All across Scotland a debate about the NHS and how its services can be preserved amidst these new financial strictures is bubbling beneath the media surface. Above the surface, what debate there is about health focusses on waiting times and budgets. But what really matters to people is the health service they receive and how effective it is.

In the early noughties, the new Scottish Parliament  sought to persuade councils and the NHS to work more closely together in the area of Adult Social Care by forming Community Health Partnerships. This drifted along for a couple of years without notable success and then the NHS Reform (Scotland) Act of 2004. The development of CHPs in 2004 was intended to build on the success of partnership working up to that point, and included a strong focus on organisational development to support new ways of working across health and social care.

In 2010, the Scottish Government took stock with a paper called Integration across Health and Social Care Services in Scotland. Though it put a brave face on things, it was hard-pressed to find much evidence of any progress on integration that might have been expected after the best part of a decade. This problem was caused by the two would-be partners for similar reasons—basically the “aye been” inertia that comes from organisations that have been left to live within their comfort zones for decades.

Neither councils nor NHS were used to working on projects together—let alone sharing resources and/or budgets. Both were proficient at attending meetings from which minutes gave the impression of progress. But, in truth, nothing much has happened. Like the ‘Shared Services’ agenda whereby Scotland’s 32 councils were expected to merge departments with each other to economise on overheads, CHPs, although formed, have remained a damp squib in terms of real progress.

Both partners are to blame but (with a couple of laudable exceptions like Highland) the NHS has been consistently worse. Their plans for rationalisations or for hospitals have soaked up all their attention and (more importantly) all their capital and the total absense of any democratic control has meant they have stonewalled and dared councils to do anything about it.

The East Lothian picture is pretty representative. The massive PFI project that is Edinburgh Royal Infirmary soaks up huge NHS Lothian revenue without paying a single nurse. The Musselburgh Primary Care Centre opened this year to serve the western half of the county. Its costs are a mystery because 2009’s 50-page Full Business Case may be public but it has had every figure (including risk factors) redacted out of it. It looks like an expensive hospital more than a Health Centre and may be why NHS Lothian has been dragging its feet for over a decade to provide the other key local component‚a ‘Community Hospital’ in Haddington to replace the badly ageing Roodlands.

But this is where the bean counters and people’s priority clash nastily. The obverse of a new CH (although no-one in NHS management will admit it) is to close the remaining small hospitals in Dunbar (Belhaven) and North Berwick (Edington). Any time this has been rumoured, the pitchforks and burning torches have been out in force.

The Edington is a GP-referred cottage hospital (9 beds) in North Berwick of the type that does not lend itself to low cost-per-bed stats. On the other hand it has 220 admissions a year and has an unequalled record of patient care/recovery and minor injury provision, partly because of joint working with the adjacent doctors’ surgery. A review of The Edington operation is underway by NHS Lothian, taking on board the imminent need for joint provision for the elderly with East Lothian Council.

A year of discussion with a forum of people from NHS Lothian, ELC, NBCC, the GP practice and Edington staff resulted in an obfuscation paper from NHS Lothian that was both incomplete and written in bureaucratese. It seems clear that, unless the community and those outside the NHS define their concept of a future and how it might be achieved, the NHS is using a classic inertial strategy to close it.

But though both the Edington and its co-located Health Centre are badly in need of upgrade, they are, in fact, a splendid example of effective community health work. Rolling together the related facilities expected with the NHS/ASC merger into a single campus actually makes both the most financial AND operational service quality sense, provided none of the components are forced to pay for it alone. The related facilities that a town of North Berwick’s size can reasonably expect are:

• A GP surgery of more doctors provided in business hours with callout 24/7
• A well used minor injuries clinic (including 20% for tourists/visitors) 24/7
• Convalescent care for local patients recovering from serious illness/surgery
• Residential care for elderly still capable of mobility and limited self-reliance
• Palliative care for end-of-life circumstances
• Supervisory care for those still physically capable but suffering dementia
• Respite care for those who normally reside at home with home help

Although NHS claim that the Edington site is not sustainable within budgets that public bodies are able to provide, nor is the site adequate for expansion, this is taking a narrow view. It may also make sense to cast the net wider and include NB Day Centre and Gullane (Health & Day Centres already in train for a joint building) in the discussion so that all local facilities and the strengths they offer are considered.

If the Scout Hall (across St Baldred’s Road) were located elsewhere and the site purchased, this could be redeveloped to accommodate a larger GP surgery with nurse station and minor injuries service. The space currently occupied by the surgery could then be redeveloped on more than one floor as an extensive adjunct to the Edington that would have several wings/wards that each specialised in one of the list of services listed above. This would include ELC’s present 28-bed care provision at the Abbey.

Map of Edington Area Showing How a Health Centre (lower red) Could be Replaced by Care Extension (upper red)

The new care extension would intrude on the present car park and, possibly, into the Lodge Grounds. A pedestrian access through the Lodge could access long-stay & staff parking in the upper Glebe. Those with appointments and other short stay would use the remaining car park. The Community Centre car park provides a temporary measure until the Glebe was completed.

Keeping all health and care facilities in the one place still capitalises on the superb personal and responsive service that adjacent doctors surgeries provides and preserves the excellent recovery statistics. Extending the Edington itself to around 30-40 beds, most of which would be non-medical residential/respite/etc retains the high quality care for which the Abbey is known.

But most of all, rather than freight people to/from Edinburgh and/or Haddington (which no-one outside Haddington considers a ‘community’ facility), the benefits to patients of the present arrangement would be preserved and the NHS goal of ameliorating their precious cost-per-bed statistics would be addressed.

What we have here in North Berwick is a gem: the ingredients of a totally new, cross-authority opportunity to address problems that all those involved with health, especially of the elderly, need to address before the demographics overwhelm us. The area around the Edington is ripe for a groundbreaking, highly effective solution that integrates all components cost-effectively in a manner the community would not just support but do so enthusiastically as elements most appreciated would continue. It could be a key model to secure much-loved cottage hospitals elsewhere.