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Socialism and Health The journal of the Socialist Health Association Winter 2004 3/2004

A glass half full?

A public health white paper we can (almost) be proud of….

Article on public health white paper.

Or half empty …… a view from the Chair

Defender of the Public Health and Well-being The big event of the autumn was, of course, the long awaited English Public Health White Paper to which SHA contributed through a very detailed response to the preceding consultation paper. In fact it is not so much a White Paper as White with Green edges and was too late to be included in the Queen’s Speech. So we will have to wait some time for implementation and there is the possibility that it will change as much between now and implementation as it did over the last 3 weeks of its incubation when it appears it changed a great deal, seemingly for the better.

But I have to confess to being thoroughly under-whelmed by it. The general view seems to be that it represents an important step in the right direction. But having been in the public health trade since 1970 I have seen too many such steps, which in the end have not amounted to very much.

I was disappointed that Whitehall still sees public health mainly in terms of lifestyle and personal responsibility, whereas we now know that the so called wider determinants, particularly income and education, play a crucial role. In Wales we now have the health, social care and well-being agenda, which recognises that everything impacts on public health and well-being and that local authorities are the major local drivers. The Welsh vision for public

2 health is more fundamentally socialist than the English one as, it must be said, it always has been.

On a more positive note I welcome the recognition of the importance of community development and of the school as a key setting for health promotion. Extra resources for tackling sexually transmitted infections will undoubtedly help as will the measures proposed in relation to smoking, alcohol and diet. But the whole document is too timid. Our proposal that serious consideration be given to examining the case for legalising the supply and use of drugs was, unsurprisingly, ignored; presumably it is just too hot to handle with a General Election in the offing.

The government is overly concerned about accusations of nanny statism and too attached to a consumerist driven market model for lifestyle change. It is true that our consumer society generates the wealth that is so important to health and well-being. But it is evident that some sectors of big business are entirely careless of the impact of their activities on health and wellbeing. Some would say that they comprise anti-health forces. This might be going too far, but what the faint hearts see as the nanny state is better conceived as the defender state – our only protection against commercial forces that are too powerful for us to tackle as individuals.

Paul Walker

WHAT DO YOU THINK ABOUT THE WHITE PAPER? Let us know by writing to: The Editor Socialism & Health 50 Wesley Square London W11 1TS or by e-mail to: jm@jblakeman.fsnet.co.uk

Growing from the Roots: PPIFs demand a national voice Article about SHA event

CPPIH and PPI: Ignore the ‘chatter’, acknowledge the facts and get on with the politics There is much chatter on the left about the recently announced abolition of the Commission for Patient and Public Involvement in Health after a mere 18 months of life. So what are the facts?

In the face of a government determined to abolish CHCs, the Commission was a hard won victory for all those who believe that there must be an independent voice for patients and the Promoting health and well-being through socialism

3 public in health decision-making, both locally and nationally. The combination of a national, local and regional presence with rights and responsibilities enshrined in legislation had the potential to counter the enduring barriers that have over decades prevented the development of authentic and effective involvement of lay people in the public sector. Prominent amongst these are the powerful vested interests of managers and professionals and an organisational culture characterised by risk aversion and defence of the status quo.

The Commission was charged with setting up independent Forums of local people for each of England’s 572 NHS Trusts, and representing their views at a national level. We were required to do this to a demanding timetable – within 11 months of start up – and on a budget that was widely acknowledged to be inadequate to support the many ministerial promises made in the heated debates surrounding the Commission’s founding legislation.

Despite all the difficulties, including Minister’s demand that we bring forward the establishment of the forums by four months, with their initial 5,000 plus members, we did set up the new system by December 2003. The logistics were challenging to say the least, with hundreds of Commission staff across the regions, and contracts to provide the essential support for the Forums, put in place in record time.

It is not true to say that the Commission spent too much on central administration. Our budget in our first year was ostensibly £33 million. However, £8 million was retained by the Department of Health to support the Community Health Councils in their last year and a further £3.2 million to manage the new complaints advocacy service leaving a budget of £21.8 million to set a new organisation from scratch.

