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.