richer countries.

This book shows, page after page, how Big Pharma has been doing this for years. The patent system that underpins their profits delivers returns that manufacturing companies can only dream about. In the 1990s, Big Pharma discovered that their most significant asset wasn't research and development but intellectual property. So they lobbied in the USA and fought court battles to extend their patents and keep their data secret. This culminated in a trade deal known as TRIPS that enforced monopoly protection everywhere - described by one journalist as ‘a brute and profoundly undemocratic expression of concentrated corporate power.’ It is now a core part of the World Trade Organisation rules.

Examples include OxyContin, the drug behind the opioid addiction epidemic that has probably killed more than 300,000 people. You can watch how they encouraged overprescribing in the Netflix miniseries Painkiller. The drug generated $35bn for the company Purdue. They are now using the same discredited tactics to market opioids in China and other countries.

We are often told that these profits are essential to develop new drugs. However, Big Pharma does very little research into new medicines. They spend between five and eleven times more on advertising than on research. The drug is created by smaller companies, often funded by the public sector, and then bought out by a big drug company for the patents. They close down competitors and make small changes to drugs to extend patents. They are also one of the most financialised industries in our heavily financialised economy – stashing cash in tax havens to buy up companies and enrich shareholders. Medicine costs are entirely unrelated to research costs; they are hard-wired into the financialisation of the industry. As a Congressional investigator put it, 'The big Pharma fairy tale is one of ground-breaking R&D that justifies astronomical prices, but the pharma reality is that you spend most of your company's money for yourself and your shareholders.'

When you read the techniques that these companies use, it could drive you to despair. However, that is not the author's intent. He wants to open our minds to the possibility of change. We created the NHS, so why not the medicines they administer? 'If our healthcare is too important to be left to the market, then that must include the research and development of the medicines that keep us well.' It would save the NHS billions in the inflated costs that drain NHS funds. The purchasing power of the NHS has resulted in some small progress in regulating costs compared to the USA. Needless to say, the drug companies are a big part of the lobby trying to privatise UK healthcare. 

Governments need to stop being embarrassed about their role in the economy. There is a long list of technologies invented in the public sector whose ownership is transferred to the private sector and then rented back to us at enormous cost. We also need to reform the patent system to be shorter and more narrowly drawn. The pandemic and the profiteering of Big Pharma should be a wake-up call for governments in the Global North as much as it has been for the Global South. We should pressure governments to change.

The reform our NHS really needs

 With NHS reform getting a lot of attention, the Socialist Health Association Scotland has published a discussion paper I drafted that outlines the issues and seeks views on the way ahead. It is vital that those who support the founding principles of the NHS engage in this debate and don't leave it to those who use 'reform' as a code for the privatisation of healthcare.

Nicola Sturgeon’s resignation has reminded everyone that she was the first SNP Health Secretary in 2007, holding the post until 2012. It has to be said she started well, building up constructive relationships with the trade unions. The previous Labour Health Minister, Andy Kerr, did many positive things but could be abrasive. In the main, she continued with the previous government’s policies. Labour had ended the marketisation of the NHS, abolished NHS Trusts, and introduced cooperation rather than competition. She went a little further by outlawing private companies running GP practices, a growing trend in England, and further developed the NHS partnership model of industrial relations. But, overall, it was continuity with emollience.

However, while continuity has its strengths, it also meant tough political decisions were ducked. Nicola Sturgeon binned a report by Professor David Kerr that proposed a shift from hospital to community care, with better social care integration. Consequently, when budgets tightened with austerity, bed numbers fell, but social care capacity did not respond to growing demand from an ageing population. After promising to scrap PFI, they rebranded it. Instead, we got worthwhile reforms around minimum alcohol pricing and free prescriptions, but the significant structural challenges were ignored. The focus on inequality and prevention, recommended by the Christie Commission, is still gathering dust on the shelf.

Now, in the wake of a pandemic, these long-standing issues are biting the NHS with a vengeance. Waiting times have spiralled along with staff vacancy rates, ambulances queue outside A&E, cancer treatment has slowed, drug deaths have doubled, and health inequalities are worsening. Even when they eventually got around to reforming social care, they took a sensible National Care Service plan around national frameworks and turned it into a centralised monster - devouring local government and community services in its wake.  

This table highlights how much NHS capacity has been reduced.

So, it is now left to others to pursue genuine reform. Not Tory privatisation or insurance systems which, as Gordon Brown highlights, would add more costs to an NHS whose spending levels have not matched similar countries. A point seemingly lost on a particular Green Scottish Government minister as well.

