I’m dying to tell you how to fix our health and social care system in Scotland – Kenny Steele

Categories: Opinion and Policy.

Everyone seems to agree that our health and social care system in Scotland needs radical reform but I’ve yet to hear a credible solution being offered.

Sometimes you have to get to the end of a story before everything makes sense. However in ‘the cradle to grave’ philosophy of our health and social care system we are failing to fully understand how the story ends and therefore failing to understand how to fix the problem.

Now for a shock statistic: 100% of us die in Scotland. That’s actually one statistic that makes us no worse or better than any other country.  Also more of us are going to be dying and needing care over the next 20 years as our population continues to age.

Of course it’s not about whether or not we die but rather how we die that should be vexing us. It’s at the end of our life where we require the most support from a system we’ve been paying for all our lives. So is it providing us with value for money? Are our current systems sustainable as more of us require end of life care?

Most people in Scotland die in hospital. 1 in 3 hospital beds in Scotland are occupied by people in the last year of life and emergency admission to hospital in the last 3 months of life accounts for the biggest use of hospital beds. However, if you ask people where they would least like to die- yes you guessed it- hospital. Where do we spend the most money caring for people at end of life? – yes you guessed right again- hospital.

Of course, this is not just delivering a double whammy of poor value. Many operations and procedures that we depend on for our quality of life are cancelled simply due to a lack of hospital beds.

In a recent study in Highland it was identified that around 70% of the identified funding (£45m) spent on end of life care was utilised on hospital care. Now of course, many people will continue to need hospital care at the end of their lives but it is estimated that between 20-40% of these people could be cared for at home if resources were reallocated .

This tells a story of a health and social care system that has become increasingly medicalised and specialist and which has invested in hospitals at the expense of primary care (GPs and District nurses) and the community /voluntary sector.

Highland Hospice has been piloting a Palliative Care Response Service in Inverness. This aims to provide responsive access to care at home within 4 hours in an emergency for people in the last 3 months of life. Over a 6 month period, 57 people were supported to die at home, with their families, who would otherwise have required hospital care. It is estimated to have saved a total of 798 bed days and nearly £0.5m savings for the system and has received overwhelmingly positive feedback from patients and families receiving the care.

So why are initiatives like this not being funded? The answer is that the system does not ration access to high cost health care- just phone 999 and ask for an ambulance. Nobody is turned away from hospitals (thankfully!). However, the system does ration access to low cost care that could prevent the need for a hospital admission or at least could get them back home more quickly.

This does not need radical reform, it just needs wiser use of resources.

So why are we failing to spend public money wisely when it comes to end of life care and what are the lessons for reform of our health and social care system?

We need to stop thinking about the NHS as an organisation but rather as a social contract. Government needs to start spending money in a different way if it wants to deliver the outcomes that are important to people. That means spending money wisely and in ways that will offer the best health and social care outcomes for the population.

It means using our hospitals for what they are really good at- fixing people when we are broken. But when it comes to long term care and supporting people with terminal illness we should be looking to community organisations such as Hospices to deliver high quality, holistic care that focusses on quality of life and delivers better value for the public.

Of course we are told that it is much more complex than this. But is it? It has been made complex by a massively bureaucratic uncompromising entity called the NHS which is currently in self preservation mode.

In Highland we have formed a partnership of over 20 organisations interested in improving outcomes for people at end of life.

Of course NHS Highland is an important partner but it is being led and funded by the voluntary sector. Yes, it is complex trying to work with so many organisations but in doing so we are able to deliver higher quality, more joined up care which will deliver far better value for our population- but to make this sustainable we need the government to shift funding from the NHS to these types of collaborative partnerships.

Every story’s ending is important – never more so than when dealing with end of life care. So let’s start finishing the story and learning some lessons for our health and social care system.


This article was published as a SPPC Blog on April 23rd, 2024 and is republished here with permission. 

This blog post is by Kenny Steele, CEO of Highland Hospice.

Highland Hospice have recently published Supporting end of life care in NHS Highland: Accounting for Value report.





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