The Royal College of Physicians of Edinburgh is an international organisation
based in Scotland with a mission statement to promote the highest standards
of medical practice. In April 2011 the College published “Health
Priorities for Scotland” recognising the health and financial challenges
facing the incoming Government. Both the summary and full report is available: http://www.rcpe.ac.uk/policy/health_priorities.php
The College is pleased to have the opportunity to respond to the Scottish
Spending Review 2010 and Draft Budget 2012-13. We welcome the commitment
of the Government to protect the core budgets of Health Boards and strongly
support the investment in preventative measures. The importance of long
term monitoring of preventative strategies cannot be overstated as the impact
on the causes of mortality and morbidity shift, particularly the effect of
delaying the onset of some diseases as the population ages – the health
benefits are clear but the financial consequences for Scotland are worrying. Specific
comments reflecting the 12 health priorities identified by the College follow:
- 1 Protecting timely
patient access to consultants
Accurate workforce planning is essential, especially in acute medicine where
unplanned admissions drive the activity throughout the hospital. If Scotland
wishes to make best use of her facilities and improve quality of care, investment
is required in the number of consultant staff involved with the acute medical
on-call. This is the only way to extend the working day for these trained
decision makers and allow time off in lieu to support safe practice.
- Protecting
time for training
The College notes that funds allocated to workforce and training budget lines
will increase modestly and then be capped for the next 3 years. Accurate
workforce planning is among the most pressing tasks facing NHS Scotland as
we will live with mistakes for decades to come. Quality of care depends
on retaining a full complement of skilled clinical staff and the global market
for doctors threatens the sustainability of services especially in the more
remote parts of Scotland.
-
Improving
hospital care for acutely ill patients
The College welcomes the priority on preventing admissions, particularly
for older people. However, the College is concerned that planners and those
developing alternate models of care may be placing too much faith in the
ability of preventative and community services to reduce the pressure on
acute medical services and inpatient beds. The numbers of patients inappropriately
admitted to hospital is low and the College refutes the assumption that the
majority of older patients are admitted for social care reasons.
The College strongly supports the aim to speed up discharge after admission
to hospital but highlights the long term benefits of comprehensive assessment
(often opportunistic, particularly for older patients), and the urgent requirement
for enhanced community based health and social care to facilitate a safe
early discharge. The College is unaware if detailed budgeting demonstrates
the affordability of this strategy.
In terms of the actual transfer of care between sectors, the current evidence
as summarised by the Health Foundation in 2011 suggests there may be
benefits of transferring care in a small number of medical specialties but
the evidence is very limited and there is a need for more research (including,
pilot studies) exploring the transferability of guidelines and protocols
and delivering robust outcome data (see 5 and 6 below). While the safe reduction
in acute admissions is an aspiration only, funds cannot be removed from the
hospital sector.
(Getting
out of hospital.pdf).
Implementing standardised clinical
documentation across Scotland including electronic access to the patient’s
record
The College notes that investment in e-Health is to be capped and warns
that this may not be sustainable if equality of access is to be delivered
across Scotland’s more remote and rural areas. Integrated care is
of particular importance to older patients and all patients with long term
conditions and e-Health innovations support the development of integrated
care; it is far from clear that the changes required can be delivered within
existing budgets.
-
Improving continuity
of care
Patients seek informed, competent and timely decisions by doctors with effective
communication skills. This is compromised by poor continuity forced on
the NHS in Scotland by the restraints of the Working Time Regulations and
the inability to cover current medical rotas. Locum use is excessive, handover
arrangements are erratic and training is compromised. Influencing the
Westminster Government on reserved issues such as EU legislation should feature
in plans if efficiency savings are to be viable and avoid clinical risks.
Ensuring care is based
on evidence based clinical standards that focus on patient outcomes
Staffing budgets may not obviously be affected by cuts, but the balance
of clinical and non-clinical time within individual contacts is swinging
away from work for the wider benefit of the NHS. Casualties include quality
initiatives such as SIGN guidelines, or the development of audit and research
to create the outcome measures that will monitor improvement and drive up
standards. The Quality Strategy will struggle to deliver its aims if consultant
time and motivation is not found to support this work. Workforce restrictions
and threats to the Excellence Award system in Scotland add to this pressure.
Evidence-based care is crucial at a time when service innovations are planned
to address patient demand and efficiency targets. For example, the College
supports the aim to maintain older patients in the community for as long
as possible, but it is unclear that this can be achieved in a cost effective
way and that clinical outcomes can be maintained or enhanced. It is essential
that the money allocated to the Change Fund is critically and systematically
reviewed through effective outcome measures.
- Implementing
medical audit
As 5 above. The quality of clinical data is equally critical to delivering
safe patient care and demonstrating the impact of changing health policy.
Medical time and investment in appropriate IT systems is essential to support
clinical leadership at a time when the NHS is committed to a 25% reduction
in NHS management costs.
Supporting
patients with long term conditions to remain in their own homes
This laudable aim will be successful only if healthcare staff have time
to devote to improving patients’ understanding of their own condition
and increasing the cooperative working between Primary and Secondary Care.
Transitional funding will be essential to avoid disruption to in-patient
services while community based teams are established and tested.
The continued support for the third sector is welcome along with the recognition
of the role and needs of unpaid carers. However, the College cautions
that this sector cannot carry a disproportionate burden of care for our aging
population
Preventing and
combating obesity
The balance of prevention and treatment is critical with a focus on effective
parenting to protect the vulnerable young and positive targeting of support
to address the clear inequalities aspects of obesity. The College warns
that access to exercise/sport and nutrition advice alone is insufficient
in the short term.
- Reducing the number of
people smoking
The College is pleased to note that the focus on tobacco control is to be
maintained, particularly as the spotlight moves from adults to children smoking
and exposure to second hand smoke. The College is a member of the Scottish
Coalition on Tobacco and commends the detailed evidence provided by ASH Scotland
on the burden of disease directly linked to tobacco and the clear inequalities
aspects of tobacco consumption in Scotland.
-
Reducing alcohol consumption
The College strongly supports a price based strategy to address excessive
alcohol consumption and is a founding member of the Scottish Health Action
on Alcohol Problems, which provides evidence-based advice to drive Government
policy and encourage public compliance. Again, it is reassuring that
budgets will be capped and not reduced given funding constraints.
Reducing hospital infection
rates and antibiotic resistance
Reducing infection rates creates an opportunity for both safer care and
efficiency, and the College notes the capping of this budget heading. Supporting
the public health infrastructure across Scotland to monitor and intervene
is essential to protect Scotland from drug resistance and from major disease
outbreak. In this regard, the College notes the increase in funding for pandemic
flu readiness in 2014-15 and seeks reassurance that this is part of a UK-wide
approach to infectious disease control.
