Opt-in, Opt-out? A new system for organ donation in Scotland

Guest blog by Findlay Smith

Credit: Soeren Stache / DPA/Press Association Images

The Scottish Government is in the process of bringing forward legislation to introduce a ‘soft opt-out’ scheme for organ donation. Public Health Minister Aileen Campbell stated that the move will be one step of many in a “long term culture change” regarding organ donation.

A ‘soft opt-out’ scheme operates on the assumption that lack of objection on an individual’s part can be considered ‘deemed consent’.

This means that people in Scotland will have a choice to:

  • actively opt in – being placed on the organ donor register; or
  • do nothing – which will now be treated as ‘deemed consent’; or
  • actively opt out – being removed from the donor register

 Current situation in Scotland

According to the British Medical Association, as of 6 March 2017 there were 530 people in Scotland waiting for an organ transplant, with more than 1 in 10 dying before receiving a transplant.

Scotland currently operates an ‘opt-in’ system – to be a donor, you must actively register with the donor card scheme.

Although support for organ donation is high among the Scottish public, and there are indications of support for deemed consent, less than half of Scotland’s population are registered organ donors, with 45% registered.

Aimed at increasing the rates of organ and tissue donation, a public consultation was held by the Scottish Government between December 2016 and March 2017. The results indicated that 82% of respondents supported the principle of a ‘soft opt-out’ system.

Comparison with Wales

One example cited by the Scottish Government of a successful ‘soft opt-out’ policy is in Wales. In 2015, following the passing of the Human Transplantation (Wales) Act in 2013, Wales became the first country in the United Kingdom to introduce deemed consent for organ donation.

Due to these changes being implemented very recently, it is too early to accurately assess the impact of deemed consent in Wales, as it can take several years for an observable change in donation rates.

However, despite the absence of concrete figures, there are some promising signs. The British Medical Association reported in December 2016 that 39 organs had been transplanted in Wales as a direct result of the change in laws.

The Spanish model

Looking elsewhere in Europe, Spain has the highest rate of organ donation in the world, at a reported 40 donors per million people in 2015.

Whilst they have a nominally similar system to Wales, in practice they operate in a different manner. Although Spain introduced an ‘opt-out’ system in 1979, the system itself is considered ‘insignificant’ when looking to explain their world leading donation rate, as in the decade following the change in legislation there was no substantial increase in organ donation. This may be due in part to the ‘opt-out’ process rarely being applied in practice, as family members always have a final veto.

Crucially, in addition to the change in system, Spain has also drastically improved the infrastructure used to identify and recruit potential donors. In 1989 the National Transplant Organisation (ONT) was established, and Transplant Co-ordinators were placed inside every hospital.

The role of the Transplant Co-ordinator is to identify potential organ donors as early as possible. What makes the Spanish model innovative (it has since been emulated elsewhere in Europe), is the widening of the pool of potential donors. Rather than focusing on people in intensive care, potential donors are also identified in accident and emergency rooms and hospital wards.

The role of family members in this process is also key. The early identification of potential donors allows a strong relationship to be built with family members. As they have the final say, getting them on board early can make a significant difference. The Scottish Government seems to be aware of this, having conducted a fact-finding mission to Madrid in 2015, consulting ONT Director Rafael Matesanz.

Final thoughts

The examples highlighted suggest that if the introduction of ‘soft opt-out’ legislation is to be successful, it may not solely be the result of the legislation on its own. Improvements in infrastructure, organisation, and dialogue with families of potential donors will also be crucial. Transitioning towards this change in practice will require a change in culture in the NHS around organ donation.

These steps taken in Scotland, which follow the lead of Wales and draw from the Spanish model, are also now being considered in England. Assisted by a lengthy campaign from the Daily Mirror, Labour MP Geoffrey Robinson’s Organ Donation (Deemed Consent) Bill was introduced to Parliament on 19 July 2017 and is due for debate on 23 February 2018.


Findlay Smith is currently in his final semester of study of the MPP Public Policy Programme at the University of Stirling. Findlay has recently completed a voluntary two week work experience placement with the Knowledge Exchange team in Glasgow.

