It is a great honour for me to chair the Parliament’s Health and Sport Committee and to open this debate on the committee’s on-going work on the preventative agenda. Members might be wondering where our report on the subject is. The fact is that our inquiry is at a very early stage and we asked for this debate in order that all members could participate from the outset and contribute to this piece of work. The Health and Sport Committee may be leading today, but the inquiry affects all members, most of the Parliament’s committees and every sector of Government. The preventative health agenda is a cross-cutting issue that involves education, justice, transport, housing, the environment, social security, culture and many other areas of Government.
When I was appointed as convener of the Health and Sport Committee, I made it clear that I wanted to run a very democratic and open committee and one that listened to real people. Over the past nine months, we have worked directly with patients, staff, carers and health professionals, not just lobbyists, policy officers and the politically connected. At our business planning event, we agreed a strategic plan for the committee that not only covers the current session but takes a much longer view of health and care. The overriding aim of the plan, which is short, concise and highly relevant to this debate, is:
“In all our actions ... to improve the health of the people of Scotland.”
That is fundamentally what this debate is about—improving the health of the people of Scotland. It is a matter not solely for the Health and Sport Committee, the Cabinet Secretary for Health and Sport or health professionals; as the motion makes clear, it concerns us all, whichever area we operate in.
Modern medicine is overwhelmingly reactive rather than proactive. People get sick, they seek medical assistance and—we hope—they are cured or made better. What is less common is the overarching community and national planning that focuses on prevention and early intervention, which is as much about housing, jobs, economic policy and environmental policy as it is about health and social care policy. The first paragraph of the Government’s “Health and Social Care Delivery Plan”, which was published in December, makes that very point, but that plan relates entirely to health services. I gently say to the cabinet secretary that that is a great pity, as the opportunity was missed to include other areas that, between them, hold the key to reducing demand on our health services while closing the inequality gap. Health inequality is a manifestation of social and economic inequality, and we will never tackle it from a health perspective alone. We have to take a whole-Government, cross-society approach.
A focus on prevention is not new but goes back through time, coming in different guises. The introduction of sanitation and clean water, slum clearance, council housing and the national health service are some of the most successful examples. That makes the point that the state has a very important role to play, and witnesses that we have heard from have been quick to point to the effectiveness of measures that use fiscal, regulatory and legislative levers to reduce exposure to harm and address inequality.
Such levers impact the whole population, rather than focusing on individual behaviours. Measures such as those that cover the sale and distribution of tobacco and alcohol, taxation of those products and other restrictions introduced to restrict smoking in public places are good examples. We need a dual strategy that includes treatment—yes—but has active prevention running alongside it.
The Christie commission on the future delivery of public services in 2011 did not believe that there was a “magic solution” to the current problem of resources being tied up in dealing with short-term problems to the exclusion of efforts to improve outcomes in the longer term. The commission saw no alternative but to switch to preventative action to avoid what it called “demand failure” swamping the capacity of our public services to achieve outcomes. It noted that it was imperative that public services adopt a much more preventative approach and address the persistent problem of the multiple negative outcomes and inequalities that are faced by far too many.
Also in 2011, the Finance Committee of this Parliament identified that all public spending could be classified as in some way preventative, and it sought from the Scottish Government a robust and measurable definition of preventative spending to be used across the public sector. It would be helpful if, in her contribution, the Cabinet Secretary for Health and Sport could cover that aspect and assist the committee with a working definition.
Moving forward to 2016, I note that in its report, “Changing models of health and social care”, Audit Scotland acknowledged what it called the “ambitious vision” that has been set by Government, but had as its key message the fact that the shift to new models of care is not happening fast enough to meet growing need. New models are generally small in scale and not widespread. Audit Scotland called for strong leadership and identification of measures of success, models of new investment and new ways of working. It called for a clear framework by the end of 2016 for how that ambitious vision was to be met.
The “Health and Social Care Delivery Plan” was the Government’s response. It aimed for high-quality services with a focus on prevention and early intervention. Prevention is mentioned frequently as a focus in the document, which speaks of a “lifetime-wide approach to prevention”. However, I say again that an opportunity is missed in the plan to think beyond the boundaries of health services.
