The unique strengths of Scotland’s NHS, in particular the way it improves quality and safety, could be undermined by serious financial pressure over the next few years.
A report by independent health think-tank The Nuffield Trust says that the UK could learn much from the strengths of Scotland’s NHS – but it goes on to warn that financial pressures could undo the good work that is going on north of the border. Scotland’s Health Minister Shona Robison has welcomed the report and says ‘significant’ reforms are helping improve service delivery.
There are many lessons from Scotland’s NHS for the other nations of the UK, in particular the way it seeks to improve the quality and safety of care given to patients, and the fact that it trusts and equips clinical staff to drive that improvement. However, there is a risk these unique strengths could be undermined by serious financial pressure over the next few years.
“Scotland’s well thought-through system of improving patient safety and quality of care works by engaging frontline staff in the process, and importantly the country has stuck with that approach rather than chopping and changing every couple of years” – Mark Dayan, Policy and Public Affairs Analyst, Nuffield Trust
That’s the message from ‘Learning from Scotland’s NHS‘, a new report from the Nuffield Trust. The research forms part of the Trust’s ongoing work looking at health and care across all four devolved nations of the UK.
The report arose initially from a round-table event the Nuffield Trust convened in Edinburgh a year ago, which brought together 30 senior leaders and experts in Scotland’s health and social care to discuss the country’s unique policies and institutions in the areas of patient care improvement, staffing and integrated care.
Over the following year, the report’s authors then carried out interviews on themes that emerged from the round-table with 24 academics, health service managers and senior government officials in Scotland.
“The dark cloud on the horizon threatening these strengths is potentially serious financial problems. Scotland’s NHS has the same resource constraints as England and Wales, but doesn’t yet have a medium-term plan for dealing with them – and in a harsh political environment, open debate and difficult decisions can seem impossible. This risk could overshadow many of the strengths that other countries can learn from” – Mark Dayan, Policy and Public Affairs Analyst, Nuffield Trust
The main finding of the research is that Scotland has a unique system for improving the quality and safety of its patient care. It argues that the features of this system offer important lessons for the other nations of the UK:
- Firstly, there is an emphasis on trusting clinical staff, getting them to drive improvements in care and giving them any extra skills they need to do so. This contrasts with an approach in some of the other nations of the UK, notably England, which involves focussing more on targets and leaning primarily on managers to improve care quality.
- Secondly, Scotland has benefitted from a great deal of continuity in both its policy and institutions: the Scottish NHS, the Scottish government department that oversees it, and Healthcare Improvement Scotland (HIS) have all maintained their current approach for nearly a decade. In England, by contrast, the picture is one of constant change and reorientation; while in Wales and Northern Ireland, studies have observed that commitments to change and improve healthcare are not always translated into institutions and systems to bring about that change.
- Thirdly, better ways of working are in Scotland tested on a small scale, quickly changed if necessary, and then rolled out. Unlike in the rest of the UK, this system is overseen by a single organisation, HIS, which both monitors quality of care, and helps staff to improve it.
The report also examines how Scotland deals with two challenges particular to the country: the need to provide healthcare to many remote areas, thanks to its geography; and the fact that it has very unequal health outcomes. It says that the ‘pioneering initiatives’ set up in Scotland to deal with these problems, such as the use of video links for outpatient care on remote islands, should be considered in other parts of the UK facing similar issues.
However, the authors warn that ‘the Scottish NHS faces a serious financial predicament’ this year and for the foreseeable future. They find that that the savings needed this year average more than 4%, higher than those in either England or Wales, and that Scotland’s health boards are struggling to balance their books.
The authors say that while the strengths of Scotland’s NHS could help it save money, there is also a risk that they could be undermined by the intense financial squeeze. And they observe that the country’s polarised politics can make it hard to take difficult decisions.
Commenting on the report’s findings, lead author Mark Dayan said: “The overwhelming message that came through from our Edinburgh round-table and subsequent interviews was that Scotland’s NHS is different. What we’ve tried to do in this report is to set out exactly how, and to identify not just individual initiatives but also whole philosophies and approaches from Scotland that could serve the rest of the UK well too.
“Scotland’s well thought-through system of improving patient safety and quality of care works by engaging frontline staff in the process, and importantly the country has stuck with that approach rather than chopping and changing every couple of years. Scotland has also worked on getting its healthcare services to co-operate for longer than the other nations of the UK. So we’re urging healthcare leaders from England, Wales and Northern Ireland to think about what elements they might want to import from Scotland.
“However, the dark cloud on the horizon threatening these strengths is potentially serious financial problems. Scotland’s NHS has the same resource constraints as England and Wales, but doesn’t yet have a medium-term plan for dealing with them – and in a harsh political environment, open debate and difficult decisions can seem impossible. This risk could overshadow many of the strengths that other countries can learn from”.
Scotland’s Health Secretary Shona Robison has welcomed the findings of the report. She said: “I’m proud that the achievements of NHS Scotland’s staff are being recognised in this report. Our world-leading Patient Safety Programme has led to 20,000 fewer than expected deaths, the lowest recorded levels of healthcare associated infections and significant improvement in sepsis and surgical mortality.
“We are also delivering the integration of health and social care, which is one of the most significant reforms since the establishment of the NHS, and which is helping improve service delivery. By bringing these services together we are ensuring people get the right care and support for their individual needs, and that staff across health and social care are equipped to work together to make full use of their shared skills and resources.
“Our ambitions for the NHS are founded on the twin approach of investment and reform, making the changes needed for future backed by record levels of investment and staffing.”
The Scottish Government’s National Clinical Director, Professor Jason Leitch said: “This report highlights the efforts of many thousands of dedicated staff who over a number of years have ensured that the healthcare system in Scotland is one of the best in the world.
“It is very encouraging to see the NHS in Scotland commended for the ‘continuity and consistency’ of the leadership and Scotland’s ‘emphasis on building up a cohort of staff equipped with skills for change’.
“The Health Secretary has been clear that there is no room for complacency and we are working to build on these successes and continue to improve the quality and safety of care provided to the people of Scotland, ensuring that wherever improvements are needed they are introduced and maintained.”
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