Beyond Brexit? How to assess the UK’s future – a new resource

The EU flag, with the Brexit on it appear, in the form of a jigsaw puzzle.

By Steven McGinty

Although Brexit negotiations are officially underway, there is no clear vision of how the UK will look once it’s left the European Union.  Politicians – including those within government – appear to be divided on the issue, with Chancellor Philip Hammond’s wish for a softer Brexit seemingly at odds with Brexit Secretary David Davis and Foreign Secretary Boris Johnson.

This uncertainty has left businesses, local authorities, and the general public struggling to plan for the future, and in search of answers to help navigate these difficult Brexit waters.

One valuable resource they may turn to is Professor Janice Morphet’s new book, Beyond Brexit? How to assess the UK’s future.

In this short guide, Professor Morphet – an expert in infrastructure, the EU and public policy – takes a long term view and attempts to understand the whole range of options that may be deployed by the UK, EU, and other international institutions.

Below we’ve outlined some of the main themes of the book.

Implications for devolved nations and territories

The impact of the EU referendum result has been strongly felt by the devolved nations and territories.

For example, Scotland’s First Minister, Nicola Sturgeon, has argued that Scotland (where 62% voted to stay in the EU) should be recognised in the Brexit negotiations, and that Scotland should be allowed to come to an arrangement on continued EU membership.

Similarly, Gibraltar (where 96% voted in favour of remaining in the EU) is looking to retain access to the EU’s single market and free access across the EU border. There have also been diplomatic tensions, with the suggestion that there should be no UK/EU agreement – that includes Gibraltar – without the consent of Spain.

But beyond these specific issues, Professor Morphet raises the wider point that EU legislation is a fundamental component of specific devolved powers.

This is because much of the powers devolved to Scotland, Northern Ireland, and Wales are derived from legislation initially agreed within the EU. In Professor Morphet’s view, devolved nations will need clarification on how they’d retain decision-making powers, including whether a new set of powers would need to be introduced. One suggestion discussed is the need to create a federal constitution guaranteeing the devolution arrangements.

Benefits of the EU

During the referendum campaign there was limited discussion on the value of EU membership. Even the Remain campaign focused on the negative impact of leaving, rather than the positive impact of being a member of the EU.

Professor Morphet provides an authoritative look at some of these benefits, including the:

  • importance of being inside the world’s largest market;
  • ability to engage diplomatically as part of a global diplomatic group;
  • development of an EU-wide energy policy, ensuring energy security; and
  • commitment to achieving higher environmental stands across the EU.

Options for future UK/EU institutional relationships

Much of the UK’s future relationship with the EU will be dependent on the current Brexit negotiations. As such, it’s unclear whether the UK will achieve a bespoke arrangement with the EU, gain an agreement similar to another country (such as the Norway or the Swiss models) or if there will be any deal at all.

Professor Morphet discusses this wide variety of options, and considers some of the challenges for the UK Government – who at the moment appear undecided on how far outside the EU they would like to be.

Immediate actions that must be taken by the UK

Before the EU Referendum result many high profile individuals and institutions claimed the UK economy would collapse. This included former Chancellor George Osborne, who suggested there would need to be an emergency Brexit Budget, and the Bank of England’s governor Mark Carney, who warned that the UK risked heading into a recession.

However, even though the economic slowdown has not occurred, there have been signs that the referendum result has impacted the UK on a variety of levels. For instance, Professor Morphet highlights that there has been an effective 11-16% devaluation of the pound, and that inflation is likely to rise in 2017. For her, stabilising the economy should be the priority for the UK government, arguing that it needs to offer a clear view of Brexit to reduce the political uncertainty.

Final thoughts

Professor Morphet’s latest book is a must read for anyone with an interest in how the country will look post Brexit. By her own admittance, the book does not provide all the answers, but it does provide a framework for making sure the right questions are asked during the negotiation period and beyond.


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Community planning in the devolved UK

Community planning is all about how public bodies and other partners work with local communities to design and deliver services that suitably reflect the needs and priorities or a local area. Effective community planning incorporates strong partnership working and a shared vision which has been created especially to fit a set of local circumstances.

