BETTER HEALTH, BETTER CARE

UNISON Scotland's response to the Scottish Government Consultation on Better Health, Better Care: A Discussion Document

November 2007

Executive Summary

·         UNISON Scotland recognises the challenges described in the discussion paper and broadly welcomes the Scottish Government's proposals that build on existing policy. The NHSiS has been the subject of considerable change over recent years and staff need some respite from new initiatives to ensure some stability in the delivery of services. We particularly welcome the concept of a Minister for Health taking a cross cutting approach to health and most of the new policies outlined in the paper as these reflect priorities set out by UNISON over a number of years.

·         UNISON Scotland supports greater involvement of patients in the design and delivery of care. This is reflected in our long standing support for direct elections to health boards. However, the ‘patient voice' must complement and not replace the ‘staff voice'. The ‘staff voice' in partnership is the key to informed policy making and effective implementation. Scotland has a decade of partnership working which has a proven track record in delivering a better NHS Scotland, better services and greater patient satisfaction. The new Scottish Government should capitalise on ‘partnership working' as a key delivery mechanism for its plans. We are well ahead of the rest of the UK in making a success of genuine partnership policy. Partnership Working with the Staff Side is the best means for the Scottish Government to achieve its objectives for NHS Scotland.

·         Partnership working is the strong enabling force which will drive and support; service re-design, role re-design, increased capacity and skill and better delivery.

·         Decisions on centralisation must be evidence based, realistic in terms of staff recruitment and retention and ensure clinical safety.

·         UNISON Scotland believes further detail is required in terms if how the proposed waiting time guarantees would function e.g. what conditions would it cover, role and freedom of clinicians to determine need?. There are also questions over the boards' abilities to fund/resource blanket waiting time guarantees.

·         UNISON Scotland also believes that a key issue in determining the success of the provision of service should also be the outcome of treatment programmes - not just how long someone had waited for treatment.

·         UNISON Scotland recognises that NHS Scotland has a duty to use public money wisely and that we all have a right to know that money is being used effectively and efficiently to improve patient care. UNISON Scotland believes that this can be achieved through promoting and developing the Scottish NHS model based on co-operation not competition

·         UNISON Scotland believes that there is no place for the private sector in capital investment such as hospitals, GP surgeries; for clinical services delivery (such as at Stracathro); for community services (such as  the ‘Keep Well' pilots); or the provision of Facility Management Services.

·         NHS Scotland, through NES, must develop effective strategies to ‘grow our own' expertise and skills across all occupational groups, providing skills escalators and career paths using the KSF framework, backed by equitable investment across all job families.

·         The role of the voluntary sector  in the provision on health services cannot be underestimated. However, clarity is needed in terms of the investment strategy, procurement rules and assurances on pay and conditions (including pensions) of those involved in delivering services to ensure the use of voluntary service does not become another route to contract out services.

·         UNISON maintains the high cost of large acute projects is an impediment to the development of community-based services and the shift of resources necessary to invest in altering the balance of care.

·         UNISON fully supports the strategy of addressing health inequality. We also welcome the recognition within the consultation document of the link between poor health and other social factors. We strongly support joint working to reduce the inequalities in people's environments, income, employment, educational attainment, skills, housing and other issues that have the biggest impact on their health.

·         UNISON Scotland supports the abolition of prescription charges, as we believe them to be inherently unfair, inequitable, illogical and inconsistent

·           UNISON sees the introduction of public sector equality duties as a step towards a society where diversity is accepted as normal and equality as a benefit to everyone.

·           New priority should be given to the transition of services for Young Persons to adulthood, particularly for the most vulnerable ‘looked after' children.

·           Allied health professionals are enablers of self care and self management abilities and require deployment in sufficient numbers and with proper strategic leadership at Board level to deliver this agenda.

·           NHS should use existing best practice PIN policies to ensure parents working in NHS are given every support to give their children the best possible start.

·           Quality in-house cleaning services are key to tackling health acquired infections.

·           There is a need to re-focus the E Health Strategy.

Introduction

 UNISON Scotland welcomes the opportunity to comment on the Scottish Government's Discussion Document: Better Health, Better Care. UNISON is Scotland's largest public sector trade union representing over 160,000 members delivering public services, more than 60,000 of whom work in the NHS.  We represent the majority of the employees in the National Health Service in Scotland including senior managers, nursing staff at all levels, Allied Health Professionals, administrative and clerical, ancillary staff, laboratory staff, technicians and paramedics. We broadly welcome the thrust of the consultation document on the future of the NHS in Scotland: 

"We must do all we can to put the expectations of people and patients at the heart of decision-making in NHS ”(Nicola Sturgeon)> 

UNISON Scotland fully supports greater patient and community involvement in health planning and service re-design. Our response to the Kerr Report stated:

"UNISON supports the KERR recommended actions on p54/55. Our 58,000 members in Scotland and their families are users of NHS services and deserve a voice as 'consumer' interests. "

The ‘patient voice' must however complement and not replace the ‘staff voice'.

