The Health and Sport Committee has called for written evidence on the Scottish Government’s draft budget for 2012/13, as it relates to the health and wellbeing remit. The Committee’s scrutiny will focus on preventative spending, looking at both ends of the age spectrum ie early years intervention and care of older people. The Committee cites a particular interest in projects such as Family Nurse Partnerships and the Keep Well projects, funding areas such as the Change Fund, and wider issues such as child poverty, workforce planning and the integration of health and social care agenda. Other matters of interest include efficiencies and reallocation, prescription costs and eHealth.
Comments on Scottish PARLIAMENT: Health and Sport Committee
Call for written evidence - Draft Budget 2012-13 and Spending Review 2011
The Royal College of Physicians of Edinburgh is an international organisation based in Scotland with a mission statement to promote the highest standards of medical practice. In April 2011 the College published “Health Priorities for Scotland” recognising the health and financial challenges facing the incoming Government.
The College is pleased to have the opportunity to respond to the Scottish Spending Review 2010 and Draft Budget 2012-13. We welcome the commitment of the Government to protect the core budgets of Health Boards and strongly support the investment in preventative measures. The importance of long term monitoring of preventative strategies cannot be overstated as the impact on the causes of mortality and morbidity shift, particularly the effect of delaying the onset of some diseases as the population ages – the health benefits are clear but the financial consequences for Scotland are worrying. Specific comments reflecting the 12 health priorities identified by the College follow:
The College welcomes the priority on preventing admissions, particularly for older people. However, the College is concerned that planners and those developing alternate models of care may be placing too much faith in the ability of preventative and community services to reduce the pressure on acute medical services and inpatient beds. The numbers of patients inappropriately admitted to hospital is low and the College refutes the assumption that the majority of older patients are admitted for social care reasons.
The College strongly supports the aim to speed up discharge after admission to hospital but highlights the long term benefits of comprehensive assessment (often opportunistic, particularly for older patients), and the urgent requirement for enhanced community based health and social care to facilitate a safe early discharge. The College is unaware if detailed budgeting demonstrates the affordability of this strategy.
In terms of the actual transfer of care between sectors, the current evidence as summarised by the Health Foundation in 2011 suggests there may be benefits of transferring care in a small number of medical specialties but the evidence is very limited and there is a need for more research (including, pilot studies) exploring the transferability of guidelines and protocols and delivering robust outcome data (see 5 and 6 below). While the safe reduction in acute admissions is an aspiration only, funds cannot be removed from the hospital sector.
Patients seek informed, competent and timely decisions by doctors with effective communication skills. This is compromised by poor continuity forced on the NHS in Scotland by the restraints of the Working Time Regulations and the inability to cover current medical rotas. Locum use is excessive, handover arrangements are erratic and training is compromised. Influencing the Westminster Government on reserved issues such as EU legislation should feature in plans if efficiency savings are to be viable and avoid clinical risks.
- 1 Protecting timely patient access to consultants
Accurate workforce planning is essential, especially in acute medicine where unplanned admissions drive the activity throughout the hospital. If Scotland wishes to make best use of her facilities and improve quality of care, investment is required in the number of consultant staff involved with the acute medical on-call. This is the only way to extend the working day for these trained decision makers and allow time off in lieu to support safe practice.
- Protecting time for training
The College notes that funds allocated to workforce and training budget lines will increase modestly and then be capped for the next 3 years. Accurate workforce planning is among the most pressing tasks facing NHS Scotland as we will live with mistakes for decades to come. Quality of care depends on retaining a full complement of skilled clinical staff and the global market for doctors threatens the sustainability of services especially in the more remote parts of Scotland.
- Improving hospital care for acutely ill patients
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Implementing standardised clinical documentation across Scotland including electronic access to the patient’s record
The College notes that investment in e-Health is to be capped and warns that this may not be sustainable if equality of access is to be delivered across Scotland’s more remote and rural areas. Integrated care is of particular importance to older patients and all patients with long term conditions and e-Health innovations support the development of integrated care; it is far from clear that the changes required can be delivered within existing budgets.
- Improving continuity of care
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Ensuring care is based on evidence based clinical standards that focus on patient outcomes
Staffing budgets may not obviously be affected by cuts, but the balance of clinical and non-clinical time within individual contacts is swinging away from work for the wider benefit of the NHS. Casualties include quality initiatives such as SIGN guidelines, or the development of audit and research to create the outcome measures that will monitor improvement and drive up standards. The Quality Strategy will struggle to deliver its aims if consultant time and motivation is not found to support this work. Workforce restrictions and threats to the Excellence Award system in Scotland add to this pressure.
Evidence-based care is crucial at a time when service innovations are planned to address patient demand and efficiency targets. For example, the College supports the aim to maintain older patients in the community for as long as possible, but it is unclear that this can be achieved in a cost effective way and that clinical outcomes can be maintained or enhanced. It is essential that the money allocated to the Change Fund is critically and systematically reviewed through effective outcome measures.
- Implementing medical audit
As 5 above. The quality of clinical data is equally critical to delivering safe patient care and demonstrating the impact of changing health policy. Medical time and investment in appropriate IT systems is essential to support clinical leadership at a time when the NHS is committed to a 25% reduction in NHS management costs.
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Supporting patients with long term conditions to remain in their own homes
This laudable aim will be successful only if healthcare staff have time to devote to improving patients’ understanding of their own condition and increasing the cooperative working between Primary and Secondary Care. Transitional funding will be essential to avoid disruption to in-patient services while community based teams are established and tested.
The continued support for the third sector is welcome along with the recognition of the role and needs of unpaid carers. However, the College cautions that this sector cannot carry a disproportionate burden of care for our aging population
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Preventing and combating obesity
The balance of prevention and treatment is critical with a focus on effective parenting to protect the vulnerable young and positive targeting of support to address the clear inequalities aspects of obesity. The College warns that access to exercise/sport and nutrition advice alone is insufficient in the short term.
- Reducing the number of people smoking
The College is pleased to note that the focus on tobacco control is to be maintained, particularly as the spotlight moves from adults to children smoking and exposure to second hand smoke. The College is a member of the Scottish Coalition on Tobacco and commends the detailed evidence provided by ASH Scotland on the burden of disease directly linked to tobacco and the clear inequalities aspects of tobacco consumption in Scotland. -
Reducing alcohol consumption
The College strongly supports a price based strategy to address excessive alcohol consumption and is a founding member of the Scottish Health Action on Alcohol Problems, which provides evidence-based advice to drive Government policy and encourage public compliance. Again, it is reassuring that budgets will be capped and not reduced given funding constraints.
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Reducing hospital infection rates and antibiotic resistance
Reducing infection rates creates an opportunity for both safer care and efficiency, and the College notes the capping of this budget heading. Supporting the public health infrastructure across Scotland to monitor and intervene is essential to protect Scotland from drug resistance and from major disease outbreak. In this regard, the College notes the increase in funding for pandemic flu readiness in 2014-15 and seeks reassurance that this is part of a UK-wide approach to infectious disease control.