導入
ヘルスケアはスコットランド政府の支出が最も大きい分野です。NHS の回復、健康、社会福祉予算は今年 206 億ポンドになる予定です。これはスコットランド政府の総予算の約 3 分の 1 にあたり、公共サービスへの日常的な支出のほぼ半分にあたります。したがって、医療費に関する決定は、他の公共サービスに利用できる資金の額や、地方分権された税金を通じて調達する必要がある額に影響を与えるため、今後のスコットランド予算にとって非常に重要です。
スコットランド政府の主要な優先事項の 1 つは、「高品質で持続可能な公共サービスの確保」です。このコメントでは、2025 ~ 26 年度スコットランド予算に向けた幅広い取り組みの一環として、今年初めのスコットランド NHS パフォーマンス分析を更新します。まず、病院の活動がパンデミック前のレベルを大幅に下回っていることを示します。次に、待ち時間のパフォーマンスのさまざまな指標が過去 1 年間で悪化していることを示します。
全体を通して、私はスコットランドのNHSの実績をイングランドの実績と比較しています。スコットランドは長い間、国民一人当たりの医療費がイングランドより多く支出されてきましたが、この差は過去20年間で大幅に縮まりました。スコットランドとイングランドの医療サービスはどちらもCOVID-19パンデミックの影響を同様に受けており、そのためイングランドはスコットランドNHSの実績と回復を評価するための重要なベンチマークとなっています。
NHSの活動
まず、スコットランドにおけるNHS活動(治療を受けている患者数)が時間の経過とともにどのように変化したかを見てみましょう。図1は、NHS活動のさまざまな指標が2019年第4四半期(COVID-19パンデミックの影響を受けていない最後の四半期)と比較してどのように変化したかを示しています。パネルAは、日帰り手術(1日以内に行われる処置)、選択的入院患者(一晩の滞在で行われる事前に計画された処置)、緊急入院患者(病院に入院した緊急患者)、外来診療(完了するのに短時間しかかからない診療所での治療または評価)という4つの重要なタイプの病院活動を示しています。パネルBは、直接接触(対面や電話による予約など、臨床スタッフと患者との直接的な接触)と間接接触(処方箋管理、病院とのやり取り、検査結果と管理を含む)というプライマリケア活動の2つの実験的指標についてこの分析を繰り返しています。
Panel A shows that all four types of hospital activity fell sharply during 2020 as the NHS prioritised capacity to treat COVID-19 patients. Although activity has recovered somewhat in subsequent years, the numbers of patients treated by hospitals for most types of activity remain substantially below pre-pandemic levels. In the latest available data, for April to June 2024, overall acute hospitals in Scotland delivered 15% fewer elective inpatient admissions, 9% fewer emergency inpatient admissions and 6% fewer outpatient appointments than in October to December 2019. An exception is day cases, where hospital activity has increased substantially over the last year, and was almost the same (0.3% higher) in April to June 2024 as pre-pandemic. Nonetheless, total inpatient and day case activity was 6% lower in April to June 2024 than in October to December 2019. At the rate of increase in activity seen over the last year, it would take another two years for inpatient and day case activity to just return to pre-pandemic levels, and three years for outpatient activity.
The NHS in Scotland has taken steps to reduce demand on hospitals, which may partly explain why activity has not recovered to pre-pandemic levels. For example, the Centre for Sustainable Delivery (a national unit commissioned by the Scottish Government to improve Scotland’s healthcare system) aims to eliminate 210,000 unnecessary outpatient appointments this year. The Scottish Government also wants to reduce what it sees as unnecessary hospital admissions for older people. But alongside these efforts, the Scottish Government has many other objectives to increase hospital activity – for example, by using National Treatment Centres to deliver 20,000 extra surgery procedures. The Scottish Government’s NHS Recovery Plan, published in 2021, aimed to increase inpatient and day case activity to 15% above pre-pandemic levels by 2024–25. The Scottish NHS is far from achieving this target, and Audit Scotland has warned that it is not being transparent about performance.
Although the number of patients treated in hospital is lower, the average length of stay in hospital has risen since the start of the pandemic. This means that the overall number of inpatient hospital bed days is almost the same (0.7% higher) as pre-pandemic in Scotland. Higher length of stay could be driven by patients requiring more complex treatment than pre-pandemic, and therefore might suggest that hospitals are providing more healthcare than activity numbers alone would indicate. This may be in part because of the continued presence of patients with COVID-19 in hospital, a driver of higher average length of stay in England earlier in the pandemic. But higher length of stay could also be driven by challenges with system flow, in particular delays in discharging patients who are medically ready to leave hospital. In September, there was an average of 1,968 beds in the Scottish NHS occupied by adults who could not be discharged, compared with 1,521 in September 2019.
One factor unlikely to explain the failure of acute hospital activity to return to pre-pandemic levels is a shortage of staff. NHS staffing in Scotland is much higher than pre-pandemic. For example, the NHS in Scotland has 13% more consultants (senior doctors) and 12% more nurses and midwives in June 2024 than in June 2019. As we discussed in our previous report, this provides suggestive evidence that the labour productivity of hospitals in Scotland is substantially lower than pre-pandemic, as is also the case in England. Rather than staffing, it may be that a lack of available hospital beds is preventing further increases in inpatient activity in Scotland (the number of acute hospital beds is 5% higher than pre-pandemic, though the total number of hospital beds is 1% lower than pre-pandemic).