As for Scottish Labour's new plan to merge health boards, that is fine as far as it goes. I recall coming across the same plan presented to a pre-devolution health minister when I worked in the health department. The problem is that merging acute boards makes sense only if you manage community services in another way. We have tried many different ways of doing this since Joint Finance in the 1970s, and none have been a complete success.

An actual reform programme would start by tackling the underlying causes of ill health. It is a national disgrace that men in the most deprived areas of Scotland not only live 14 years less but can expect to spend 35% of their lives in poor health. NHS capacity has to be grown, not cut. That means better primary care, dentistry and more beds in our hospitals. A fully integrated NHS that ends the costly small business model and the growth of corporate dentistry, financed from tax havens. 

A National Care Service based on local accountability, which improves pay and conditions for carers in Scotland, improving the quality of social care and relieving the pressure on hospital capacity. We now have more patients that don’t need to be in a hospital than the number of beds in our largest hospital. We also need proper workforce planning and fair pay and conditions to tackle recruitment and retention in health and social care, ending reliance on exorbitant agency costs, locums, staff banks, and the private sector.

And last but not least, recognising that one size does not fit all in a diverse Scotland. A strategy for rural health care services.

The NHS is on life support. However, real reform must address the underlying pressures, which means tackling health inequalities and social care.

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.

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.

 

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.

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.

L

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.

Health and Care Workers Covenant

 The pandemic has seen many key workers going far beyond their contract of employment to keep services running. That is particularly the case for health and care workers who have worked incredibly hard, at no small risk to themselves, to prevent the spread of the virus and treat those affected. It is time we recognised this commitment through a Health and Care Workers Covenant and that employers take action to minimise the impact on workers and their families.

Research shows that people who work in jobs like care, which are often called a calling, tend to have higher levels of resilience against the negative effects of overwork and stress and are less likely to experience burnout. However, that resilience can come at a price, both individually and for their friends and families. In a recent article, the authors argue that the families of workers in such roles also suffer massively. Called people can struggle to switch off after work and are less able to manage a balance between work and private life. Divorces and difficult relationships with children are not uncommon, as are exhausted family members. That is bad enough for the individual workers, but families shouldn't pay the price of their loved ones’ self-sacrifice.

Too many employers in the health and care sector have an operating model that depends on these workers going the extra mile. And we as a society also expect these workers to go beyond their contracts, particularly during the pandemic. They have delivered for us in challenging circumstances through governments' faltering actions and often without proper protective equipment and other safety measures. Employers have a duty of care to address this. I have recently been working with one social care organisation who have recognised this and taken a range of actions. But others take this level of commitment for granted.

NHS workers have had to deal with much larger numbers of critically ill patients than normal. Often in a far from an ideal situation, knowing this may lead to poor outcomes for their patients. This is having an impact on their mental health. A recent study of staff working in critical care during the pandemic showed they report more than twice the rate of probable post-traumatic stress disorder (PTSD) found in military veterans who’ve recently experienced combat. The authors of this study argue that there might be some lessons we can learn from PTSD in military veterans to help NHS workers cope during the pandemic. Both during the trauma and in the recovery period.

The link to the military is one made by a number of Socialist Health Association Scotland members who raised the idea of a Health and Care Workers Covenant. This is modelled on the existing Armed Forces Covenant while recognising the important differences between the groups of workers. Not least gender, insecure work and the wider range of employers and unpaid carers. Their proposal, published today, outlines and promotes the concept of a covenant. The elements could include commitments on pay and conditions, training, safety equipment, and occupational health. It should also engage the wider community as some business have already done with staff discounts. It should be taken forward as a partnership involving government, local authorities, trade unions, care providers, carer representatives and others.

It is important to emphasise that a Health and Care Workers Covenant is not a substitute for collective bargaining and strong trade union organisation. This remains the best way to protect and improve the pay and conditions of these workers. The implementation of the Fair Work Convention recommendations, as supported by the Review of Adult Social Care, would be an important starting point. 

We need to pay workers with something more than just gratitude, and a covenant is an additional way of society recognising the sacrifices these workers and their families make for us all.

Contrasting approaches to the crisis of care

The COVID-19 pandemic has inspired several new books, which seek to analyse the impact on our healthcare systems and broader society and propose reform. I have read a number of these as background to a paper for a European wide study of the impact of the pandemic on older persons and other work. In this blog, I will share two contrasting examples of these.

 

The Care Manifesto (Verso Books) has been written by a group calling themselves the Care Collective. It analyses the impact of the marketisation of care, which has resulted in those most at risk from COVID-19 receiving too little support. This has allowed multinational corporations to make huge profits out of financialising and overleveraging care homes while work in the care sector was subsumed into the corporate gig economy, mostly at the expense of women as workers and carers. This has been achieved because “ideas of social welfare and community had been pushed aside for individualised notions of resilience, wellness and self-improvement, promoted through a ballooning ‘selfcare’ industry which relegates care to something we are supposed to buy for ourselves on a personal basis.”

