Richard Norris, a CSPP Board Member and former Director of the Scottish Health Council, gives his thoughts on health and social care policy after the COVID-19 lockdown.
It is notable that NHS policy in Scotland has had no significant changes since Sam Galbraith announced the end of the internal market in 1997 (i.e. before the Scottish Parliament was set up). Of course healthcare policy has developed since then, but when in 2010 the Scottish Government produced its Healthcare Quality Strategy, followed up with the ‘2020 vision’ (2011) and the Health and Social Care Delivery Plan and National Clinical Strategy (both in 2016) these documents restated and formulated new ways of achieving existing goals, rather than making any significant breaks with previous policy direction.
Perhaps because of this cognitive continuity, there is an assumption that the same problems are the main problems e.g. chronic and long term illness, health inequalities and low life expectancy. Maybe it is because of this that pandemic planning was not mentioned in any of these documents. There is, in fairness, one sentence about infectious diseases in the Health and Social Care Delivery Plan, which reads:
“Scotland’s ability to respond to infectious diseases and other risks to health matches and, in some cases, exceeds that of much of the developed world.”
The document then goes on to talk about there being ‘greater challenges elsewhere’.
One of the most startling points about Covid 19 has been that, despite earlier fears around SARS and bird flu, this health crisis was not foreseen. For example, the National Clinical Strategy lists 13 challenges facing Scotland’s NHS with no mention of infectious disease or pandemics. Of course, this lack of foresight (easy for us to spot in hindsight) is true not just in Scotland, but many other places.
That will now change. From now on, pandemic planning will be the New Normal. Other changes could well be on the way as a result of the nasty surprise given by Covid 19.
There could be a reappraisal of the current strategy of transferring resource from hospitals to a mixture of centralised super hospitals and community settings (aka ‘shifting the balance of care’). The chronic disease model on which this policy is based is now looking deficient. The hasty building of the NHS Louisa Jordan is a testament to the extent to which bed capacity to cope with health pandemics has been degraded. And the fact that it has not admitted any patients is not necessarily a success that we should be ‘delighted’ about. Many non-urgent treatments have been cancelled to enable existing hospitals to cope with Covid 19, and this has its own consequences. Of course, spare capacity is the enemy of efficiency, but here we see that highly efficient resource utilisation (beds, staffing and equipment) has a cost in the resulting lack of capacity for coping with unexpected events. In future, when paring resources in the name of ‘efficiency’, there needs to be a thorough risk assessment. Pandemic planning can supply more balance to those discussions.
In any event the ‘shifting the balance’ policy, involving as it does the depletion of much loved local hospitals, has proved to be unpopular with the public, and difficult to deliver in practice. Audit Scotland says progress has been ‘too slow’ and also says very bluntly that the 2020 Vision “will not be achieved by 2020”. Perhaps it is time to look again at this, not just to develop systems better able to cope with pandemics, but also to understand why the policy is so difficult to deliver.
The integration of health and social care, whilst more necessary than ever, may also need to be rethought. Much of the rationale for integration was ‘sustainability’, i.e. transferring care from expensive healthcare services to relatively less expensive social care services based on cheap labour. The growing realisation that the lack of ‘parity of esteem’ between the health and social care sectors is costing lives, and consequent demands that those providing social care should be properly valued and rewarded, threaten to put a stake through the financial heart of integration. We will need a radical reappraisal of the care sector in terms of funding, governance and accountability. Whatever else this means I suspect success going forward will depend on devolving more powers to local structures, and finding quite a lot more money. Both of these things tend to be unpopular with the centre.
There will be a rediscovery of the importance of those elements of public health covering epidemiology and virology. In recent times, much public health work has been about changing behaviour, tackling health inequalities and broader societal approaches. These are important, and will no doubt continue, but more old fashioned public health themes, i.e. preventing infectious diseases, are back. The six Public Health Priorities for Scotland (2018) don’t include risk from infectious diseases. Contrast this for example with Public Health England which says its ‘first duty is to keep people safe from ‘environmental hazards and infectious disease’.
Perhaps from now on we shall see more epidemiologists in senior positions in the NHS in Scotland, and a move towards a public health narrative with greater focus on risk and practical strategies for coping with pandemics. The fact is we are living through a time which is witnessing the early deaths of people who are not getting access to care when they need it.
The new financial pressures that the above changes will bring (combined with the devastating impact of the lockdown on our economy), will in turn lead to a new emphasis on achieving equity in how we use health and social care resource. How do we spend money that is fair to everyone, effective, and can be justified in terms of societal need? Finding answers to these contentious questions will entail a lot of dialogue and a fair amount of bartering. This means that the issue of how resource is allocated (not just how much in total is spent) will become more political. And this is probably a good thing.
 Health & Social Care Delivery Plan, Scottish Government 2016 para 31, page 16
 National Clinical Strategy, Scottish Government 2016 pp 42-43
 Public Health England Strategy 2020-2025. (2019)