UNISON maintains that the workforce is the key to NHS capacity and service re-design. It is NHS staff who will deliver the NHS of the future and therefore their representatives must have a strategic role in the implementation of any changes. Representatives should be involved at all levels during the development of the implementation plan rather than asked to comment on a finished plan. Staff are in a unique position to contribute to the plan as they view the health service from within as providers and as patients or carers. Partnership working with staff representatives needs to be embedded in structures at all levels (within the Scottish Executive Health Department through the Scottish Partnership Forum, at Regional Planning Committees, in Area Partnership Forums and Community Health Partnerships) to ensure the success of Better Health, Better Care.

The ‘staff voice' in partnership is key to informed policy making and effective implementation. Scotland has a decade of partnership working which has a proven track record in delivering a better NHS Scotland, better services and greater patient satisfaction. The new Scottish Government should capitalise on ‘partnership working' as a key delivery mechanism for its plans. We are well ahead of the rest of the UK in making a success of genuine partnership policy. Partnership working with the Staff Side is the best means for the Scottish Government to achieve its objectives for NHS Scotland.

UNISON is keen to ensure that UNISON members' experience as health care providers informs the process of change and is integral to the development of the Scottish Government's New Action Plan for healthcare in Scotland.

The Challenge of Health and Wellbeing

UNISON Scotland is committed to transforming and supporting public services. Our Revitalise Scotland's Public Services principles underpin our approach to the Scottish public service model. We welcome the Scottish Government placing these values at the heart of its policy making. We believe the private sector has no place in helping NHS Scotland deliver better health and better care, be that in the construction and maintenance of new NHS facilities (PFI/PPP); clinical service delivery, (e.g. the Stracathro contract); community services (e.g. care of the elderly), ‘Keep Well' pilots; support services,( e.g. facilities management, shared services).

The NHS in Scotland has a highly trained and committed staff complement. There is a need to build on the well of human resource through a culture of improved leadership, collectivism, and engagement with all staff using the partnership approach described above

Substantial and sustained investment in education and training for all NHS staff groups is the key to unlocking capacity and to modernising models of NHS care.

UNISON Scotland recognises that since the publication of "Building a Health Service: Fit for the Future” in 2005, new insights, evidence and experiences have emerged which need to be considered in terms of progressing an action plan for the years ahead.

UNISON Scotland notes the approach to deliver on the Scottish Government's strategic vision in terms of health and wellbeing in Scotland, and the proposed new policies outlined in the consultation document and comment on these below.

CHAPTER 1 - IMPROVING YOUR EXPERIENCE OF CARE

UNISON Scotland notes the focus of the consultation document "putting the needs of patients at the centre of our health Service”. However, we also wish to highlight that the challenge of change can only in our view be achieved through mature partnership working with staff side organisations in NHS Scotland at all levels.

Partnership working is the strong enabling force which will drive and support:-

·         service re-design

·         role re-design

·         increased capacity and skill

·         better delivery.

This can be achieved within an employee relations environment which is stable, positive, constructive and forward-looking.

Patient Voice - Election to Health Boards

Our 160,000 members in Scotland and their families are users of NHS services and deserve a voice as 'consumer' interests. UNISON believes that directly elected Health Boards would strengthen the public and patient voice. We assisted in drafting of the Non-Executive Bill on this issue proposed by Bill Butler MSP in the last parliamentary session and are therefore supportive of the commitment to direct elections by the new Scottish Government. Of course further consultation will be required on the detail of how boards would be elected.

Centralisation

We accept that many members of the public believe that NHS care should be delivered locally.  UNISON supports the concept of local care which is safe, effective and sustainable. We accept the premise that the management of long-term conditions must succeed at local level, otherwise demand on acute services will continue to increase and will never be met. There is a need to invest in primary care and to co-ordinate the management of long-term conditions, through areas such as multi-disciplinary teams, integration of Health & Social Care; Continuing Care of the Elderly, care co-ordination/case management; community hub resource.

Nevertheless, UNISON recognises that there are cases where centralisation is the most appropriate method for delivering specialised services.  We would much prefer to see centralisation in Scotland of, say, Cardiac and Thoracic services, rather than Scottish patients having to go to England for surgery, as used to happen with Heart Transplants, because there was no expertise in Scotland.