They argue for a model of ‘universal care’, which puts care at the heart of our society from our kinship groups and communities to our states and planet. Chapters explain how this would apply to our politics, family, communities, the state and the world. It addresses care in its broadest context, rather than looking specifically at systems or structures. I thought the communities chapter was strong, chiming with a number of the themes I set out in my recent Reid Foundation paper. They propose four core features to the creation of caring communities: mutual support, public space, shared resources and local democracy.

 

While it is hard to disagree with most of the content, even if it is prone to assertion rather than evidence, the language is likely to jar with the general reader. As they say, “The Care Manifesto offers a queer–feminist–anti-racist– eco-socialist political vision of ‘universal care’”. Fine, but this is not likely to find its way into a political programme. Overall, it’s a concise and broad picture of what a different society could look like, but too few practical steps to really call it a manifesto.

 

In contrast, Madeline Bunting’s, Labours of Love: The Crisis of Care (Granta Books), is a more personal argument about the invisibility of care, and its historic under-valuing – based on extensive interviews with people caring for others. The purpose of the book is to make visible the nature of the vast web of care – its importance, extent, subtlety and complexity.  She too hopes the pandemic will see a new politics of care emerging which recognises our interdependence as families, friends, communities, nations and as a human species. 

 

The chapters take the reader through various aspects of care with a final section in each chapter on what we mean by key words, kindness, compassion etc. I enjoyed her story of the manager who, “advised staff to ‘populate the document’ with the ‘likes and dislikes’ of the ‘service user’ as a form of person-centred care: it amounted to getting to know someone with the help of tick boxes”. To be fair, I have seen much worse management speak in the sector.

The hospital chapter includes a story about a snap session with a consultant, which had to be followed by the nurse spending time finding out and sorting the patient’s problem; “Once he (the consultant) has gone, the work of nursing starts. Sam (the nurse) sits down, and places a hand on Derek’s arm to try and calm his anxiety. Finally, he can start to explain”. This is something every nurse can relate to. Time to care is a key issue as the pressure to free up beds is intense and becomes one of the main preoccupations of nurse managers. Hospitals are clocking up record, and potentially dangerous occupancy levels as the number of hospital beds have declined - by a quarter in Scotland since 2009. The chapter on GP services shows similar time constraints.

 

When it comes to time to care, the chapter on home care highlights much that is wrong with social care. Even in what looks like one of the better care organisations in the private sector, “More than half the clients left every year, and the turnover of staff was just as high. The instability necessitated continuous marketing and recruitment, requiring full-time dedicated staff, a substantial cost for this small business”. In another company, home-care visits were fifteen minutes. A new care worker was shocked, ‘I was very green and willing; they trusted me with very vulnerable people after only three hours of basic health-and-safety training. I had no training in moving and lifting, and it’s left me with historic back pain. I wasn’t paid for travel time”. Another care worker highlighted a common response that I used to see in UNISON surveys, “A lot of people literally pleaded with me to stay for a moment, just to have a cup of tea”.

 

This is a beautifully written book that balances traditional evidence with the stories of care workers and communities, all in language we can readily understand. She spoke to individual care workers who are expected to reconcile market principles with their own understanding of people’s needs and their responsibility, and it is those at the bottom of institutional hierarchies who felt the contradiction most keenly. It is also an overwhelmingly gendered role, which in itself says much about our society.

 

Bunting concludes that the marginalisation of relationships may be most graphic and disturbing in low-paid parts of the care economy, but it has infiltrated virtually every dimension of care. Paperwork has become the way to avoid blame and manage risk and marketisation, bureaucracy and technology, is diminishing the primacy of people and the care relationship. 

 

Two contrasting studies reach similar conclusions through different routes. Well worth a read.

Passing on the Scottish healthcare experience

I am in Stockholm this week talking about health and care systems. Sweden has a healthcare system which is generally free at the point of use. However, there is greater local autonomy at the regional level than in the NHS and is increasingly adopting market-based systems with private sector providers, particularly in Stockholm.

Privatisation is being challenged in Stockholm, and I was invited to speak at a seminar to explain the Scottish experience. We moved from a command and control NHS model, to the internal market and now to a collaborative system. Having tried the market for around 15 years, they are interested in our experience and why we changed in the years after devolution. And why we have retained the model despite privatisation in England.

International comparisons in healthcare are notoriously difficult, and my approach is to explain the Scottish system, rather than suggest it should or could be copied directly. While Sweden starts with universal health care, the health challenges are very different to Scotland with our massive health inequalities. If only we had their more equal society, even if they are rightly concerned that the post-war gains are being eroded.