One of the major challenges facing the new Commission was to decide how to provide support for the 572 Forums required by the legislation within the budget available in our first year. In our view the Forum Support Organisations were an innovative and courageous response to budget constraints which aimed to link the new structure into the wealth of experience and expertise of involvement and engagement built up over many years in the voluntary and community sectors. Over half of our first year budget - £12 million - was spent on setting up these forum support organisations – many of them located in local voluntary groups - and recruiting 400+ staff to provide support to the fledgling forums. £2 million was used for the campaign to recruit forum members, which involved a genuine attempt to bring in people who had little if any previous experience of involvement in the public sector. Establishing and running the central and regional offices cost around £8 million in our first year.

We have not yet completed a second year so we can’t yet report fully on how the distribution of expenditure between local, regional and central elements of our structure has changed.

However, once we realised that our annual budget would not be significantly increased – as we had hoped – we made strenuous and successful attempts to increase the proportion of the budget going directly to the Forums. We were and remain unapologetic about our decision to continue to support a significant regional and national presence as we believe that this is essential for effective involvement and engagement of people in health related decision-making.

A second challenge for CPPIH was to design a system that would enable Forums to focus on healthcare and pubic health issues and allow their collective voices to be heard at local, regional and national levels. Like other organisations with a healthcare and public health remit the new PPI system has to develop mechanisms to ensure that the wider public health concerns do not Promoting health and well-being through socialism

4 become marginalised by the role in monitoring healthcare. The Commission was intending to support the establishment of a broad ‘Our Health’ network within local areas. This would have given the Forums a popular base from which to recruit and with which to engage and a means for maintaining a focus on the social determinants of health.

Perhaps the most important but difficult challenge we have faced is how to shape and influence the culture of our new organisation – for culture is not something that can be ‘established’ in the direct way that is possible with other aspects of organisational form. Even in relatively straightforward organisations, the cultural context and its relationship to other aspects of an organisation will be complex. In CPPIH this complexity is arguably unparalleled in the public sector. As an organisation we are a combination of paid employees and volunteers working alongside a rich diversity of community and voluntary groups delivering support to the Forums. The Forum Support Organisations have their own cultures and as they develop, so too will the local Forums. The newly appointed staff within the national and regional offices also came from very diverse backgrounds in terms of the organisational cultures they were used to operating in.

In our experience of public life the composition of CPPIH’s board is also exceptional with the strong presence of people with considerable experience of active involvement as patients and lay people in health decision making. They bring a rich cultural heritage as well as a passion to their work. And last of all CPPIH is accountable to the Department of Health – a formidable cultural presence in our short life! It is far too early to describe the cultural fabric of CPPIH with any degree of precision or accuracy. As we have worked to put in place systems for governance, accountability and delivery in this complex and dynamic environment many cultural and political forces will have been operating – some more controlling some more enabling. How the balance between such tendencies would have evolved as the organisation matured we will never know.

It is of course the outcome of all this activity that is important. Only a fool would suggest that the empowerment of patients and the public could be achieved in 18 months. The exclusion of their voice is a consequence of centuries old processes and hierarchies, now firmly embedded in the public sector and which have been remarkably resistant to change. They will take time, energy, ingenuity and considerable political commitment to reverse. The Commission has made enormous efforts to include traditionally excluded groups in forum membership but much still needs to be done to ensure that the Forums reflect the diversity of the communities they serve. Additionally, it was always going to take time for Forums to get to grips with exercising their new powers and continued thought must be given to the way in which they can be best supported to do this. The signs are promising, as the Forums begin to get down to their work. Now that the set up months are over, some 85% of Forums tell us they are pleased with the support they are receiving.

There is much to play for in the months ahead as the government and their civil servants decide on the organisational forms to be put in place for delivering many, if not all, of the functions CPPIH was set up to fulfil. Some understanding of the factors that led to our abolition and of the complex issues the new organisation has been grappling with may help here. But this will only come from careful reflection and analysis, not from the ill informed, sometimes vindictive and often self serving commentary emanating from some quarters. The demise of CPPIH is a victory for no one – save perhaps for those who pooh-pooh the notion of accountability in health and health services.

Promoting health and well-being through socialism

5 The Forums are to remain, we are told, but as yet the infrastructure for their support is unclear.

At our insistence, the Department of Health is currently conducting a consultation exercise with Forums and key stakeholders with a view to determining the shape of PPI in the future. It is to be hoped that many Forum members will have their say. The Department has also produced a position paper setting out their expectations of the future role of Forums and the ‘givens’ in the new arrangements. From a public health perspective it was good to see that the wider role of Forums in contributing to population health improvement and the reduction of health inequalities still figures in the Department’s ‘vision’. However, given that ‘Our Health’ will not now be developed, it remains to be seen whether the new arrangements will cause the public health role of PPI Forums to wither on the vine or to grow and mature in the context of the new White Paper.