A central part of meeting the vision is the national clinical strategy, with its focus on realistic medicine. The problems that we have in committee in scrutinising prevention remain the same as those highlighted by the Finance Committee in 2011—understanding how the shift to prevention is to be defined, how it is being planned and funded and how it can be measured.
That takes me to the committee’s work to date. In January, we agreed that we needed to understand what we were dealing with—what exactly preventative spend and preventative expenditure are. The Scottish Parliament information centre told us that those terms are both vague and conceptual and that all public expenditure could be argued to be preventative. It warned us that because of a lack of definition, public services can be fitted retrospectively under those headings. It also warned us that it is difficult to attribute outcomes to any one policy. We also noted another Audit Scotland report, “Changing Models of Care”, which urged effort to address the gap in cost information and to evidence the impact of new models.
We put out a call for views on the definitional question and on how such spending could be identified and tracked. We also asked how spending could be shifted from the reactive, on acute services, to the preventative, in primary services, and how that shift could be speeded up and incentivised. We received nearly 70 comprehensive and thoughtful responses.
In March, we explored those issues further with a group of expert practitioners in the public health field, with integration joint boards and with eminent academics. They confirmed difficulties with definitions and warned us about what they called “counterfactuals”—what would have happened anyway without interventions. We heard about false dichotomies when considering the relative merits of addressing social determinants of health versus carrying out more specific interventions. We were also told that shifting the balance of care does not mean the same as shifting resource. Community-based care will not necessarily save money, even if all the work to shift the balance is successful. We were warned of the need to compress mortality, to reduce the time people spend in ill health and to keep people healthier for longer.
Overall, however, most of them were saying the same thing to us—that we need a whole-system approach and joined-up government with a focus on reducing the shocking levels of health inequalities that we see in Scotland today. Fundamentally, we all need to agree what actions on the ground will make a difference and how the existing barriers to the use of resources can be tackled. I guess that we also need to know how we can measure the outcomes that are achieved—a subject that, I am sure, my colleague Ivan McKee will cover later in the debate. The committee was also told that the necessary evidence, information and data are available but that we need to get better at measuring them from the outset and interpreting them before using them. There is, however, a need to avoid the danger of paralysis by examination, modelling and testing.
We heard from the Midlothian integration joint board about work that it is undertaking to better understand its communities and about how it is using that knowledge to design new targeted, holistic interventions that look at the social determinants of people’s issues. It is measuring improvements or changes using gap indicators, which are, in effect, the measures that are being taken to close the gap. However, that work needs a long-term view and the conclusions are not always clear—we heard about the difficulty in making linkages between a single intervention and an impact—which may take us back to counterfactuals.
My time is not sufficient for me to fully cover our inquiry, but I have tried to give a flavour of what the Health and Sport Committee is looking to consider. Our next steps will be determined partly by what we hear today and partly by what members say. Should we look at discrete initiatives and evaluate how successful or otherwise they have been, trying to read their outcomes across into other areas, or should we focus on how improvement, outcomes and benefits are being evaluated? Could or should we do both? On our strategic plan and its focus on health inequality, should the committee focus on health inequalities and measures to address those only through the prism of health interventions?
I and the committee would really value members’ thoughts today. My one plea is that we all endeavour to take a longer-term view of the issue and to resist viewing the next election as the horizon. It seems as though we are having an election every five minutes just now, but the committee’s strategic plan commits us to at least a 15-year view.
We will see meaningful progress only with a concerted cross-governmental approach that is properly resourced, and it is absolutely appropriate that the issue is being discussed early in our work. Only by joint and joined-up action will progress be possible towards taking a preventative approach and tackling the root causes of health inequality.
On behalf of the Health and Sport Committee, I move,
That the Parliament recognises the importance of the work of the Health and Sport Committee in its inquiry into the preventative health agenda; welcomes its examination of policies and actions, which prioritise and build in actions to reduce demand on health in the longer term following on the work of the Christie Commission on the Future Delivery of Public Services, and the Finance Committee in 2010; notes that the cross-cutting nature of health inequalities also encompasses housing, education, justice, transport, the environment and other portfolios, and welcomes attempts to meet the growing demand for public services by preventing health problems before they occur by early interventions and by tackling causes as well as their effects.