Thanks very much for inviting me to talk about the experience in Scotland. In this very short time, I hope to convey a sense of public health in devolved Scotland in terms of structures and governance. The issues are complex - an ageing population, a rising birth-rate, poor housing, huge problems with alcohol (shown here by the infamous drink Buckfast) and obesity, sparsely populated rural areas and an increasingly diverse population especially in the Central Belt
The main question to cover is whether Scotland is different from other parts of the UK in terms of how public health is addressed - and in what ways. I plan to answer this question by setting out some of the governance and accountability structures concerning strategy and delivery in the NHS and local authorities, and then to give some current examples of joint working and integration between health and social care. The recent report by the Scottish Government’s short term Christie Commission will then help to put this into context.
First – is there any evidence that Scotland is different? Well, contrary to the opinions of some, the NHS in Scotland, and in fact education, were already different to England and other parts of the UK before devolution. The system was always much flatter and less about the internal market. Since devolution in 1999, the Labour-controlled administrations, then the SNP minority and now majority governments have prioritised public health for a range of political, economic and social reasons. Media has been very keen to discuss health – it’s a bit issue in Scotland, partly because of lack of other issues. The 2007 – 2011 SNP minority government was partly constrained re public health i.e. minimum pricing - now able to move that on. It is important to note that the SNP government has continued to reiterate a resistance to the private sector in healthcare. This difference has also arguably been helped by other factors - a tendency in Scotland towards co-operation and to find collective solutions, and a small senior civil service.
There is not time in this presentation to describe health inequalities in Scotland but this slide will suffice. From the WHO, this shows the stark difference of nearly 30 years in male life expectancy in different parts of Glasgow – Calton, a very poor inner-city area by the River Clyde, and Lenzie, a leafy, middle-class suburb. As you can see, people in India fare better on average than some people living in Scotland.
If we look at the NHS in Scotland – the top picture is St Andrews House where the Cabinet and senior health civil servants are based, and the bottom is the debating chamber at the Scottish Parliament. Note the difference in architecture and feel ! Deputy First Minister, Nicola Sturgeon is also the Cabinet Secretary for Health which is important. And there is a Minister for Public Health – Michael Matheson. The Directorate for Health and Social Care (like the DoH) brings together Health & Healthcare Improvement , Public Health & Sport , Health & Social Care Integration and Children & Families and is headed by Director General also the Chief Executive of the NHS in Scotland. The post is currently being advertised if anyone is interested. The national lead for public health lies with the Chief Medical Officer, Sir Harry Burns, a major influencer concerning public health, and a post which has historically put tackling health inequalities at the centre – also reinforces the fact that public health is seen as medical and remains in the NHS side, not local authority, as in England
The NHS in Scotland, briefly, comprises 14 geographic and 7 special Boards that cover central functions – inc. Education for Scotland, Health Scotland (public health), Waiting Times, Quality Improvement Scotland, NHS24 (= NHS Direct), Ambulance Service.– there are no foundation Trusts, PCTs etc. It is likely that the number of the Boards will reduce over time, but little likelihood that any other structural levels will be introduced. 1/3 rd of the Government budget goes on health, and the amount is increasing. The main remit for public health lies with NHS Health Scotland. Locally, each area NHS Board has a Public Health Director, with two so far being joint appointments with the local authority, and this would be expected to increase over time as part of joint planning. The SNP Government made a commitment to integrating health and social care in their manifesto but there is limited evidence of progress at the moment.
And to now look at how Government and local authorities work together. The Government provides Scotland's 32 Local Authorities with the vast majority of their funding by means of a block grant. The SNP Government states that it is committed to developing a stronger and more productive relationship between central and local government - and since 2007 has set out various methods to do this via COSLA (Convention of Scottish Local Authorities). The aim is to reduce the number of very specific national targets and to allow councils to more easily respond to local need which they do through developing Single Outcome Agreements. Local authorities have been given a strong lead in addressing public health in partnership with the NHS and others through joint planning, and to some extent integrated services. But it is important to note that not all local authorities are co-terminous with geographic health boards, which does affect joint planning and delivery.