In the meantime the commitment of the CPPIH Board and staff is to maintain continuity of support for the Forums over the transitional period and to seek to ensure that the new arrangements for the appointment and training of Forum members; for providing support for Forums; and for the management of their ‘performance’ retain the principles of independence, authenticity and diversity that are fundamental to the new system of PPI. We believe that it is also vital that the new arrangements recognise and support the voluntary nature of PPI and allow the Forums to develop their own interpretation of good governance, rather than imposing from above a more traditional bureaucratic model. Finally, we believe that it is imperative that the new structures provide an effective and independent means for the Forums to get their collective voice heard at a national level.

There will always be those who will claim that the Commission has failed in its task – although it is clear that many of these critics simply fail to understand the complexity of the task we were charged with. Our main regret is that the Board and staff of CPPIH are not now going to have the opportunity to try to deliver out vision for PPI – and it was an ambitious one. To some extent it was ever thus in public life! Despite the uncertainty and the regrets, one thing is certain. Assuming that we are allowed to - and despite some personal misgiving about the alternatives being proposed – we will stay the course to do whatever we can to ensure that the new arrangements are consistent with the development of a more authentic and sustainable system of PPI in both healthcare and public health into the future.

Jennie Popay & Sharon Grant Vice Chair & Chair Commission Patient & Public Involvement in Health

Great minds think alike?

The Local Government Association, the NHS Confederation and the UK Public Health Association have recently published a paper - Releasing the potential for the public's health – that supports the SHA’s longstanding contention that there should be a Secretary of State for Public Health in the Cabinet. This Cabinet minister would have cross-departmental responsibility and the Chief Medical Officer would be jointly accountable for health matters to the Public Health Minister and the Department of Health. Primary care trusts and local authorities should also

Promoting health and well-being through socialism

6 have a strengthened role and responsibility for public health, so all should have co-terminous boundaries.

The three bodies argue the need for a radical change in the way public health in the UK is addressed and promoted. They believe that government should move away from its focus on hospital treatment to a broader approach that tackles the root causes of ill-health, including poverty, housing, diet and social inequalities. Because local councils play a key role in many areas affecting public health, such as education, sustainable development, housing and transport, they are urging government to give local authorities and local communities more control over public health issues, with sufficient resources to drive health improvement in a way that best suits local needs.

The report reiterates the facts that only 25% of the variation in health is due to the quality of healthcare services, the other variations being 50% due to socio-economic differences, 15% to biological inheritance and 10% to environmental factors.

It is encouraging to note that the Local Government Association in particular endorses the SHA’s stance on public health. Perhaps in time it will also take that extra leap and recognise that democratically elected primary care trust boards that work in partnership with democratically elected local authorities is the best way to tackle health inequalities within local communities.

Pharmacists to develop their healthcare remit Pharmacists are being encouraged to vote “yes” for a new contract that will enable them to extent the range of services they offer to their communities. Under the new contract they would no longer be rewarded for the amount of medicines they dispense but for the range and quality of their services. If the new contract is accepted, the new arrangements will start in April 2005.

This means that pharmacists will then be able to check people’s blood pressure, offer smoking cessation services, monitor blood glucose levels, help people to manage common complaints and generally promote healthy lifestyles. They will be able to work with GPs on the repeat prescriptions that often cause so much irritation to patients by reducing the number of times the patient will have to return to the GP. Patients will get just the one prescription for up to a year, and the pharmacist will be able to dispense it in instalments.

Pharmacists often point out that they are an underused resource in the NHS. The new contract, if approved, will help them to work more closely with primary care professionals and, with the support of their PCT, provide better services to local residents.

A new approach to monitoring healthcare The Healthcare Commission wants comments on how it should assess healthcare in both the NHS and the independent sector after 2005.

The Commission has published a consultation document setting out one proposed approach that it hopes will monitor the things that matter to patients, the public, clinicians and managers.

Promoting health and well-being through socialism

7 The emphasis is on improved outcomes within the context of the new targets and standards for healthcare set by government.