The debate on centralisation should also involve the future of the Golden Jubilee Hospital in Clydebank, currently being used as the National Waiting Times Centre, and soon to become the West of Scotland Regional Heart and Lung Centre as well as a centre of excellence for major and minor orthopaedic surgery, with two additional operating theatres due to open at the end of 2007. 

UNISON believes that decisions on centralisation must be evidence based and realistic in terms of staff recruitment and retention and ensure clinical safety.

Waiting Time Guarantees

UNISON Scotland believes further detail is required on how proposed waiting time guarantees would function, e.g. what conditions would it cover, role and freedom of clinicians to determine need? There are also questions over the boards' abilities to fund and resource blanket waiting time guarantees. UNISON Scotland also believes that a key issue in determining the success of the provision of service should be the outcome of treatment programmes - not just how long someone had waited for treatment.

The establishment of a maximum whole journey time, complemented by annual targets to reduce the median waiting time, could ensure continued improvement. This would leave clinicians greater flexibility to use their own professional discretion about the order in which patients should be seen.

A blanket waiting time may have the inadvertent result of centralising services in some health board areas e.g. NHS Highland, as many consultants travel to outlying areas when there are enough patients for a full list to be treated. As waiting times come down, these remote clinics become less viable, resulting in a requirement for patients to travel to access clinics more quickly - when they may have preferred to have been seen locally.

Locally Delivered Services

UNISON supports the concept of local care which is safe, effective and sustainable. We accept the premise that the management of long-term conditions must succeed at local level, otherwise demand on acute services will continue to increase and will never be met. There is a need to invest in primary care and to co-ordinate the management of long-term conditions.

Patients Rights

UNISON Scotland believes that the rights of patients should be made clear in NHS Boards patients' charters as well as a minimum standard of accessibility to information for service users. These should complement the rights of staff enshrined in the Staff Governance Standard: to be properly trained; well informed; involved in decisions which affect them; provided with a safe working environment; treated fairly and consistently.

Transport

UNISON Scotland recognises that it is important that patients are supported by an effective transport system if they need to travel far from home in order to receive the kind of care that is only available in a specialist centre.

However, we also believe that transport issues are much broader than this, and should include the access of staff to transport to work as well as charges for parking for staff, patients and visitors at hospitals in Scotland. These issues must also be considered and transport and accessibility issues must be considered early in the planning process of where and when services will be delivered.

Information and Communications Technology

UNISON Scotland welcomes the commitment to improving and using technology to deliver health services. However, we do not believe that this can be realised without significant financial investment to set up the infrastructure required.

UNISON acknowledges the need for an electronic patient, record and quantum leaps in ICT provision for case management and care co-ordination. There is partnership engagement around the E-health agenda. However, UNISON maintains that NHS Scotland is too embroiled in 'partnership' with private sector companies around key ICT Infrastructure Projects. We do not believe that this will lead to long-term effectiveness or value-for-money.

Internal capacity and capability in ICT needs to be re-introduced and developed within NHS Scotland to be strategically and operationally effective in the long run.

Joint Working

Joint Health Improvement Plans must be supported by shared budgets and shared accountability for performance.  Best Practice should be identified and shared from current effective examples of joint working. There is a cluttered planning landscape around joint working and there needs to be greater clarity around the role and make up of local community planning partnerships and a clear vision and framework from the Scottish Government around outcomes and accountability.

It must also be recognised that the voluntary sector has a major role in the planning, commissioning and provision of services, as both service providers and accountable partners. There is a need for relevant information to be made available to all partners in the community planning process.

Remote and Rural Challenge

Delivery of locally based services is problematic in a number of remote and rural areas in Scotland. It is sometimes not safe or sustainable, not to mention best use of NHS money, to deliver services in some areas and therefore patients need to travel. A focus on a transport and accommodation system which supports patients (and their families) travelling to receive care is vital. It is also important that the high transport costs of NHS staff working in remote and rural areas in Scotland are addressed.

Moving services into a community is not a same cost option. Remote and rural services cost more to deliver and the provision of services in these areas requires different issues to be considered from urban areas. The provision of out of hour's services in rural areas such as NHS Highland is very expensive and whilst health outcomes and the value of money for these services are reviewed the extra cost is borne by the Board.

Travel reduction and improved access to the highest quality of care could be achieved through the rise of tele-health technology. Remote and rural communities have highlighted in the past that services designed for urban locations are not always appropriate for island and remote and rural areas in Scotland. It is also important to recognise that the retention of health services in some remote and rural areas is what makes many communities viable.

It is important that health policy is not designed to deliver a one size fits all approach, as this would effectively reduce the Scottish Government's ambition to deliver services as close to patients as possible.