Providing effective and efficient services, promoting community engagement and enterprise and engaging the third sector are all things that could now be considered part of “community planning”. It is founded on the idea that communities know best; they know what they need, they know how it can be delivered and how they will use services in the most effective way to get the most value from them. With an increase in political devolution we have seen different approaches to delivering community planning emerge in England, Scotland, Wales and Northern Ireland. Some nations embraced it from a very early stage, others less so. However, it has become an increasingly popular model over recent years, with all four administrations now using some form of community planning model.

England

In England, the focus has largely been on housing and land use and the relationship between community plans (which consider services and public engagement) and local development plans (which focus more on the physical aspects of planning in the community, such as land use). Neighbourhood plans give communities the opportunity to develop a shared vision for and shape the development and growth of their local area. Neighbourhood plans are not a legal requirement, but a right which communities can evoke if they wish to. They are designed to fit alongside local authority produced “local plans” and provide an opportunity for communities to set out a long term vision for their area in terms of development, and “may encourage them to consider ways to improve their neighbourhood other than through the development and use of land.”

Scotland

The introduction of the 2015 Community Empowerment (Scotland) Act is a clear indication of the stance of the Scottish Government with regards to community planning. As well as statutory rights being strengthened with regards to consultation and community consultation, the legislation also places statutory requirements on public bodies with regards to supporting local community based service delivery, and actively engaging local people in decision making processes. As a result of the legislation 32 Community Planning Partnerships (CPPs) now exist in Scotland and they are responsible for developing and delivering community plans. These can take two forms:

  • a larger plan, which takes account of the whole CPP area (Local Outcomes Improvement Plan)
  • a smaller plan, which focuses on a smaller geographic area which has been identified as being in need of improvement (locality plan)

There is no limit to the number of plans CPP’s can create in a year, but the views of local communities are particularly important in creating these as that is the way to best reflect local needs and priorities.

In Scotland a consultation is also currently underway to consider ways to align community and spatial planning more closely, as it was recognised that planning for services should also be mapped along with physical development.

Wales

In a Welsh context the use of community planning focuses on resource allocation and the direction of resource to where it is needed. Promoting community cohesion and well-being through community planning is also something which can be seen in both Wales and Scotland. Increasingly, plans have attempted to incorporate a “place-centred”, “service focused”, “partnership led” approach, with the emphasis on individual need. It is hoped that by bringing service providers and other partners back in touch with the people who use their services that their views can be taken on in future planning projects. As in all community planning projects, partnerships are key; however in Wales one of the biggest challenges has been forming these partnerships and getting buy-in from local businesses. A similar challenge has also been seen with national level bodies.

This challenge of engaging national bodies in community planning has also been seen in Scotland. National bodies are expected to engage with rural and urban CPP’s in ways which reflect individual community need, something they had not been used to doing previously. As a result, promoting flexibility and adaptability and encouraging participation from a range of stakeholders in order to support the creation and delivery of community plans has been high on the agenda across the UK.

Northern Ireland

The situation in Northern Ireland is, to a large extent, still evolving. Executives at Stormont, as well as planners and developers, see engaging local people as important but they are also trying to find a model which works best for a Northern Irish context. Potential options for integrating community based models have included adopting models from England or Scotland respectively; creating their own model which takes elements from a number of different models; or making attempts to align the Northern Irish model closer to that of the Republic of Ireland.

Currently the legislative basis for community planning in Northern Ireland is set out in the Local Government Act (Northern Ireland) 2014. The Act makes a statutory link between community plans and local land use development plans, and makes the link between community planning for a district and well-being more explicit.

category-picture-community-development

Engaging difficult to reach communities in community planning

The views of local communities are particularly important when creating community plans, as their fundamental principle is to reflect service and resource need more effectively in order to benefit communities. As a result community planners across the UK face the unilateral challenge of getting people to engage. Different groups within a community may have different capacity and ability to engage. ‘Hard to reach’ groups are particularly important to the consultation process as it is often they who make the most use of services or have the greatest need for specific service provision. People in this group may include young people, older people, ethnic minorities or other socially excluded groups, and small businesses. They are also sometimes referred to as ‘seldom heard’ groups.