I now want to look at how this works in practice in Glasgow City Council, the biggest local authority in Scotland, that’s the City Chambers by the way. Glasgow contains some of the most extreme examples of health inequalities in the UK – and improving health and wellbeing is one of the Council’s key objectives. I am going to use obesity as an example - approximately 60% of Glaswegian adults and 20% of Glaswegian pre-school children are either overweight or obese. The Council’s Single Outcome Agreement at the top right is set out in relation to the Government’s priorities for Scotland – read out – and includes some specific strategic aims concerning obesity. At the bottom, we can see how this translates into local action where the Council will increase access to its pools as one of its attempts to get the population more active. The Council has also developed a Healthy Weight Action Plan which sets out its intentions in a lot more detail.
And now to look at some examples of joint working between the NHS and local authorities in relation to public health. READ OUT. But there are some issues. A recent Audit Scotland report on CHPs found lack of authority; duplication; lack of role clarity; cultural and operational differences between NHS & LAs At national level, limited progress made in shifting balance of care across health and social care system and recommended fundamental review of partnership arrangements. This should include improved governance and accountability arrangements, and joint strategies for delivering health and social care and objectives for measuring CHP performance. Report recommended greater GP role in service planning. Audit Scotland found one example of fully shared budgets – Clackmananshire mental health servcies Cabinet Secretary for Health and Wellbeing reported as saying CHPs “have to change” (BBC News, 2011).
A recent report which is beginning to have much influence emerged a couple of weeks ago from the Christie Commission – a short-life working group set up by the Scottish Government to consider the future delivery of public services in Scotland. The challenges they set out – on the left - are fairly obvious and mirror those across the UK, but their findings – on the right - capture some of the specific issues in Scotland, as they acknowledge that a flatter structure can sometimes exclude genuine community involvement and be too top-down and that systems can be cluttered and fragmented because of the lack of cohesion across geographies and administrations. The thrust of their report is to encourage a more radical approach to change and to call for reform that prioritises accountability and that public agencies genuinely work together.
So to summarise – this presentation has confirmed that governance is a major determinant of whether and how public health policy defines problems and opportunities - and then responds. Governance is country or nation-specific - no universally applicable policies. Scotland has very specific health challenges. Scottish experience of tackling health inequalities cannot be applied off the peg. Scottish governance, political landscape, public sector, culture and media is very different.
If those involved in the Christie Commission have their way, the future for public health in Scotland is less like this, and more like this Thank you for listening.
Rosie Ilett: Public health lessons from home: The view from Scotland
Lessons from home: The view from Scotland Dr Rosie Ilett Deputy Director Glasgow Centre for Population Health The King’s Fund July 13 2011
Is Scotland different − how? <ul><li>inequalities </li></ul><ul><li>NHS and local authorities </li></ul><ul><li>governance and accountability </li></ul><ul><li>policy drivers for public health </li></ul><ul><li>the Christie Commission </li></ul><ul><li>lessons from home </li></ul>
Is Scotland different − how? <ul><li>Health policy was effectively devolved before devolution. </li></ul><ul><li>Post-devolution, priority to reduce social and health inequalities to improve Scotland’s economy and fairness and equity. </li></ul><ul><li>Labour/Lib Dem coalition and then SNP promoted public health. </li></ul><ul><li>Health more important in Scottish governance and media because of lack of defence, taxation etc. </li></ul><ul><li>Public and private sector leaders and professionals may favour universalism more in Scotland – cultural mindset. </li></ul><ul><li>Government resistance to private sector involvement in healthcare delivery and policy influencing. </li></ul><ul><li>Devolved government is consensual and consultative in terms of structures, committees. </li></ul><ul><li>Small number of senior civil servants – 250. </li></ul>