Staff Survey

Systematic action to address staff survey concerns will improve staff morale and translate into improved patient experience on NHS Scotland. A particular priority is a Scotland wide campaign to eradicate bullying and harassment, in support of the good work achieved around violence to staff. As UNISON Scotland's recently survey on violence shows, the NHSiS has made better progress in improving the monitoring of violent incidents that other public service organisations.

Flexible GP hours

If hours are extended to enhance access then concerted efforts need to be made to ensure the full team of staff who support practice operation are on proper Agenda For Change contracts to safeguard the correct payments for working unsocial hours. Clinical staff have benefited from enhanced payments for Waiting Time initiative work denied to staff groups covered by Agenda For Change.

CHAPTER 2 - BEST VALUE

UNISON Scotland recognises that NHS Scotland has a duty to use public money wisely and that we all have a right to know that money is being used effectively and efficiently to improve patient care. UNISON Scotland believes that this can be achieved through promoting and developing the Scottish NHS model based on co-operation not competition, and in particular through:

• Directly employing and resourcing cleaning staff as an important element in improving hospital cleanliness and tackling infection.
• Developing a Food for Good programme of improvement to hospital catering that ensures that food is nutritious locally sourced and prepared by directly employed staff on fair pay and conditions.
• Ending incentives for the development of private sector involvement in NHS care and provide a level playing field between private finance and conventional procurement. Making sure public procurement ensures full compliance with Equality duties.      
• Employing student nurses on a proper salary as part of a series of measures to tackle drop out rates; reducing dependency on agency nursing and tackling exploitation and discrimination against overseas nurses, particularly in the private care sector. 

Other issues which must be considered in terms of investing to developing sustainable services which address the needs of a changing population in as efficient, effective and affordable way are;

PFI/PPP

UNISON Scotland believes that there is no place for the private sector in capital investment( such as hospitals, GP surgeries); for clinical services delivery( such as at Stracathro); or for community services, (such as the ‘Keep Well' pilots). UNISON Scotland has long been a critic of PFI/PPP over quality, costs, accountability, inflexibility and the effects on the terms and conditions of staff.  Scottish people want to see public funding of public services and an end to profiteering at the expense of hospital patients and the taxpayer. 

UNISON Scotland recently asked all health boards for details of any PPP/PFI contracts and Lothian Health Board refused to give details of the contract for the Edinburgh Royal Infirmary. However, following representations by UNISON, the Scottish Information Commissioner ordered NHS Lothian to release the whole Edinburgh Royal infirmary PFI Contract. Other Board's are now responding with greater transparency.

UNISON Scotland's recent report ‘At What Cost?' further highlights the huge additional cost of PFI, the unnecessary secrecy and most importantly a way forward for capital investment without PFI. Whilst we have no difficulty in principle with the introduction of a not-for-profit Scottish Futures Trust we believe that action can be taken now to abolish PFI without any lengthy constitutional wrangling.

UNISON believes that a new capital procurement regime should be established quickly which would enable health boards to develop essential infrastructure in the most efficient manner possible, without the expense of PPP/PFI until longer-term solutions such as the Scottish Futures Trust can be developed.

Investment in all NHS staff

Investment in public services must include investment in staff and training. Partnership Working is the key to empowering front-line staff. National Strategies for service change should be informed by debate in the renewed and refocused Scottish Workforce and Governance Committee and delivery will be assisted by the reform of SEHD structures. Strong and effective leadership is required. Develop its staff and NHS Scotland will develop its services and enhance quality. The wealth of knowledge, skills and experience of all NHS staff should contribute to change and innovation. Best practice needs to be systematic. The reference to improving and integrating workforce-planning processes for all staff groups on Page 8 of the consultation document does not make the link to education and training for staff, which is a vital element.

NHS Scotland, through NES, must develop effective strategies to ‘grow our own' expertise and skills across all occupational groups, providing skills escalators and career paths using the KSF framework, backed by equitable investment across all job families.

Affordability and Sustainability

UNISON recognises the high levels of current investment in NHS Scotland. There are however areas where value for money should be examined, in particular:

o    The economics of existing and any newly proposed PFI projects, including the quality and value for money of the provision of ‘soft fm' services.

o    The use of Private consultants by SEHD and Boards to support strategic projects. There is a need to build up in-house expertise in NHS Scotland and for it to be a ‘smart' client when it comes to commissioning large projects, particularly around capital projects.

o    The impediment of the high costs of large acute PFI projects to the development of community based services and the shift of resources necessary to invest in shifting the balance of care.

Standards and Quality   

Standards can only be raised by improvements, not only in clinical governance, but also Staff Governance considerations.

