Urgent action is needed to tackle mounting pressures on the NHS in Scotland including “major workforce challenges”, with health boards struggling to recruit and retain nurses and other staff, the country’s chief auditor has warned.
The annual review of the health service by the Auditor General for Scotland found performance continued to decline in 2017-18, with the health service achieving just one out of eight key national targets.
“In the face of these pressures, a committed workforce has continued to work to deliver high-quality care”
The NHS in Scotland is “not financially sustainable” in its current form, with boards finding it hard to break even and increasingly relying on government loans and one-off savings, said the report.
Workforce issues were among key challenges facing the health service with recruitment remaining “difficult” in 2017-18, while sickness and turnover rates increased, found the review.
The auditor’s report showed nursing and midwifery vacancy rates were 4.5% in 2017-18, up from 2.7% in 2013-14. In addition, 30% of nursing, midwifery and allied health professional vacancies had been open for three months or more.
Most NHS boards overspent on their pay budgets and agency costs remained high having increased 38% in the past five years, said the report.
“The scale of the challenges facing the NHS means that decisive action is needed now”
In all, £165.9m was spent on agency staff on 2017-18, although this was a 5% real terms decrease on the previous year. However, the amount spent on bank nurses was £152m – up 5% on the previous year – with a 21% increase in spending in the past five years.
Withdrawal from the European Union would create additional challenges, according to the report, with 17,000 people from other European countries currently working in health and social care in Scotland – 4.4% of the workforce.
It noted that data from the Nursing and Midwifery Council suggested Brexit has already had a damaging impact on the number of EU nurses keen to work in the UK.
The review found sickness absence had increased to 5.4% in 2017-18 up from 5.2% in 2017-16, while staff turnover was at 6.6% up from 6.3% the previous year.
Meanwhile, staff survey results showed less than half – 46% – said they could meet all conflicting demands on their time at work, while more than a third – 34% – reported there were not enough staff to do their job properly.
Crucially, performance dropped against all eight national targets between 2016-17 and 2017-18, with the biggest decline in the proportion of children and young people needing child and adolescent mental health services (CAMHS) seen within 18 weeks.
“Simply put, patients and staff are not getting the support and resources they need”
Audit Scotland, which put together the report, said it had long warned of growing pressures including the tough financial climate, increasing demand for services, recruitment difficulties and rising public and political expectations.
“In the face of these pressures, a committed workforce has continued to work to deliver high-quality care,” stated the report.
“However, the demands of a growing and ageing population on top of these pressures mean the current healthcare delivery model is not sustainable,” it said.
It highlighted that major change was needed to keep the health service afloat and called for a more robust approach to financial management and efforts to strengthen leadership and governance.
“Leaders play a crucial role in developing and delivering change. There is evidence that the NHS is struggling to recruit and retain the right people, and ensure they have the time and support they need,” said the report.
Meanwhile, it said detailed workforce planning was “overdue” and said the government must work with NHS boards and integration authorities – which oversee primary, community and social care services – to develop a comprehensive approach that reflected future staffing requirements and costs.
“The nursing profession is in no doubt that Scotland needs legislation on safe staffing”
Caroline Gardner, Auditor General for Scotland, said solutions lay in changing how healthcare was accessed and delivered but added “progress is too slow”.
“The scale of the challenges facing the NHS means that decisive action is needed now to deliver the fundamental change that will secure the future of this vital and valued service,” she said.
“Alongside longer term financial planning, this must include effective leadership, and much more engagement with communities about new forms of care and the difference they make to people’s lives,” she said.
“This will help to build support among the public and politicians for the changes required,” she added.
In response, Scottish health secretary Jeane Freeman maintained that her government was already taking forward the recommendations in the report.
“Under this government, NHS funding has reached record levels of more than £13bn this year, supporting substantial increases in frontline NHS staffing, as well as increases in patient satisfaction, reductions in mortality rates, falls in healthcare associated infections, and Scotland’s A&E performance has been the best across the UK for more than three years,” she said.
Key developments cited by her included a new waiting times improvement plan that would see £850m put into improving the experience of patients waiting to be seen or treated.
She said efforts to shift care from hospitals and specialist services into the community meant “more people are receiving care in the right place and the right time and able to live independently for longer”.
Meanwhile, the government’s Medium Term Health and Care Financial Framework, published earlier this month, was “another important step in driving forward more improvements across our health and social care system”.
However, opposition politicians said the Auditor General’s report showed the government must do more. Scottish Liberal Democrat health spokesman Alex Cole-Hamilton said the challenges it outlined were “taking the NHS to the brink”.
“Simply put, patients and staff are not getting the support and resources they need,” he said.
He added: “That’s why we are calling for a step change to how we treat mental health, an end to bed blocking, new workforce planning measures to ensure our health service has the staff it needs and an exit from Brexit which threatens to have a huge impact on staffing and medicine supplies.”
Theresa Fyffe, director of the Royal College of Nursing in Scotland, said: “Workforce planning to meet the actual demand on NHS services is vital and it is welcome to see that receive such emphasis in this year’s report.
“The message from the Auditor General around recruitment and retention challenges in Scotland’s NHS underlines what those in the nursing profession have been warning about for a number of years – an unsustainable pressure on staff to deliver more care,” she said.
“This leads to staff burnout and, in some cases, a choice between staying in the profession and their own health,” warned Ms Fyffe.
But the RCN leader highlighted that the Scottish government was in the process of introducing legislation on safe staffing, in a similar way to Wales.
The Health and Care (Staffing) (Scotland) Bill is currently before the Scottish parliament and, if passed, should ensure Scotland had the “right number of nursing staff, with the right skills and experience, to deliver care to all those who need it”, she noted.
She added: “The bill is not just an opportunity to enshrine safe staffing in law, but a chance to get the processes which support long-term workforce planning right.
“This will take investment in services and in those who deliver them,” she said. “But the nursing profession is in no doubt that Scotland needs legislation on safe staffing for the wellbeing of staff and, crucially, for the safety of patients.”