According to latest research from Centre for Public Policy for Regions (CPPR) and KPMG,, the rapid rise in health budgets across the UK over the last decade has improved health outcomes in all the constituent countries significantly, but there has been no narrowing of the relative health gaps between Scotland and England, despite a 12-16% higher spend per person and 30% higher staffing levels north of the border .
The report was triggered after a recent Nuffield Trust report[1] on the performance of the NHS across the UK which claimed that Scotland not only had the highest levels of poor health, health expenditure and staffing, but also had the lowest rates of staff productivity. Today’s report by the CPPR however found that data problems in relation to staff numbers and activity rates mean that many of the Nuffield Trust’s detailed findings, including those relating to staff productivity rates across the UK, were not robust. In addition, the Nuffield Trust report did not attempt to look at some of the needs factors that might help explain why spending on health varied across different parts of the country. These health needs factors can include sparsity of the population, levels of deprivation, behavioural patterns and length of illness – however at this stage it is difficult to conclude what the spending implications of these different needs may be.
Jenny Stewart, head of public sector for KPMG in Scotland, said, “As is now well known, we are entering a decade of austerity for the public sector. In Scotland, health spending has doubled in the last 10 years. We are now spending just short of £2,000 per head per year on the NHS in Scotland - some £212 - £267 per head more than in England. Huge improvements have been made in death rates, particularly cancer, heart disease and strokes, but the rate of improvement is no more than other countries. Given that funding will become ever tighter - while demand increases – we need to find more innovative ways to secure better health outcomes and focus strongly on productivity.”
Among the report’s key findings:
Staffing levels
Given the 30% higher staffing levels of the NHS in Scotland, Jenny Stewart of KPMG said, “The research suggests that we need a much better understanding of where and why staffing levels are higher in Scotland across all staff groups, including doctors, nurses, management, admin and support staff. With a lack of robust data on either staff levels or productivity it is not currently possible to compare productivity rates across the UK. [
Jenny Stewart continues, “In Scotland, we have large integrated Health Boards responsible for all services in their areas. We need to be able to demonstrate that we have delivered all the economies of scale that this type of management structure can bring.”
Jo Armstrong of CPPR also says, “Introducing an economic regulator into the health sector may be one way of encouraging further efficiencies. England is already doing this and Scotland may wish to understand what this new arrangement is achieving and also to assess the effect it may have on Scotland’s health Barnett consequentials.”
Life expectancy and mortality rates
Scotland continues to suffer from higher mortality rates than anywhere else in the UK for each of the main causes of death – cancer, heart disease and stroke, with the country’s high level of deprivation playing a significant role. Deprivation accounts for some 50% of the difference in excess mortality ratios over England, but much of the remainder, the so-called “Scottish effect”, remains shrouded in mystery.
Over time Scotland’s life expectancy has improved but not by as much as England. Decreases in mortality rates have been broadly similar between Scotland and England between 1999 and 2008.
John McLaren of CPPR says “Attempts to measure the length of ‘unhealthy’ life expectancy across the UK suggest that there is no longer a significant difference between Scotland and elsewhere in the UK, and that possibly it is even shorter. This implies that a longer period of treatment for illness cannot explain Scotland’s higher spend per capita.”
Deprivation, smoking and alcohol
Deprivation can help us understand around 50% of Scotland’s excess mortality rate over England but this explanatory power is declining and leaves another 50% that is difficult to explain, the so-called ‘Scottish effect’. Having such a large unknown element with regards to understanding Scotland’s relative health makes it difficult to know what higher spend, relative to England, would assist in narrowing the gap or where it would best be spent.
On behavioural patterns linked to deprivation, smoking has declined significantly in Scotland over the last 10 years, although the number of smokers remains higher in Scotland than elsewhere in the UK – smoking on average is 10%-15 % higher in Scotland than in England and some 50% higher for heavy smokers.
Rates of alcohol related deaths (ARDs) are more than double those in England, but the evidence over relative alcohol consumption is mixed. UK survey data shows Scotland exhibiting average UK consumption levels, but sales data suggest significantly higher sales in Scotland. This could imply that consumption patterns differ in Scotland or that some other factor(s) is combining with alcohol intake to produce such an effect.
Across Scotland and the UK, rates of ARDs were unchanged from 1979 to 1993, then more than doubled to 2002, before falling back slightly to 2008. This pattern is difficult to reconcile with rising consumption of alcohol figures over time. Furthermore, figures for Greater Glasgow Health Board showed rates of ARDs doubling in the 3 years after 1992, such a sharp increase in this relatively short period of time needs further exploration.
John McLaren of CPPR says: “Smoking apart, Scotland’s health related behavioural habits do not appear to be that different from the rest of the UK, on average. With regards to alcohol, however, the UK data does not allow a comparison of very heavy drinking levels. Sales and consumption data do not tie up and we need to understand that better. Although the consumption evidence is mixed, harm evidence is nonetheless still strong.”
Geography
It is an uncontroversial fact that, for geographical reasons, it costs more to supply the same level and quality of service in Scotland than England. Scotland has less than 1/10th of the UK’s population but about 1/3rd of its land mass. In addition, Scotland has a series of inhabited islands to service.
However, while the geographical spread of Scotland’s population can impact on health spending, available estimates suggests that this accounts for just 1-2% of the 12% - 16% higher spend identified.
The future
John McLaren of CPPR says: “Further work from the Scottish Government, NHS Scotland and the Glasgow Centre for Population Health should help improve our understanding of: causes of death: alcohol consumption and distribution across the population; the post smoking ban impact; and, especially with regards to the relatively high ‘mental and behavioural’ and ‘intentional self harm’ causes of death.
“In addition, we need to understand Scotland’s relative performance within the UK better, Greater comparability of UK health needs, health systems and behavioural patterns is required, along with the incorporation of lessons to be learnt from international evidence. This research should be conducted with an eye to what potential savings or reductions in demand with regards to future health budgets might be possible.”
Jenny Stewart of KPMG commented,“Over recent years declining productivity in the NHS, across the UK, as a whole has become a cause for concern. Improving productivity will be a key issue as future budgets tighten and demographic trends require that better health outcomes are delivered without rising resources.”
Richard Harris, Director of CPPR, commented “This report is a very useful contribution to the wide ranging debate the country will need on what its priorities ought to be, faced with the years of budget cuts to come.”