Role of Voluntary Sector 

The role of the voluntary sector and social economy in the provision on health services cannot be underestimated. However, clarity is needed in terms of the investment strategy highlighted on Page 8 of the consultation document, and assurances on pay and conditions (including pensions) of those involved in delivering services and ensuring use of voluntary service does not become another route to contract out services.

Community Based Services

Whilst hospitals can dominate public debate on the NHS - 90% of patient contact is in community settings. Action is required to:

• Make more use of salaried GPs working in NHS health centres supported by other directly employed community health staff.
• Develop and resource the implementation of the 21^st Century Review of Social Work.
• Invest in Community and District Nurse Services
• Expand community dentistry staffed by salaried dentists and their essential support staff.

UNISON Scotland notes the proposal on Page 8 of the consultation document to "develop incentives to shift the balance of care” from hospital to community based services. It is important that it is recognised that delivering community based services is not a cheap option; clarification will be required in terms of how this will be funded.

In this connection, however, the generic "Community Health Nurse” model, proposed by "Visible, Accessible and Integrated Care, the Review of Nursing in the Community in Scotland”, which will see a new role of Community Health Nurse replace the time honoured traditional roles of district nurse health visitor, school nurse, public health nurse and family health nurse, causes a number of concerns for UNISON.

Since the publication of the review, consultation has taken place in many areas throughout Scotland, including the four development sites in which the model has been tested since April 2007.  In each of these consultation processes, concern has been raised by practicing nurses, that the impact of the proposed changes to their roles will result in a reduction in the standard and range of services that are already available to the people of Scotland.

It is feared that rather than enhancing nursing practice within Scotland, the model being rolled out will have a detrimental effect on motivation, participation and retention of the many highly skilled and experienced community nurses practicing within Scotland. It is also feared that the generic post will mean a dilution of skills, with no benefit to community nursing practice other than apparently to cover numbers.

One of the primary concerns of staff in relation to the review of community nursing is that the vital elements of current posts focussing on public health promotion and ill- health - prevention will, as a matter of course, be relegated in terms of priority, against delivering acute health services. This would be in direct contradiction to the fundamental aims and objectives of both the review and the stated aims of "Better Health, Better Care”, particularly in relation to combating health inequalities, drug misuse, early years provision and services targeted to ill- health prevention and health education services.

The Scottish Government must address the concerns of community nurses on these issues in order to deliver on the aims and objectives set out in Better Health, Better Care”.

CHAPTER 3 - TAKING RESPONSIBILITY

UNISON Scotland supports the key focus within this section of the consultation document in terms of helping people to sustain and improve their health and encouraging and supporting people to take more responsibility for their health and well being.

Improving Scotland's health should be the priority recognising that poverty is the underlying cause. UNISON Scotland believes that key priorities should be to:

• Build on existing cross-cutting partnerships to address inequalities in health through health promotion and by addressing issues such as housing, employment, food labelling and fuel poverty.
• Promote health at school through education support staff, teachers and others supported by school and community nurses. Provide free, nutritious school meals, healthy snacks, sex education and enhanced physical activity.
• Enforce and support the ban on smoking in enclosed places through targeted smoking cessation programmes in areas of greatest need.
• Increase support to national programmes for improving mental health, and focus on high suicide rates, self harm and drug dependence.
• Introduce a new workplace health initiative that recognises the impact poor working conditions have on health.
• Developing a better environment through a comprehensive climate change strategy. The NHS should also lead the way with greener workplaces. Clean water and the effective treatment of waste are essential to any public health strategy. This requires the development of a democratically accountable public water service.

Health at Work

There is increasing evidence that many of our most intractable health problems are linked to the long hours culture and the increasing complexity and pressure under which many workers are placed.

There is a view that health conditions such as alcohol abuse, obesity, sexual and mental health, which are all rising in Scotland, are causally linked to this problem. We therefore need to consider a new wave of public health solutions. As an organisation with a key goal of addressing these issues, the NHS itself should play its part in terms of its own family friendly, flexible working and occupational health policies. The manner in which NHS Scotland as an employer deals with its own staff with addiction problems merits Scottish wide examination.

UNISON also maintains that the OHS Extra service, providing a ‘case management' approach to staff to avoid absence from work and to hasten return to work has been a success and should be rolled out throughout Scotland.

Smoking

The provision of smoking cessation services and the enforcement of the ban on smoking in public places will underpin the success of Scottish legislation. However, UNISON believes that it is important to recognise that smoking cessation is primarily about tackling a nicotine addiction and not a lifestyle choice. Specific cessation activity should be targeted at young people, young mothers and the elderly.