Health policy in Scotland <ul><li>Cabinet Secretary and Minister </li></ul><ul><li>Scottish government − Directorate for health </li></ul><ul><li>and social care </li></ul><ul><li>Director General, Scottish Government/Chief Executive of NHS </li></ul><ul><li>Chief Medical Officer </li></ul><ul><li>NHS boards and local authorities </li></ul>
NHS in Scotland <ul><li>2011/12 budget = £11.35bn </li></ul><ul><li>33.9% of govt spending </li></ul><ul><li>Since 2005/06, health spending has risen by 29.7% in real terms − faster than total Scottish budget </li></ul><ul><li>14 geographic NHS boards </li></ul><ul><li>7 special NHS boards </li></ul><ul><li>Public Health posts </li></ul><ul><li>HEAT targets − relating to key objectives: </li></ul><ul><ul><li>health improvement </li></ul></ul><ul><ul><li>efficiency and governance improvements </li></ul></ul><ul><ul><li>access to services </li></ul></ul><ul><ul><li>treatment appropriate to individuals </li></ul></ul><ul><li>National guidelines and standards </li></ul><ul><li>Annual accountability reviews </li></ul><ul><li>Regulation and inspection </li></ul>
Local authorities <ul><li>Health improvement is increasingly understood as partnership activity between health, local authority, voluntary and community sectors, rather than only in health domains of policy and practice. </li></ul><ul><li>Two joint Director of Public Health posts... </li></ul><ul><li>One example of shared budget... </li></ul><ul><li>- 32 Scottish local authorities </li></ul><ul><li>- £11.5bn spend in 2011-12 </li></ul><ul><li>2007 Concordat − joint delivery relationship between govt and LAs – National Performance Framework. </li></ul><ul><li>Gives LAs more control over budgets & services, use of resources to achieve agreed outcomes, less ring-fencing and savings re-invested locally. </li></ul><ul><li>Combine statutory obligations and national & local priorities including government objectives. </li></ul><ul><li>Government monitors performance. </li></ul>
Glasgow City Council – SOA for health Local Outcome 12: Increase proportion of population with healthy BMI Attendance at City Council owned indoor and outdoor sport, recreation and leisure facilities Glasgow City Council / Annual / Council Plan 4,249,932 (2006/07) 4,463,789 by 2008/09 Free swim sessions for juveniles and over 60s Council Plan 245,506 (2006/07) 264,965 by 2008/09
Policy drivers for public health <ul><li>Equally Well − joined-up thinking and action to tackle health inequalities supported by government – prioritising health inequalities; early years; tackling poverty and socio-economic inequality and economic recovery − test sites across Scotland. </li></ul><ul><li>Community health partnerships − formed in 2004 (Labour initiative) as key mechanism for moving services into community and making NHS more seamless − 36 in Scotland – £3.2 billion per annum health and social work spend. May change. </li></ul><ul><li>Community planning partnerships – formed in 2007 (SNP initiative) encourage integrated planning and budget between public, voluntary and private sectors – public involvement − varied outcomes. </li></ul><ul><li>But, CHPs and CPPs are not always co-terminous... </li></ul>
Charting the way ahead: findings from the Christie Commission <ul><li>Challenges </li></ul><ul><li>demand on public services – changing demographics and continued inequality </li></ul><ul><li>constrained public expenditure </li></ul><ul><li>public services ‘have to do more with less’ </li></ul><ul><li>need to better meet needs of people and communities </li></ul><ul><li>reform public services. </li></ul><ul><li>Solutions </li></ul><ul><li>empower communities and people via genuine involvement in design & delivery of public services </li></ul><ul><li>public sector has to work in partnership to integrate service provision and improve outcomes </li></ul><ul><li>prioritise expenditure on services which prevent negative outcomes </li></ul><ul><li>reduce duplication and share services. </li></ul>
Lessons from home… <ul><li>Political : </li></ul><ul><li>Strong public health steer from Scottish government. </li></ul><ul><li>Fairly flat structure between government and NHS. </li></ul><ul><li>Complex relationship between government and LAs. </li></ul><ul><li>Public health seen as medical and NHS, but LAs have to adopt health improvement mantle. </li></ul><ul><li>Cultural : </li></ul><ul><li>Recognition of the need to tackle inequalities. Tendency towards collectivism and collaboration. </li></ul><ul><li>Resistance to private sector in health care. </li></ul><ul><li>Structural : </li></ul><ul><li>Universal access, community development and integration to improve public health and reduce health inequalities. </li></ul><ul><li>Lack of co-terminosity between NHS and LAs restricts joint planning and outcomes. </li></ul>