Do you believe that healthcare organisations are getting things right? How should they develop and improve in the coming years? How can the Commission inspect healthcare providers effectively but without unnecessary disruption? How should the Commission co-ordinate its work with the other bodies that inspect and regulate the NHS? If you wish to join in this discussion, the consultation document is at: http://consultation.healthcarecommission.org.uk/download/Exec%20summary.pdf

Government moves towards a national framework for fully-funded NHS care The problems faced by disabled and elderly people in getting NHS funding for long term care are highlighted in a new report from the Health Service Ombudsman, Ann Abraham, that was published on 16 December. This is the long term package of care that is arranged and funded solely by the NHS for people who need it because of disability, accident or illness, which is provided in a care home, the patient’s own home or in hospital. The report is based on evidence gathered from almost 4,000 complaints received since the publication of a first report on the subject in February 2003.

The Ombudsman believes that, from the patient’s point of view, applying for funding for long term care has been a lengthy and sometimes hit and miss process, causing real hardship for a number of disabled and elderly people and their carers. She wishes to be assured that no-one has been wrongfully denied NHS funding for long term care and that the lessons learned from the current review of cases are used to make sure that open and fair procedures are put in place across the country.

In anticipation of the Ombudsman’s report, the Department of Health has said that it is to develop a nationally consistent approach to assessment for fully funded NHS continuing care.

The Health Minister, Stephen Ladyman, said that his Department will work with the Strategic Health Authorities and, learning from good practice and the findings of an independent review, will produce a national approach to improve consistency and make the process easier to understand for practitioners and patients alike The Ombudsman’s report makes six key recommendations that point to the need for national minimum eligibility criteria; a national set of assessment tools; and the right skills and capacity at local level to help patients get the funding to which they are entitled. Other recommendations include developing accredited assessment tools and good practice guidance; supporting training and development to expand local capacity so that cases are assessed and decided properly and promptly; and improving record keeping and documentation.

Age Concern has called for clear assurances that there will be a full consultation and that the system will be improved as a matter of urgency to stop older people being penalised by a failing care funding system.

Promoting health and well-being through socialism

8

Letters to the Editor Madam Michael Howard and the Tory party have had a brilliant idea for the NHS. They will get rid of the civil service managers (pejoratively called "bureaucrats") and have the NHS run by the doctors and nurses, and also get rid of targets for waiting times etc., etc.

So doctors and nurses can spend their time at meetings instead of with patients and the waiting times will escalate. This of course will favour their friends in the private sector who will stand to benefit and are currently feeling the pinch as waiting times are dramatically reducing under the government's targets.

I hope people will understand the import of their policy.

Derek Marcus Potters Bar .

FORTHCOMING SHA EVENTS Public Health and Consumerism Friday 18th February in Sheffield 10.00 a.m. to 4.00 p.m.

Main speakers: PROF. CHRIS DRINKWATER Head of the Centre for Primary and Community Care Learning Centre University of Northumbria PROF. RICHARD WILKINSON Division of Epidemiology and Public Health University of Nottingham Medical School Author of many publications on Income and Health Venue: The Quaker Meeting House 10 St James Street Sheffield S1 2EW Lunch provided.

Costs £90 for statutory and commercial organisations £45 for voluntary organisations, CHCs and PPIFs £25 for individuals £20 for SHA members Promoting health and well-being through socialism

9 Some free places for people on means tested benefits To book a place, contact Martin Rathfelder 22 Blair Road Manchester M16 8NS Tel: 0870-013-0065 E-mail: admin@sochealth.co.uk Or complete the form on the Website: www:sochealth.co.uk

SHA BRANCH CONTACTS Greater London: Greater Manchester: North East: Scotland: Wales: West of England: West Midlands: 0

Huw Davies Martin Rathfelder Rita Stringfellow Ali Syed Anthea Symonds Paul Walker John Charlton

020-8748-7284 0161-286-1926 0191-200-6672 0141-942-8804 01792-295313 0117-968-2205 0121-475-770

CONTACT THE SHA Do you have a point of view? The pages of Socialism & Health are open to everyone. All letters and articles will be considered for publication. And the SHA welcomes any other expertise or help you can offer to ensure that the SHA remains a dynamic and respected campaigning pressure group in the 21 st Century.

Promoting health and well-being through socialism

Socialist Health Association 22 Blair Road Manchester M16 8NS Tel: 0870-013-0065 E-mail: admin@sochealth.co.uk Website: www:sochealth.co.uk Editor: Judith Blakeman The views expressed in this journal are not necessarily those of the SHA