Dental Health

Dental health in children is a significant priority and should be linked to a healthy diet. Levels of dental problems in under five-year-olds are on the increase. Significant difficulties are faced by many individuals in seeking a NHS dentist and we support the outlined goal of attracting and retaining dental professionals, developing the school dental service and the creation of a third Scottish Dental School in Aberdeen. Community dentistry also requires planning for a high level of elderly patients with teeth.

Education

Recent television programmes, such as "Jamie Oliver's School Dinners”, have placed a spotlight on the quality and accessibility of school dinners. This impacts on the physical and emotional wellbeing and education attainment of our children. UNISON Scotland believes free school meals should be available to all children, which would reduce the stigma faced by those currently entitled to free school meals as we argued during the passage of the Schools Nutrition Act. We therefore strongly support the recently agreed pilot scheme.

UNISON values the contribution made by education support staff, teachers, health and community education staff and others to support health promotion within schools. We support a multi-disciplinary approach to working with young people in a range of different settings. There is a clear need for investment in staff development at all levels to develop skills mix necessary for individual and group support activities and to promote a positive experience for young people trying access services to deal with their health issues. A school nurse in every secondary school and its primary cluster should be the minimum provision.

UNISON believes that sex and relationships education is a community and family responsibility which should involve a range of agencies that have different but complementary roles, including school based programmes. They should be grounded in broad-based learning that builds on a wide range of life skills including self-esteem, respect for others, communication and emotional intelligence. Where young people have the necessary confidence they should access sexual health services as a couple. Growing levels of sexual infection require positive programmes. In addition to initiatives based in schools further support should be given to nursery staff and child and family centre staff to work with children and engage with adults to empower them to raise health issues with their child. Particular emphasis should be on supporting changes in behaviour with children and how families can help children live more active and healthier lives.

Physical Activity - Physical activity is an independent variable for coronary heart disease and stroke. We support the recommendations within the consultation document in relation to an increase in physical activity. However, consideration needs to be given to the access issues of school children and communities themselves to sports and physical activity facilities.

CHAPTER 4 - TACKLING HEALTH INEQUALITIES

UNISON Scotland welcomes the creation of the Ministerial Taskforce on health inequalities and the emphasis on greater targeting of resources to support the most disadvantaged people in our communities, including those with long- term conditions. We also welcome the recognition within the consultation document of the link between poor health and other social factors. We strongly support joint working to reduce the inequalities in people's environments, income, employment, educational attainment, skills, housing and other issues that have the biggest impact on their health.

In terms of "greater targeting of resources on services that support disadvantaged people and communities” UNISON Scotland believes that many challenges rest in this area in terms of cost implications and delivery.  It is also important to bear in mind that in targeting locations of areas of multiple indicators of deprivation, in many areas, people that require specific services can be hidden as they live in areas regarded as more affluent.

UNISON recognises the range of topic-based work to improve public health. With so many initiatives however, there is a danger of a fragmented approach and the use of less empowering models. In the interests of joint working, a more client-based approach is needed to support the efforts of our members within the local authorities. Community Planning Partnerships should be encouraged to focus on improving the health of specific care groups with the recognition that improving living standards is also an important strand of improving the health of local populations.

Mental Health and related issues 

UNISON supported much of the work taken forward by the previous administration for improving mental health and well being. However, significant investment is needed to sustain and mainstream development. Mental health spending is often the first to be cut from a budget in times of financial constraint.  It is vital that work continues to be taken forward to raise public awareness and promote positive mental health and emotional well being; to eliminate the stigma of mental health; prevent suicide and support recovery.

As is highlighted in the consultation document, Scotland has a rising rate of suicide, particularly amongst young men.  The rates of self-harm are also high and give cause for concern, particularly amongst teenage girls and younger women. Implementation of initiatives like "Choose Life” and "Breathing Space” must be expanded and supported to tackle these problems. The contribution of colleagues within the Voluntary Sector, in particular to mental health services must also be recognised and supported.

Public Sector Equality Duties

UNISON sees the introduction of public sector equality duties as a step towards a society where diversity is accepted as normal and equality as a benefit to everyone. Progress on tackling discrimination has been distinctly slow over the years and has often led to individual legal remedies that do not tackle underlying problems. The public sector equality duties are a fundamental change to this.  NHS Boards must demonstrate they are positively promoting equality rather than solely taking steps to prevent discrimination, both in terms of an increase in equality for service users and for staff. Action in this area must be monitored and reviewed to ensure progress is being made and to ensure they are delivering results.

Services for Children and Young Adults

UNISON Scotland believes this is an area that there had not been a great deal of focus on within the consultation document. It is essential that thought is given to the provision and funding of services for children and young adults, particularly in relation to the transition of services for patients from child to adult. Also, the particular group of ‘looked after children' should be a high priority for new strategic, multi agency input of investment and support.

