Contribution from the Scottish Joint (Medical) Consultative Committee – represented by doctors from across the Scottish Medical Royal Colleges and the British Medical Association in Scotland.
Doctors across Scotland have a vitally important part to play in the discussion about the future of the NHS in Scotland.
There is overwhelming agreement, most recently emphasised by Audit Scotland, that while it remains one of the safest health services in the world, the NHS in Scotland is now facing unprecedented pressures. Increasing numbers of people are living longer lives with the amount of time they spend in need of support from the NHS also growing, alongside continuing constraints on resources and increasing unfilled medical posts. Doctors therefore welcome the decision by the Scottish Government, with cross-party agreement, to embark on an open and honest debate with the public about the future of the NHS in Scotland. It is only through a national recognition of these challenges and a collective agreement on how to tackle them that we will secure the healthcare we expect for everyone in Scotland now and into the future.
As an initial contribution to the debate, a group representing doctors from across the Scottish Medical Royal Colleges and the British Medical Association in Scotland set out below a number of their key areas of concern and some questions for public consideration.
First – some facts.
The likelihood of living with more than one illness increases with age, and with over 70 % of people aged 75 and over living with multimorbidities, and the number of people aged over 75 almost doubling between 2012 and 2037, the number requiring care and support to manage multimorbidities could be expected to increase at the same rate.
An analysis of the impact of this ageing population on demand for hospital beds was carried out recently for NHS Forth Valley. It showed a projected increase in time spent in hospital for those aged 65 or over from around 2500 in 2014, to over 4600 (an increase of 84%) by 2035 – a new, additional hospital would need to be built in Forth Valley alone, unless care is remodelled and provided in a different way, in a different setting. This analysis could be replicated in every health board area in Scotland and illustrates clearly that continuing to deliver services using the current models and pathways of care is simply not possible.
The level of funds available to the Scottish Government in Scotland in 2009/10 will not be reached again in real terms until 2025 under current resourcing plans. Unless government changes the prioritisation of public sector expenditure, or increases the overall level of funding, we can expect that the funds available to the NHS in Scotland will be constrained in a similar way.
Hospitals and GP practices are seriously struggling to recruit doctors to existing vacancies. 34% of GPs in Scotland said they intended to retire from general practice over the next 5 years while 14% said they intended to move to part time working. In hospitals the situation is just as challenging – there has been an almost 30% increase in the number of consultant vacancies (in the year to June 2015) with a doubling of those vacant for over 6 months during the same period. The total vacancy rate for consultants in Scotland hospitals stood at 8.3% in June 2015 – with a huge variation in the level between locations and specialties across Scotland. In some areas the vacancy rate is well over 20%. Compounding this, junior doctors are increasingly choosing to move abroad during or after training where they expect to find better working conditions. This level of vacancies is having a huge impact on the cost of locums/temporary cover. According to the most recent Audit Scotland report, there was a 15% increase in expenditure on all temporary staffing between 2013/14 and 2014/15.
A recent piece of research carried out by Dundee University uncovered some serious concerns amongst consultants in Scotland, and a strong sense of frustration that their views are not being heard, and that they are therefore finding it difficult to influence those who are trying to plan for the future.
This increasing problem in attracting and retaining doctors in Scotland is already affecting the ability of hospitals to deliver services in some areas.
Our NHS needs to change.
It is clear that without significant additional resources (human and financial), the status quo in terms of the existing models of care and range of services is no longer an option.
The First Minister and the Cabinet Secretary for health and social care have recently announced additional investments of £200m and £60m in new centres for routine operations and for primary care respectively. These commitments will require significant involvement of the medical profession to ensure that these investments deliver the best and most sustainable benefits for patients. However this is just the tip of the iceberg, and as the Cabinet Secretary acknowledged herself in response to the most recent Audit Scotland report, much more is needed, at a greater pace, if the ambitions we have for a health service fit for 2020 and beyond are to be realised. The total amount of money spent on the NHS in Scotland in 2014-15 was £11.7bn. These new increases represent only 2% – and they are for a short period only. We are facing an increase in demand from the over 75s of around 100% in the next 20 years.
The continued focus by politicians and the media on a small number of high-level national targets is distorting clinical judgment, skewing scarce resources away from those patients who need the most care, and creating an unhealthy culture within health boards which is contributing to the recruitment and retention challenges in Scotland.
A review of the now outdated approach to targets should be undertaken to ensure that priorities in the NHS are not skewed, and that clinical judgement is prioritised.
It is vital that the NHS adopts measures to stem the tide of doctors leaving the NHS in Scotland to work elsewhere. In addition, supporting return to work either from overseas, research or maternity leave could enhance the existing medical workforce.
The answer to the current recruitment and retention challenge is not simply to produce more doctors in Scotland to fill the gap in demand for NHS services. It takes 10-15 years to train a doctor so it is vital that NHS Scotland markets itself as a good employer where doctors can expect to be employed on fair terms and conditions; where training opportunities are part of professional development; where contributions to medical research are valued. Scotland must continue to diverge from the approach being taken by the government in England and work with doctors to find a fair approach which makes Scotland a preferred destination for medical training and working. We need to work together across Scotland to identify innovative approaches to creating attractive options for doctors, which are internationally competitive.
Some important questions need to be considered by politicians and the public –
- The NHS in Scotland will require more resources to retain the current range and locations of services. Do we want to spend more money on the NHS?
- How much would taxpayers be willing to pay for new drugs and treatments, for new staff to deliver services, and to support people living longer healthier lives?
- How far would people be willing to travel for the most complex treatments to ensure they are high quality, world leading and secure for the future?