On systems, we can offer some relevant experience. The local newspaper was interviewing me outside a large new hospital built with private finance. Unsurprisingly, they have already discovered the cost of these projects and the creeping privatisation that comes with them. Scotland didn't have the cheap borrowing powers when most of our PPP hospitals were built. So why a country like Sweden, which can borrow for next to nothing would want to pay private sector rates is difficult to understand. Even the Tories have largely abandoned this model.

My interview in the main daily newspaper

I outlined our experience of market-based systems in healthcare and the benefits of collaboration over competition. The key points include:

·       The private sector brings extra costs through private finance, profits and dividends.

·       To work, they need to create surplus capacity, which in a universal healthcare system has to be financed by the taxpayer.

·       Markets also have administrative and other costs. Prioritising marketing managers over nurses seems a poor choice at a time of scarce resources.

·       Collaboration enables the sharing of best practice. If one hospital innovates that is shared in a collaborative system, rather than patented in a private sector one.

·       National and local planning is difficult when hospitals and other care systems are competing. Not to mention the considerable procurement savings in an integrated system, most notably on drugs.

From a workplace perspective, partnership working has brought stable industrial relations and better staff engagement in service design. The private sector approach brought expensive management consultants, with their 'Blue Peter' method, 'here is one I prepared earlier'!

That is not to say that despite high user satisfaction there are no problems with NHS Scotland. Performance under budgetary, workforce and demand pressures are rightly highlighted in Parliament and elsewhere. We are not achieving a meaningful shift in resources from acute to primary care, and community engagement is limited, not least because of limited local democratic accountability. However, none of these issues would be addressed in a market-based system.

I also spent some time explaining the problems we face integrating health and social care. Ironically, many of these exist because we retain the use of market mechanisms in social care. Most Scandinavian countries have fewer problems with this because these services are integrated with primary care in local government. 

So, while the Scottish healthcare system is far from perfect, it does at least avoid the disaster that marketisation brings. It is up to the Swedes to make their own decisions, but at least they can learn from those who have been there and won’t be returning anytime soon.

Austerity is killing us

Two reports published today show that the increase in life expectancy in Scotland has now stalled and that health inequalities have worsened.

One report compares life expectancy trends in Scotland to those seen internationally. The other report explores the relationship between stalling mortality improvements and socioeconomic inequalities.

The international comparative report shows that 2012-2016 life expectancies in Scotland increased by 2.5 weeks/year for females and 4.5 weeks/year for males, the smallest gains of any period since the early 1970s. The best estimate of when mortality rates changed to a slower rate of improvement in Scotland was the year to 2012 for males and the year to 2014 for females.  Among the UK countries Scotland has the lowest life expectancy, with a life expectancy 2 years lower for women, and 2.5 years lower for men than in England.

Of the 24 high-income countries for which data was available, nearly all had smaller life expectancy gains in 2012-2016 than in the immediately preceding period. Denmark is notable for having maintained mean life expectancy gains of around 10 weeks/year among females across the period 1997-2016, and even greater gains among males.

The second report concludes that as mortality improvements in Scotland stalled in 2012-2017, socioeconomic gradients in mortality became steeper. With increased mortality rates over this period in the most socioeconomically deprived fifth of the population.

This table shows what we already know and what additional information this reports gives us.

Dr Gerry McCartney, Head of the Public Health Observatory at NHS Health Scotland, said:

“What we see here is a worrying trend. Life expectancy not only gives an indication of how long people are likely to live, but also serves as a ‘warning light’ for the public’s health. In addition, the fact that socioeconomic position now plays a bigger role in how long you live than it did before is cause for concern.”

The question is why these figures are going in the wrong direction, bucking a long standing trend since the Second World War. Gerry suggests that austerity is the strongest factor:

 “There are likely to be a number of factors at play. The strongest candidates are recent policies that address recent economic setbacks which have reduced spending on benefits, squeezed incomes and trapped people in poverty – these may all have contributed. Cuts to council budgets and pressures on key local services, such as social care, could also have had an impact. There have been some severe flu outbreaks in recent years which will have increased demands on services too.”

He suggests three key actions:

• Protecting budgets that determine our health, like social care, housing, benefits etc. And ensuring they are provided according to need.
• Reducing poverty for all groups and protecting the most vulnerable.
• Maximise the take up of the flu vaccine.

While pension funds may regard these figures as having something of a silver lining, they are bad news for almost everyone else. Governments and policy makers should be taking particular notice, and develop appropriate responses. Austerity isn’t just damaging the economy, it is literally killing us.