Sh0507

Socialism and Health

The journal of the Socialist Health Association

Editorial

Summer 2005

The re-election of a Labour government for a third term is to some extent a recognition of the importance to the public of the NHS as an ideal, and distrust of the Conservatives to look after it. Nevertheless we in the SHA have our concerns about the present state and future direction of health policy, and in this issue we examine several of these issues.

Gavin Ross, Hon Editor

REFLECTIONS ON THE GENERAL ELECTION Martin Rathfelder This was the first General Election in which I have been a really active participant. For the previous 9 elections since I have been old enough to vote I was in a safe seat where there was no reason to think anything I might do would affect the result one way or another. In that respect I am pretty typical. Only about 10% of the population are in a position to affect the result in most elections. This time I was agent for Gerald Kaufman in Manchester Gorton. So this does not pretend to be an impartial account of events viewed through the TV. We ran a vigorous and successful campaign on the streets and this is how I saw it.

Clare Bambra, Debbie Fox and Alex ScottSamuel, in their recent article Towards a politics of health, produced useful definitions of the political nature of health: • health is political because, like any other resource or commodity under a neo-liberal economic system, some social groups have more of it than others • health is political because its social determinants are amenable to political interventions and are thereby dependent on political action (or more usually, inaction) • health is political because the right to a ‘standard of living adequate for

health and wellbeing’ (United Nations, 1948) is, or should be, an aspect of citizenship and a human right.

What is not very clear from this analysis is whether health is different in significant respects from, for example, housing, or employment.

Nor is it clear how we could put operational flesh on these theoretical bones.

Manchester Gorton includes most of the area of Central Manchester PCT, which was for a long time the unhealthiest place in England. So we might have anticipated interest in the public health agenda. But there was neither opposition to the proposed anti-smoking measures nor enthusiasm for them. No one talked about obesity. Social services and mental health issues do not impinge on the political radar. In Manchester mental health services are still in poor shape, but voters in general don’t seem to care. They don’t see themselves as potential users of those services in the way that they see themselves as potentially in need of a hip replacement or cancer treatment. And even those who are involved in mental health services did not regard it as an issue they should raise in the election.

To be fair, we in our campaign didn’t talk about

Director, Martin Rathfelder, 22 Blair Road, Manchester M16 8NS admin@sochealth.co.uk

these issues either. We would have liked to, because we see the NHS as a good issue to talk about locally. Manchester Royal Infirmary is in the middle of an immense building programme, PFI financed. I have stood several times unsuccessfully in local elections and put stuff about public health in my leaflets, but it did me no good. Gerald wrote his own leaflets and he talked about money spent on the NHS – although health is not his strong subject. The Liberal Democrats said that the money wasted in Iraq could have been spent on better hospitals. There are no Tories in Gorton, so they didn’t say anything locally, but their national campaign about MRSA didn’t seem to do them much good.

Nor did there seem to be much interest in proposals to reduce the number of bureaucrats or NHS targets. The war of Rose’s Shoulder did not really take off. Tony Blair was caught off guard on TV with a question about GP appointments, but did not seem to be particularly damaged by it.

There were a number of campaigners in the election with a clear health agenda. Ivan Bennett, who stood in Manchester Withington, is my GP. He stood on an anti-privatisation platform and ended up with 243 votes. Ian Mack, Liberal Democrat in Norfolk South was also, like Ivan, Chair of the PCT PEC. He got a respectable result, but nothing startlingly better than other Liberal Democrats. Professor Keith Greene, a prominent consultant at Derriford Hospital in Plymouth stood as an independent in Devonport and got 747 votes, rather better than Ivan’s 243, but still nothing to get excited about.

The significant result was Kidderminster where Dr Richard Taylor, only the second successful independent candidate since 1945, held on to his seat with a very respectable 39.9% of the vote for his “Independent Kidderminster Hospital and Health Concern”.

What that tells me is that hospitals are political dynamite. Just as proposals to reorganise hospital services in Hartlepool became a key issue in the by-election there. Manchester Withington, one of Labour’s worst results, was won by the Liberal Democrats on the strength of a campaign to Save Christie Hospital (from threats which were at best unspecific). Keith Bradley, the losing Labour candidate had campaigned vigorously to defend Withington

Hospital which despite his efforts was closed and replaced by “a clinic with knobs on”, as his opponents described it. Although all the decisions were made before the previous general election it is only now that voters see the space where the hospital was covered with a new housing development.

What can we learn from this? Firstly that no politician wants to be associated with any proposal that could be interpreted as closing a hospital. One of the effects of the market economy, Foundation Hospitals and patient choice, may be that some hospitals are unpopular and lose so much business that they are under threat of closure. John Reid said that if patients did not want to use a particular hospital he would be content to see it close. I am sure that in such circumstances the local MP will campaign vigorously to save it. There are several hospitals in Greater Manchester which have poor reputations and some which the NHS has tried to close in the past, only for them to be saved when an election was imminent. It remains to be seen whether politicians will really let market forces finish them off.