Hospital activity remains below pre-pandemic levels in Scotland, but this is not the case in England. As we have recently reported, NHS hospital activity in England is now substantially above pre-pandemic levels. For example, in April to June 2024 (the latest period we have data for Scotland), the number of elective admissions delivered in the English NHS was 8% higher than pre-pandemic, the number of emergency admissions was 2% lower and the number of outpatient appointments was 11% higher than in October to December 2019. Taking all of this together, hospital activity in both Scotland and England is increasing, but Scottish activity remains substantially below pre-pandemic levels. This is despite the fact that hospital activity in England has been reduced by frequent and widespread industrial action, which has not occurred in Scotland.
Measures for primary care activity are experimental. But they suggest that primary care activity in Scotland has recovered by more than hospital activity (Panel B of Figure 1). In the latest available data, for July to September 2024, GP practices in Scotland delivered 8% fewer direct contacts than pre-pandemic, but they delivered 16% more indirect contacts. The primary care sector therefore seems to have recovered better from COVID-19 than hospitals, although appointments remain below pre-pandemic levels.
NHS activity is an important measure of how well the health system is performing and how well it is translating its resources – staffing, beds, funding, and so on – into healthcare outputs. But what matters for a person needing treatment is the ease of accessing treatment and the quality of the treatment they receive. While it is hard to measure the quality of treatment in general, one important measure of NHS performance is how long patients need to wait for treatment.
Table 1 therefore shows how a range of NHS waiting times measures have changed over time in Scotland and England. The first column for each nation compares current performance with pre-pandemic performance, while the second column of each pair shows how performance has changed over the last year.
Starting first with changes since the start of the pandemic, NHS performance is currently worse than pre-pandemic across all measures considered in Scotland. The elective waiting list is higher (having risen from 362,000 in December 2019 to 725,000 in September 2024) and waiting times are longer. For example, the share of patients waiting less than four hours at AE is lower (falling from 81.6% in December 2019 to 65.9% in September 2024). The same is also true in England – across all measures considered, performance is worse than pre-pandemic.
There is a clearer difference between Scotland and England when it comes to performance over the last year. In Scotland, almost all measures of NHS performance have worsened over the last year. For example, the elective waiting list has continued to grow (from 692,000 in September 2023 to 725,000 in September 2024), and the share of patients waiting less than four hours at AE has fallen slightly (from 66.5% in September 2023 to 65.9% in September 2024). The only measure considered that has improved in Scotland is for diagnostic tests, where the share waiting six weeks or less has risen (from 49.8% in September 2023 to 53.6% in September 2024). But in England, most measures have improved over the last year. For example, a smaller share of patients are waiting more than four hours at AE, a larger share of patients are being treated within 62 days for cancer, and a larger share of patients are receiving diagnostic tests within six weeks.
This therefore suggests that hospital performance is still worsening in Scotland, while it is improving in England.
Conclusion
スコットランドのNHSのパフォーマンスは、多くの指標でパンデミック前のレベルを下回っています。さらに懸念されるのは、多くのパフォーマンス指標が過去1年間で悪化し続けていることです。その主な理由は、NHSの病院活動のほとんどがパンデミック前のレベルをはるかに下回っており、スコットランド政府の2021年NHS復興計画の野心的な目標からは程遠いためです。病院は全体的にパンデミック前よりも少ない患者を治療しており、過去1年間で改善は緩やかであるため、待ち時間が改善されていないのも不思議ではありません。実際、待ち時間のほとんどの指標で、過去1年間でパフォーマンスが悪化しています。
病院の活動をパンデミック前のレベル以上に増やすことができなかった理由の1つは、平均入院日数がパンデミック前よりもはるかに長いことです。これは、病院が治療しなければならない患者の複雑さが増していることを反映している可能性があり、これにはCOVID-19の患者が病院に引き続き入院していることも含まれます。しかし、病院の活動を増やすことができなかったのは、患者の退院に課題があることも反映している可能性があります。ただし、スタッフ不足では説明できない可能性があります。スコットランドのNHSには、パンデミック前よりも多くのスタッフがいます(ただし、スコットランドでのパンデミック開始以降のスタッフの増加は、イングランドよりも小さいです)。
イングランドのNHSのパターンは異なります。つまり、両国のパフォーマンスはパンデミック前のレベルを下回っていますが(政府や国民が望むレベルよりも低い)、スコットランドでは状況はむしろ悪化しているのに対し、イングランドでは改善し始めています。イングランドの多くの種類の病院活動は、回復目標にはまだ程遠いものの、パンデミック前よりも増加しており、ここで検討するパフォーマンス指標のほとんどは、過去1年間で改善しています。イングランドでは、前政権と現政権の両方がNHSのパフォーマンスと生産性の向上に大きな重点を置いてきました。スコットランドでも同様の重点が必要です。
スコットランド予算を展望すると、重要な問題は、このNHSの業績の悪さが、スコットランド政府に他のサービスと比較して医療費のさらなる増加を優先させるほどの影響を与えるかどうかだ。そして、予算決定とは別に、資金が適切に使われ、スタッフが効果的に配置され、NHSの生産性が向上するようにするという継続的な課題が残っている。これらはすべて、待ち時間を短縮するために不可欠である。