Whilst supporting the broad thrust of the framework of discussion for tackling health inequalities in Scotland. UNISON Scotland believes that that further consultation should take place following the report of the task-force to Cabinet in May 2008.

CHAPTER 5 - ANTICIPATORY CARE & LONG TERM CONDITIONS

 "Challenge of shifting from reactive system of healthcare to one which seeks to anticipate and prevent health problems before they develop requires significant cultural change within NHS in Scotland.”

Whilst UNISON Scotland supports this objective, it recognises that it would involve a huge amount of funding to bring about such a change of culture.   With resources in many Board areas tied up in PFI contracts, it would by no means be the same cost option to transfer acute services to being delivered in the community.

Carers

Support and information to help patient and carers manage conditions would require additional resources to be allocated to the support of carers, particularly young carers. It must be recognised that carers are workers, an unpaid army of people who are providing services to patients that if they did not continue to provide, would have to be delivered by the NHS. The focus of resources would need to be in terms of provision of relief and financial support such as training and basic equipment.

Prescription Charges

UNISON Scotland supports the abolition of prescription charges, as we believe them to be inherently unfair, inequitable, illogical and inconsistent. UNISON Scotland believes in a National Health Service based on the ideals of a public service for healthcare which is free at the point of delivery and accessible to all.

These are the principles which have underpinned the NHS over 50 years and should still be the principle on which the current NHS is based. In our view, the current system of prescription charges is unfair in that it adversely affects many more people on low incomes and in chronic ill health. These are the people who find themselves unable to afford the medicines they are prescribed.

There are believed to be approximately 75,000 prescriptions in Scotland that are not dispensed each year, due to rises in the costs of prescriptions. According to evidence from the Citizens Advice Bureau this situation increases in line with every rise in the charges.

Over a number of years, five separate studies of the effects of charging for prescription medicines have concluded that increases in prescription charges lead to a decrease in the uptake of prescribed drugs. These and other studies have concluded that when patients do not take their prescribed medicine, this leads to deterioration in their health and can cause extra costs to the health service with admission to hospitals and emergency treatment. This is particularly relevant in treating coronary heart disease and strokes, the two biggest killers in Scotland. A greater take-up of medication could play an enormous part in saving Scottish citizens from the worst effects of these two diseases, which have a greater prevalence amongst lower income groups.

Other groups particularly vulnerable are those suffering from mental health problems. Whilst in hospitals, these patients have their medication freely available, but on discharge, there are no funds available to ensure that they can afford vital medicines, even if subject to a Compulsory Treatment Order. The current system is seen as illogical as there many life-threatening diseases not given exemption, whilst lesser acute conditions are included. Prescriptions for conditions such as chronic heart disease, arthritis, asthma, cancer, including chemotherapy drugs taken in the community, MS, Chronic Leukaemia, Glaucoma, Hepatitis C, HIV/Aids, etc. all have to be paid for. UNISON Scotland believes that the Scottish Parliament should follow the example of the Welsh Assembly and bring forward a programme to abolish all prescription charges in Scotland.

However, in the event of a successful passage of a Bill into law, we need assurances that staff employed in Prescription Pricing/Practitioner Services and Counter Fraud would be consulted over any changes to their jobs and be given adequate retraining over changes to their work practices.

UNISON Scotland supports the introduction of the proposed HPV vaccination programme.

We also approved of the proposals in Delivering Care, Enabling Health to support Nursing, midwifery and allied health professionals to become enablers of self-care and self-management abilities.  Our members are keen to implement these proposals but at present are not allowed to.  Such impediments must be removed.

We support the introduction of individual health plans for school pupils and would welcome an increase in the capacity of school nursing across Scotland.  However, as stated above, we believe that the implications of the current Nursing in the Community Review threatens the role of school nurses and would be detrimental to the health of children.

CHAPTER 6 - THE BEST POSSIBLE START

"Effective support to help parents meet the challenge of parenting in the earliest years”

UNISON Scotland supports many of the measures mentioned in the document which contribute towards the development of a child's physical and mental health and wellbeing. We believe strongly that early intervention is crucial to reducing reliance on care services and can prevent children from any future involvement in the criminal justice system. 

Early Years

UNISON Scotland believes in universal, flexible services for all children, provided by the public sector, delivering high quality early years education and childcare by appropriately trained professionals receiving appropriate levels of pay and we welcome the proposals to introduce a new Standard for Childhood Practice which gives professional recognition to nursery and childcare workers. The Standard will help build an integrated qualification and professional development framework for early years and childcare workers in Scotland.