Secondly, health issues are seen by most voters and politicians as being complicated. Choice, privatisation and PFI may upset people who work in the NHS but the voters don’t seem worried by them. The emphasis on reducing waiting lists has been successful politically, and if the NHS succeeds in reducing overall waiting times to 18 weeks, including diagnostic investigations, those complaining from the Right that the NHS is inefficient will be silenced.

Furthermore the private health business as we know it will have disappeared, to be replaced by a series of private facilities surviving mainly on NHS contracts. Thirdly and most importantly, that there seems to be scope for much bolder measures in public health. The Labour Party has been terrified of being labelled as the Nanny State. There seems to be room for more effective measures to be taken against smoking and obesity, as in Ireland without widespread opposition.

In early 2004 the King's Fund, an independent think-tank, surveyed more than 1,000 people and found most favoured a "nanny state" controlling diet and public smoking. Responses varied with

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3 socio-economic background, with people from lower classes wanting cheaper food. Higher classes wanted action on smoking and alcohol.

Those in lower socio-economic groups felt they had less control over their own health.

90% want healthier school meals 66% want a smoking ban in public places 80% want government action to ensure fruit and vegetables become cheaper 72% want laws to limit salt, fat and sugar in foods 73% want a stop on advertising junk foods to children 72% want food labels informing them of nutritional value On the other hand ICM interviewed a random sample of 1,003 adults aged 18+ by telephone

between 19-21st November 2004 and asked: “Recently, the government has introduced legislation on things like hunting, smoking and parents ability to smack their children. Thinking about such issues generally, which of the following comes closest to your view?”

The government should legislate on such things even if they mean restrictions on personal liberty 27% Too many infringements on personal liberty are being proposed on matters that should be for individuals to decide for themselves 71% No strong views either way 2% Don't know1% Patricia Hewitt seems to be more prepared to take a hard line than John Reid did, so perhaps now is the time to start campaigning.

A VIEW FROM THE CHAIR:

REFLECTIONS ON THE NHS – OR HOW DID WE LET IT HAPPEN? Paul Walker Three recent experiences as an NHS hospital Young doctors were intermittently present – as inpatient at one remove – it was my wife who in my own day – and even consultants from time was the patient – prompt me to share some to time. But no sense of someone being in reflections on a service which I have worked for charge and no sense of discipline. in a variety of capacities for almost 40 years. I regret to have to conclude that, generally The net result? A lack of communication and speaking, I am not impressed. Of course a coordination of the care of patients manifested in sample of three does not permit me to generalise inconsistent messages from staff and decisions but then neither do I believe that my experience made in the absence of key information. There involving two premier hospitals in my home seemed to be a great deal of writing things down region is atypical. It is consistent with what I in compendious patient’s notes but, seemingly, have observed and been told over recent years. no one read anything written by anyone else. It appeared that coordination of treatment and care So what was wrong? In a nutshell, a lack of was left to the patient, as the new style leadership, poor communications and consumer! The general attitude seemed to be idiosyncratic rather than evidence based practice, that OK was good enough – patient observations all compounded by a careless attitude to patient taken, bedpans brought to desperate patients, and morale. doctors instructions heeded as and when convenient to nursing staff; and sometimes not at When I was young and worked in hospital the all. On each occasion I felt that I should take up ward sister was very evidently in charge. Not residence to ensure that the appropriate the consultants – occasional visitors only; but treatments were given, and at the right time; and sister supported by her trio of staff nurses and a that basic needs were attended to. bevy of student nurses; and her charge included the domestics. And now? There was, of course, a ward sister but her presence was not pervasive.

The most visible nursing staff were nursing assistants with trained staff in the background.

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out of mind. No arrangements made for someone from the primary care team to pop in to look at the operation wound and the pressure sores acquired in hospital because of nursing inattention and a lack of ripple mattresses.

As for patient morale, this seemed to matter not at all. The sheer inactivity and boredom of ward life has to be seen to be believed and this must be inimical to treatment and recuperation.

Keeping patients active mentally, and physically where possible, is clearly not easy within the constraints of a ward regime and of treatment plans but it amazes me that no attempt seems to be made to address this issue.

Not forgetting the medical treatment: the occasion I had to suggest quite forcibly that the chest firm who admitted my wife should seek consultant dermatologist advice on the best treatment for the worsening cellulitis, the condition for which she had been admitted; the 60 hours’ delay in carrying out surgery which all the books say should be done as soon as possible after emergency admission; and the lack of post operative prophylactic anticoagulation that I had assumed, as had my GP, was routine.

And the final indignity. Being put under the care of a Consultant in the Care of the Elderly at the ripe old age of 64!

Discharge means what it says – out of sight and

As for rehabilitation, the third and arguably the most important leg of Beveridge’s edifice, we still just play at it. I have never understood whether this is because the paradigm for rehabilitation is educational with active participation of the patient – rather different to the traditional healthcare model with an essentially passive patient; or because the disciplines concerned with rehabilitation are low status and, very significantly, have no visible medical leadership.