Methods to improve communication and consultation with hard to reach groups vary, but some potential barriers and solutions to engagement include:

  • Jargon and technical language – Policy and planning documents can be very long, and very dense, with lots of planning specific technical jargon, create an easy access version so that everyone can be engaged in discussions and not feel intimidated by “high level” documents.
  • Digital illiteracy – Increasingly consultation documents, some forums and copies of the plans themselves are held online, and improving access to these would help to encourage more people to participate.
  • Awareness and accessibility – Promoting consultations or community planning events, and holding them at a variety of times and in a variety of settings to allow people from different groups to attend. In addition providing them in multiple languages, using language that is more accessible for young people, or in a larger type size may also help to encourage people to participate.
  • Showing impact – Create follow up documents so that people can see how their input has made a difference. Even if the plan won’t be implemented for a number of months, let people know how what they said influenced or changed the decisions that were made.

It is clear that England, Wales, Scotland and Northern Ireland are at different stages in their community planning journey. However, they have all, in one way or another recognised the importance of engaging communities to identify needs and attempt to allocate resources accordingly. In many instances, these community agendas have not just been linked to spatial, or even service planning, but also to wider issues around inequality and well-being and how resources and planning across all areas can best be directed to tackle this. It may be that we see this reflected further in future legislation.


This blog reflects on a recent paper by Deborah Peel and Simon Pemberton “Exploring New Models of Community based Planning in the Devolved UK” a study funded by the Planning Exchange Foundation.

Idox Information Service members can access our research briefing on engaging communities in planning.

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Debating the cost of alcohol to society

“Society is paying the costs – alcohol-related harm is now estimated to cost society £21 billion annually.”

So said David Cameron, launching the UK government’s alcohol strategy in 2012.

The prime minister was echoing the widely held view that alcohol is a financial burden on taxpayers. The British Medical Association has put the costs of alcohol harm in Northern Ireland and Wales at £680m and £1bn respectively, while the Scottish Government believes the annual cost of excessive alcohol consumption to be £3.6bn (equivalent to £900 for every adult in Scotland).

An alternative view

But now the popular view of alcohol as a drain on taxpayers has been challenged. A new report from the Institute of Economic Affairs (IEA) claims that the net cost of alcohol to the state is minus £6.5 billion.

The report found that the direct costs of alcohol use to the government in England – including NHS, police, criminal justice and welfare costs – amount to just under £4 billion each year, whilst revenues from alcohol taxes amount to over £10 billion. And it claims that even if the government halved all forms of alcohol duty, it would still receive more money in tax than it spends dealing with alcohol-related problems.

Commenting on the findings, the report’s author, Christopher Snowden said it was time to stop regarding drinkers as a burden on taxpayers:

“Forty per cent of the EU’s entire alcohol tax bill is paid by drinkers in Britain and, as this new research shows, teetotallers in England are being subsidised by drinkers to the tune of at least six and a half billion pounds a year.”

The report received a hostile reception from Alcohol Concern. Deputy chief executive Emily Robinson told the Daily Telegraph:

“Non-drinkers suffer the consequences of alcohol related problems every day; whether that’s from drink driving accidents, being the victim of crime or anti-social behaviour, family breakdown, waiting in Accident and Emergency departments for their turn, even through to the costs of street cleaning town centres after a Friday night.

She went on to argue that policies, such as minimum unit pricing (MUP), were needed to tackle the harm caused by alcohol.

A setback for minimum unit pricing?

The IEA report appeared on the same day that the European Court of Justice (ECJ) advocate general advised that the Scottish Government’s policy on MUP breached EU competition and free trade laws.

The proposal to introduce minimum retail pricing for alcohol appeared in the Scottish Government’s 2009 alcohol framework, and in 2012 the Alcohol (Minimum Pricing) (Scotland) Act 2 paved the way for the introduction of a minimum price of 50p per unit. The policy was challenged by the drinks industry, which believes that there are more effective ways of tackling harmful drinking.

While the advocate general’s advice may influence the ECJ’s final decision, The Scottish Government is standing by its policy. “While we must await the final outcome of this legal process,” said Scotland’s First Minister, Nicola Sturgeon, “the Scottish Government remains certain that minimum unit pricing is the right measure for Scotland to reduce the harm that cheap, high-strength alcohol causes our communities.”