UNISON Scotland believes that the public sector provides a better service and with more qualified staff than other sectors. Public sector providers are subject to greater scrutiny than those within the private and voluntary sectors and routinely face inspections by Her Majesty's Inspectorate of Education and the Care Commission as well as councils' own internal quality assurance procedures.

UNISON Scotland also has concerns regarding the funding of this sector. There are far too many funding streams which are ring-fenced, e.g., Childcare Strategy Funding, Surestart Funding, Free Education for 3 and 4 year olds and Changing Children's Lives Funding etc. These should be amalgamated into one fund to deliver integrated early years education and childcare targeting more money into providing further flexibility for parents by reducing bureaucracy.

The election of a new government has seen an invigorated campaign to extend the role of teachers in nursery education - worryingly for UNISON, often at the expense of nursery nurses. Statements by new SNP ministers before and after the elections, and increased lobbying by teachers suggest that the increasing role of nursery nurses in delivering and managing nursery education is under threat - similarities between the work of a nursery nurse and a nursery teacher, their relative qualifications and pay, and the need to ensure that early years workers were not sidelined in pandering to teachers' status. We believe that nursery nurses are fully-qualified, early year's professionals whose job requires professional discussion and reflection, based on a shared vision of their aims for children.

Looked-after Children

We believe that our children and young people deserve the best possible start in life to maximise their full potential.  However, this must also apply to looked-after children who, after many years of placement in residential care are left with no support when they reach the age of 18.  There are pilot schemes in some of our cities and these should be evaluated and rolled out to all boards and local authorities. 

PIN Guidelines on Flexible Working

To enable parents working in the NHS to best support their own children, the PIN guidelines on Flexible Working should be actively promoted in all Boards.

CHAPTER 7 - CONTINUOUS IMPROVEMENT

UNISON Scotland supports the drive towards a culture of continuous improvement and the pursuit of quality.  However, it has to be recognised that with an increasing older population and an NHS no longer being seen as an attractive employer will make the aim of continuous improvement in Healthcare more difficult to again.

There needs to be an investment in staff skills at all levels, using the   role of KSF as an integral part of workforce planning. Real money for training - e.g. clinical support workers must be provided so that all staff have options for career paths which suit their circumstances.  There is a need for proper career workforce planning tied to staff development.  It must also be stressed that transition careers for example, from auxiliary to nurse provide committed members of staff who must be supported by training and education.

Healthcare Associated Infections (HAIs)

Improving the quality of cleaning and ensuring that staffing numbers in ancillary and nursing are improved are one of the key ways to tackle the problems behind HAIs.  The quality of cleaning in hospitals has declined since the introduction of competitive tendering of hospital cleaning in the 1980s and the continuing outsourcing of cleaning at PFI hospitals. It is no coincidence that the lowest levels of HAI in the UK are found where there are the lowest levels of contracting out - in Wales.

The first comprehensive Scottish Executive report into HAIs released earlier this year shows that the problem of HAIs occur across all hospitals in Scotland. UNISON welcomed the report and the suggested monitoring, but believes that the service needs to tackle the root problems behind infections. What is required is to address the issues of cleaning and staffing that need to be resolved if the good work of the HAI task force is to deliver reduced levels of infection.

UNISON recommends a series of steps to tackle infection in hospitals, including:  improving the quality of cleaning, which is more likely to be effective than specific virus-related control measures; increasing the numbers of staff - both cleaning and nursing staff and setting minimum safe staffing levels for cleaning services; end contracting out, and bring back into the NHS family the cleaners in hospitals. Allow for greater involvement of staff:  cleaners, supervisors, nurses and managers, in setting and monitoring cleaning standards. Make sure cleaning staff have the best equipment, materials and training and ensure that all hospital staff and visitors make sure they abide by cleaning guidelines.

Whilst UNISON does not oppose pre-admittance screening for MRSA and other HAIs, it believes that this is not a panacea which will cure the problem in isolation and that new measures, in addition to those mentioned above, must be developed and introduced into hospitals across Scotland.

E - Health

UNISON believes that it is essential to involve the trade unions in implementing the new E-Health strategy.  Whilst resources are being targeted there is no apparent clear strategy. An effective E-health strategy will be essential to deliver on many issues outlined in Better Health Better Care consultation document and there needs to be a comprehensive assessment of the technology required to implement such a strategy.  There needs to be investment in skills to provide the IT services needed and these would be better delivered by using in-house internal skills, rather than outsourcing to the private sector.

For Further Information Please Contact:

Matt Smith, Scottish Secretary
UNISONScotland
UNISON House
14, West Campbell Street,
Glasgow G2 6RX

Tel 0845 355 0845 Fax 0141 342 2835

e-mail matt.smith@unison.co.uk