THE coming of the Scottish Parliament provides a unique opportunity to bring about fundamental improvements in Scotland's health. However, such gains are not automatic consequences of devolution, and the parliament will have to work hard to secure public consensus around solutions to a number of major challenges.
The first challenge will be to ensure a smooth transition of power from Westminster to the people of Scotland. The Edinburgh parliament must find ways of working which give effect to the widespread desire for more open, responsive policy-making. The parliament's health committee could involve not just MSPs, but also those who speak for users of the health service and those who work within it.
Similarly, these ''health partners'' could become more involved at the level of health boards and trusts. Since 1979, class inequalities in health in Scotland have doubled. A man from the lowest social class is now three times more likely to die before he retires than a man from the highest class. The second challenge for the Scottish Parliament will be to develop a public health strategy that will address and dismantle social determinants of ill health.
A Minister for Public Health, reporting to a Public Health Committee, might be responsible for commissioning research investigating the social determinants of health; for promoting social and political action to achieve health gains; and for collecting health and social statistics. The committee could oversee the work of different government departments in promoting public health, and might be able to initiate legislation, for instance on food safety, pollution, or housing matters.
For many individuals, support from the NHS and their local authority may be instrumental in allowing them to continue to lead independent lives. However, in some cases, the transition from NHS-funded to local authority-funded care is not easy. The third challenge for the Scottish Parliament will be to make this transition seamless.
Merging the NHS with local government is not practical because of differences in boundaries, the small size of some local authority areas, and the need to provide specialist services at a regional level. A more radical solution would see the abolition of health boards, with their responsibilities being transferred to elected and accountable central and local government.
A less radical approach might include resource pooling, where both agencies contribute to a fund from which care packages are purchased. In residential and nursing homes, a single national inspectorate enforcing common standards across the NHS, local government, private and voluntary sectors, along with national accreditation for the training of those who work in such homes, would enhance standards of care for all.
Patients expect that the treatments prescribed for them are likely to work. However, some ''well established'' treatments, and even some modern treatments, do not work. They may be part of medicine's unquestioned folklore, or the result of the understandable desire of doctors and patients to find treatments for disabling and life-threatening conditions. The fourth challenge for the Scottish Parliament will be to ensure that treatments offered by the NHS in Scotland work.
Although some progress has been made through the Scottish Intercollegiate Guidelines Network, the incorporation of evidence based clinical guidelines into routine practice is still some way off. The new Parliament will have to monitor and encourage their adoption. Serious concerns remain about the practicality of maintaining up-to-date evidence-based guidelines covering the range of NHS activity, and there is scope for international co-operation in a rolling programme of review. The development of guidelines based on healthcare will also make rationing decisions explicit and open to public scrutiny.
For too long important decisions affecting the NHS have been taken by those who work in it and with too little reference to the users of the service. On a personal level, the extent to which patients feel informed about, involved in and have ownership of their treatment has been too limited. A fifth challenge for the Scottish Parliament will be to promote the interests and autonomy of users of the health service. This will require the provision of up-to-date information, in an accessible form, on all aspects of the NHS, and the promotion of patient-directed care.
There are, of course, other important questions for the new parliament, including the future role of PFI in the building of new hospitals, and how best to work with the drug industry to secure value for money from the #650m NHS drugs bill.
This weekend's conference aims to begin the process of discussing what the health priorities of the parliament should be, and to ensure that those discussions are as broad, and as inclusive as possible.
n Dr Malcolm Macleod is Convener of the Centre for Scottish Public Policy Health Commission and a research neurologist in Edinburgh. He will be speaking this Sunday morning at the New Scotland conference in Glasgow, organised by the Centre for Scottish Public Policy and sponsored by The Herald. For details of timings and tickets for the whole weekend of discussion and debate phone the Tron Theatre box office on 0141 552 4267.
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