The devolved administrations in Wales and Northern Ireland have set out plans to introduce their own MUP legislation. In England, the 2012 alcohol strategy included a commitment to introduce an MUP for alcohol. However, in 2013 the coalition government decided not to proceed with this, and instead to impose a ban on the sale of alcohol below cost price.

Last year, a report from Sheffield University suggested that below cost price policy would have small effects on consumption and health harm, while an MUP set at  a level between 40p and 50p per unit, was estimated to have an approximately 40-50 times greater effect. The research appears to support evidence from Canada, the first country in the world to introduce MUP, indicating that MUP could bring significant health benefits.

With the IEA report introducing a provocative new perspective, and the final judgement on MUP awaited, it’s unlikely that ‘last orders’ will be called any time soon in the debate on alcohol’s impact on society.


 

Enjoyed this article? Read our recent blog posts on the night-time economy and on ten years of the Licensing Act.

Follow us on Twitter to see what developments in public and social policy are interesting our research team.


Further reading*

Alcohol pricing and purchasing among heavy drinkers in Edinburgh and Glasgow: current trends and implications for pricing policies

Understanding the alcohol harm paradox in order to focus the development of interventions

Understanding the development of Minimum Unit Pricing of alcohol in Scotland: a qualitative study of the policy process

Alcohol’s harm to others

The cost of binge drinking in the UK

*Some resources may only be available to members of the Idox Information Service

Grey men dreaming of vibrant cities?

Image by Neil Howard under Creative Commons

Image of MediaCity, Manchester by Neil Howard under Creative Commons

By Morwen Johnson

They control combined budgets of over £10bn, deliver 24.4% of the combined economic output of England, Scotland and Wales, and are home to over 21 million people. What are they? The Core Cities of the UK – and as pre-election lobbying ramps up a gear they are at the forefront of the devolution debate.

Last week I attended the Core Cities Devolution Summit. This event, hosted in Glasgow, marked the launch of a modern charter for local freedom. It also gave those interested in the current cities agenda a chance to hear from the city leaders on the potential benefits of reform.

I won’t summarise the charter, or the main recommendations of a new report from ResPublica which argues for the fullest possible devolution of public spending and tax raising powers to the UK’s largest cities and city regions. Instead, here are a few reflections on the day.

Bespoke devolution

The hype over Manchester’s recent devolution agreement with the Treasury shouldn’t distract from the fact that devolution is not a one-size-fits-all model. The idea isn’t to try and mimic Manchester’s journey – what’s on the cards is an approach that takes account of local circumstances.

I’m not sure that the end result of this – potentially radically different priorities in revenue generation, service delivery and spending between neighbouring metropolitan areas – is being communicated in a transparent way. Ben Page from IpsosMori shared some interesting survey results which suggest that public opinion also lags behind the political agenda:

ipsos survey 1

ipsos survey 2Leadership not bureaucracy

Mention devolution and one of the immediate responses of naysayers is to complain it’s just yet another layer of governance – more costs, more staff, more vested interests. This was raised during Q&A and the panel responded by saying that what they are proposing doesn’t require massive reorganisation – it’s about effective leadership. The same pots of money are used but funds can be accessed in different ways for different purposes.

This was only half-convincing. Repeated reference to place-based decision-making (breaking down functional /organisational silos to ensure services are focused on outcomes and those residents with complex needs) didn’t really explain how you build the trust and political capacity that’s needed to roll out transformation across multiple agencies/workforces at the same speed and scale.

Equalities

Presenting a different perspective on the day was Professor Lesley Sawers, who highlighted the risks of unintended consequences from devolution in terms of social justice and inequalities. She argued that so far localism has led to an approach to investment that has not been particularly effective in tackling equalities issues.

Cities should be great agents of social reform but the rhetoric around growth has a tendency to focus on infrastructure and macroeconomics – ignoring social challenges such as skills, poverty and under-achievement. And it may seem an easy point to score, but running an event with only 3 female speakers out of 25, didn’t really send a great message to observers. Don’t even mention the lack of ethnic diversity on the platform.

What now?

The devolution agenda may be the ‘only show in town’ but whether the core cities can take advantage of this to benefit and engage their own populations remains to be seen.


