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.