John Swinney, the Cabinet Secretary for Finance, will reveal the nation’s budget next week. And when all around are preparing to feel some real financial pain, the NHS in Scotland will emerge unscathed, even getting a small budgetary increase.
But does the NHS deserve more money? Most would immediately say yes, but look at these ten killer facts and then decide:
First up, the context. The burd has discovered heaven in the form of the Costs book for NHS expenditure. There are more data spreadsheets in here than even I know what to do with. The Costs book covers 93% of all NHS Scotland expenditure across 16 NHS Boards. In 2008-09, they spent £9.3 billion, an increase of 6.1% on the previous year. So what did they spend it on?
- Expenditure varies hugely from hospital to hospital and from board to board. For example, it cost £105.5 million to run Yorkhill children’s hospital but only £49.8 million to run Sick Kids hospital in Edinburgh; it cost £140 million to run Wishaw General hospital (whose standards of cleanliness were criticised in a recent inspection) but only £136.8 million to run Raigmore hospital in Inverness; and it cost £255.8 million to run Ninewells in Dundee but only £209.8 million to run Southern General hospital in Glasgow. Who’s the daddy in hospital expenditure? The Edinburgh Royal Infirmary coming in at a hefty £328.4 million. There may well be a rational explanation for these differences but drilling down into the areas of expenditure actually reveals more anomalies.
- How about average cleaning costs per square metre of hospital? You might expect it to cost more to clean smaller hospitals and particularly smaller rural hospitals. But does that adequately explain why it costs £58 to clean a square metre of hospital in NHS Borders but only £32 in NHS Fife? You might expect some difference in catering costs too, but surely not a cost per patient consumer week of £252 in NHS Shetland and one of £83 in NHS Ayrshire and Arran? The average cost in Scotland is £75 yet NHS Greater Glasgow and Clyde manages to spend a paltry £71. Economies of scale perhaps? But could lower cost also mean lower quality, in one of the unhealthiest areas in the country.
- Running costs too are an eye-opener. Try this one: spend on heating and lighting in hospitals rose by 22.7% on 2007-08, to £87.7 million. Yet, reducing energy consumption is one of the HEAT targets and has in fact fallen steadily since 2003. In 2008-09, it fell 1.2% on the previous year. So how to explain the increase in costs?
- These HEAT targets are a vital part of the equation. They measure improvement in key areas of the nation’s health. So let’s look at child health. And here is a fact that frankly makes the burd gag. As a nation, we spend more on providing GP out of hours services than we do on child health. Yep, that’s right. Paying for the privilege of GPs being able to have weekends off (£84.8 million) costs us more than making our weans healthy (£73.3 million). Only in Scotland. But spending on child health has actually rocketed in recent years, more than doubling from £30.4 million spent in 2005. Is that money improving the wellbeing of our children? Not according to the HEAT targets, of which there are three for children: to reduce childhood obesity, increase the number of babies exclusively breastfed and the number of preschool children registered with a dentist. On this latter target, progress has been good, with the target of 80% of all children to be registered by 2011 surpassed in June 2010. But breastfeeding is still limping along at just over 26%, as it has been since 2007, with a target of 33% to reach by 2011. And on obesity, the target of 6317 healthy weight interventions by March 2011 ain’t gonna be met: only 1584 had been achieved by March this year. So we spend a woefully low amount on child health, yet the money we do spend is making very little progress in improving children’s health in two key areas. Shame on us.
- Labour has accused the SNP Government of cutting staff in the NHS in recent years: certainly staff costs have gone down, in hospitals and particularly in community services (from 69.5% in 2008 to 64.9% in 2009). Fewer staff? More, cheaper staff? Hmm.
- There are other lower costs too. Something, perhaps, that should cheer us but actually they are quite puzzling. For example, hospital theatres are being used for fewer hours per week. Fewer people needing surgery and therefore a good thing? Or not enough staff and money available to maximise their usage? And why is the average hospital theatre only in use for 26 hours per week?
- Ah but spend on catering has gone up from an average of £59 per week in 2005 to £75 per week in 2009. Hurrah! Yet, shamefully people still die of malnutrition in Scottish hospitals every year and few people would testify to the quality and healthiness of hospital food. And hang on, that’s £75 per week per patient – about the amount I spend on feeding a family of three.
- Here are a couple of facts that should interest local authorities. The resource transfer from health boards to local authorities to contribute to the costs of community care fell in 2009. That’s right, despite record increases in funding, despite having more to spend, NHS boards chose to share less of it with councils, leaving them to pick up more of the community care tab. The amount of money transferred fell by £22 million or 7%.
- At the same time, the NHS has been subject to lower efficiency savings. Under the HEAT targets, the NHS has been expected to save 2% every year by improving efficiency. During the same period, councils have had to find savings of 5%. Hardly a level playing field then.
- Would any of this matter if the NHS was delivering better health for the nation? Of course not. But a glance at the HEAT targets shows a real mixed picture of progress, so finally, let’s look at two where performance is pretty woeful. The first would do much to improve efficiency, that of moving to electronic referrals between GPs and consultants for outpatient treatment. The target is 90% and despite remarkable progress from the low starting point of 8.7% in April 2009, only 62% of referrals are currently being made electronically. And as it’s so topical, how are we doing on reducing problem drinking? Well the NHS was set a target of appropriate brief alcohol interventions – no I’m not sure what that involves either but it doesn’t sound particularly pleasant – of 149,449 by March 2011. By March 2010, it had made a total of 82,564 interventions over two years. The rate of interventions will have to almost double if the target is to be met. What it doesn’t measure of course is the rate of success of any of these interventions in actually reducing the number of drinkers. Small point really.
Does the NHS deserve more money? No, not if it means other areas, such as education, social work, police and fire services, all taking a bigger hit to keep our bloated, inefficient, underperforming NHS in the style to which it appears to have become accustomed. There’s still time to change your mind, Mr Swinney.