The Idox Information Service has a wealth of research reports, articles and case studies on governance and city regions. Members receive regular briefings as well as access to our Ask a Researcher enquiry service.

A ‘can do’ culture? Planning reforms in Wales

Flag of Wales in the windDevolution in the UK has seen the development and continued divergence of public policy and governance arrangements. The land-use planning system is just one area where devolution has been seen as an opportunity to devise more appropriate arrangements to tackle specific issues.

In a recent article in Scottish Planning & Environmental Law, Professor Greg Lloyd (Emeritus Professor of Urban Planning at the University of Ulster) considered recent moves by the Welsh government to reform and modernise the planning system.

As the political landscape of devolution has matured, the modernisation of planning has taken place within the context of wider reforms. In Scotland, for example, the National Performance Framework and the community empowerment agenda have added new dimensions to local governance and planning. Wales is also engaging in creating a new context to land-use planning and effectively repositioning planning.

A series of reviews (including the Welsh Assembly’s Legislative Statement 2011-2016; the inquiry into the planning system by the Sustainability Committee of the National Assembly in 2010-2011; and the Simpson Review in 2011) laid the foundations for further change.

In summer 2014, the Well-being of Future Generations (Wales) Bill was introduced which will place a duty on public bodies to make decisions that leave a positive legacy for future generations. Professor Lloyd highlights that this “adds an explicit intergenerational articulation of what is considered to be sustainable development practice. The context to planning in Wales is being changed significantly and dramatically”.

This was followed in October 2014, by the introduction of the Planning (Wales) Bill 2014. At the time, the Minister for Natural Resources – responsible for land-use planning – said “I look forward to seeing these reforms, coupled with a “can do” culture across the planning sector, providing a system which can make a positive and lasting impact on our communities.”

The Bill seeks to provide a modern delivery framework for the preparation of development plans and planning decisions, including allowing Welsh Ministers to decide a limited number of planning applications in defined circumstances.

It also aims to strengthen the plan-led approach to decisions on planning applications by providing a legal framework for the preparation of a National Development Framework and Strategic Development Plans.

Improving collaboration and engagement with communities are other key objectives.

Professor Lloyd argues that while the rhetoric of reform and modernisation of the planning system is familiar, there is a real sense of purpose about the drivers of change.

“Could it be that planning in Wales is rediscovering an explicit ambition for planning to serve the public interest – both for the present and the future? There are lots of lessons from elsewhere in the Celtic fringe.”

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This blog draws on the article by Professor Greg Lloyd, “A can do culture? Planning reforms in Wales”, Scottish Planning & Environmental Law 166, December 2014, pp123-124

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To regulate or not to regulate? Housing standards in the private rented sector

To Let housing signs

Image from Flickr user Locksley McPherson Jnr, licensed for reuse under a Creative Commons License

The Scottish Government published its ‘Consultation on a New Tenancy for the Private Sector’ on the 6 October 2014. The paper states that 333,231 homes are rented privately in Scotland and it puts forward proposals to modernise the sector including giving tenants greater security of tenure, including:

  • Landlords to offer tenancies of not less than 6 months.
  • A bar on repossession except in specific circumstances.
  • The introduction of a model tenancy agreement.

The consultation poses a series of questions relating to rent levels, in particular ‘what action, if any, should the Scottish Government take on rent levels in the private rented sector in Scotland?’ Clearly the focus of the consultation is on the affordable private rented sector, but the implications of legislative change are likely to be far broader and impact across the whole rental sector.

The consultation raises a number of big issues for a range of stakeholders including tenants, landlords, citizens’ advice bureaux, local authorities, and indeed for the broader social rented sector, because any changes may well have knock-on implications far beyond the private sector tenant/landlord relationship.

Continue reading

Key themes from the 2014 Wales Planning Conference

idox-info-service-stand-rtpi-walesby Rebecca Riley

Last week we attended the 2014 Wales Planning Conference, which was also the Wales’ Centenary Conference, at City Hall, Cardiff. We were primarily there to highlight our products and services to planners but fortunately we also got to attend some of the sessions.

The key themes and ideas to emerge from this highly engaging event were: Continue reading