Lessons from home: The view from Scotland

Dr Rosie IlettDeputy Director

Glasgow Centre for Population Health

The King’s FundJuly 13 2011

Is Scotland different − how?

• inequalities

• NHS and local authorities

• governance and accountability

• policy drivers for public health

• the Christie Commission

• lessons from home

Is Scotland different − how?• Health policy was effectively devolved

before devolution.• Post-devolution, priority to reduce social and

health inequalities to improve Scotland’s economy and fairness and equity.

• Labour/Lib Dem coalition and then SNP promoted public health.

• Health more important in Scottish governance and media because of lack of defence, taxation etc.

• Public and private sector leaders and professionals may favour universalism more in Scotland – cultural mindset.

• Government resistance to private sector involvement in healthcare delivery and policy influencing.

• Devolved government is consensual and consultative in terms of structures, committees.

• Small number of senior civil servants – 250.

Health policy in Scotland

• Cabinet Secretary and Minister

• Scottish government − Directorate for health

and social care • Director General, Scottish

Government/Chief Executive of NHS

• Chief Medical Officer• NHS boards and local

authorities

NHS in Scotland • 2011/12 budget = £11.35bn

• 33.9% of govt spending

• Since 2005/06, health spending has risen by 29.7% in real terms − faster than total Scottish budget

• 14 geographic NHS boards

• 7 special NHS boards

Public Health posts

HEAT targets − relating to key objectives: • health improvement • efficiency and governance improvements • access to services• treatment appropriate to individuals

National guidelines and standards Annual accountability reviews Regulation and inspection

Local authorities• 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.

• Two joint Director of Public Health posts...

• One example of shared budget...

- 32 Scottish local authorities

- £11.5bn spend in 2011-12

• 2007 Concordat − joint delivery relationship between govt and LAs – National Performance Framework.

• Gives LAs more control over budgets & services, use of resources to achieve agreed outcomes, less ring-fencing and savings re-invested locally.

• Combine statutory obligations and national & local priorities including government objectives.

• Government monitors performance.

Glasgow City Council – SOA for health

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

Local Outcome 12: Increase proportion of population with healthy BMI

Policy drivers for public health

• 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.

• 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.

• Community planning partnerships – formed in 2007 (SNP initiative) encourage integrated planning and budget between public, voluntary and private sectors – public involvement − varied outcomes.

• But, CHPs and CPPs are not always co-terminous...

Charting the way ahead: findings from the Christie CommissionChallenges• demand on public

services – changing demographics and continued inequality

• constrained public expenditure

• public services ‘have to do more with less’

• need to better meet needs of people and communities

• reform public services.

Solutions• empower communities

and people via genuine involvement in design & delivery of public services

• public sector has to work in partnership to integrate service provision and improve outcomes

• prioritise expenditure on services which prevent negative outcomes

• reduce duplication and share services.

Lessons from home…Political: Strong public health steer from Scottish government. Fairly flat structure between government and NHS. Complex relationship between government and LAs. Public health seen as medical and NHS, but LAs have to adopt health

improvement mantle.

Cultural: Recognition of the need to tackle inequalities. Tendency towards

collectivism and collaboration. Resistance to private sector in health care.

Structural : Universal access, community development and integration to improve

public health and reduce health inequalities. Lack of co-terminosity between NHS and LAs restricts

joint planning and outcomes.

Less of that... and more of this?