In summary, there is much good will and genuine caring but the approach is amateur in the extreme. A case of muddling through with a smile and the best of intentions! And the real tragedy – whatever happened to nursing, the bedrock of all healthcare?

So, behind the government rhetoric which at one stage almost convinced me that the SHA should take the NHS off its agenda, there are real and serious problems at the coalface to be addressed.

We must continue to keep the NHS centre stage.

My personal remedy would comprise freeing the Service from its central stranglehold and reempowering the professional staff, working in concert rather than as separate and competing clans, to take charge. Experience has taught me that it is not puppet managers we need in the NHS but more managerially oriented professionals supported by first class administrators.

Paul Crawford Walker, Chair

OVERSPENDING – OR UNDERFUNDING? Gavin Ross Many NHS Trusts are in the red this year, and the Health Secretary is taking a tough line.

Balance the books, or else! But who is to blame? Poor financial management, inefficiency, inappropriate referrals, unrealistic targets, or rising energy prices, greater activity, and underfunding?

West Herts Hospital Trust, like many others, managed to overspend by 6 per cent in the last financial year. A junior manager was assigned the task of explaining the situation to a hostile and sceptical audience at a meeting in public of the PPI Forum in June. In spite of record increased spending in Hertfordshire and a projected new hospital at Hatfield, all Trusts www.sochealth.co.uk

5 were in the red, and deficits from previous years were increasing. Up to now deficits could be eliminated by curbing activity and increasing waiting lists, but this was no longer allowed.

Hertfordshire is an area of high cost housing, too close to London to attract top quality staff, and provided with a number of medium sized hospitals in medium sized towns, each anxious to retain its own local hospital and services.

Patients are often referred outside the Trust area, at much greater cost in London. Staff recruitment is difficult and much extra money is spent on agency and locum staff. Hospital buildings are in a poor state of repair. The Consultants’ Contract and the Working Hours Directive have put up costs, as have fuel price increases, shortfalls in the pensions fund, and new requirements relating to investment in emergency care.

So what action does the Trust propose to prevent the deficit increasing from £13 million in 2004-5 to £30 million in 2005-6? Increasing efficiency is a favourite management mantra, and many in the audience had heard it all before: reduce length of stay in hospital, increase use of day care, prevent cancellation of appointments, persuade GPs not to demand unnecessary tests, improve theatre utilisation, reduce the range of drugs and supplies, switch to generic drugs.

Efficiency, from a management point of view, means using all staff and resources 100% of the time. From the patient point of view efficiency means having beds and treatment available whenever they are needed – a very different equation economically, requiring empty beds and staff on standby rather than queues and waiting lists.

The Trust clearly does not expect the efficiency

drive to be effective enough to eliminate the deficit, and so they are talking of closing buildings (reducing rent, heating and capital charges), and eventually closing Hemel Hempstead General Hospital altogether as a DGH and moving services to Watford. If this was a long-term objective the deficit is a convenient excuse to implement it. To campaigners in Hemel Hempstead this is madness, as access to Watford is difficult, the site is limited and is next to the football stadium, whereas Hemel Hempstead has the land for expansion.

As the Trust spokesperson was unable to remain to answer questions the Forum chair allowed the discussion to continue, and the questions to be submitted in writing. How could GPs know in advance that a referral would be found to be unnecessary? To what extent are consultants cancelling operations in order to do private work? What provision had been made for the rising population and change in age structure leading to more demand? When did the Trust become aware of the impending deficit and the need to take action? Was there a cover-up because of the General Election campaign? To what extent are the deficits being simply passed on to the primary care sector and to patients and their carers?

The government has a difficult task in balancing its laudable aims of cutting waiting lists and providing new hospitals with Treasury demands to balance budgets and control public finances.

But to patients’ representatives the situation is all too familiar: overspending, cuts, rationalisation, and longer journeys to hospital.

Gavin Ross is a member of St Albans and Harpenden Primary Care Trust PPI Forum.

Does the government have a clear and specific mandate to privatise more of the NHS? Peter Draper

The recent reductions in NHS waiting lists are excellent but the public funding of private surgical capacity on a permanent rather than temporary basis is totally unacceptable. Now that significant public funds are at last available the NHS should

be built up, not health corporations. In announcing controversial 5­year NHS contracts for more private surgery in England to raise its proportion within the NHS to 11%, Patricia Hewitt, the health secretary said "I want to make clear my

5 Promoting health and well-being through socialism

determination to continue both the direction and the pace of reform set out by the prime minister and my predecessors to deliver the patient­led NHS for which the government has a mandate."

The Health Service Journal was not alone in being none too impressed that this announcement came only days after the new health secretary had promised to spend her first three months 'listening and learning from the service'. Clearly neither Patricia Hewitt nor Tony Blair could be accurately described as experts in health policy but their arrogance seems to know no bounds.

A New Labour trademark?

Over the coming months, it is a safe bet that we shall hear a lot about the government having a mandate for what amounts to developing corporate services with public funds. Perhaps the first point is that only 22% of the electorate voted for the government and of those who voted, only 36% backed it. In this extraordinary situation, there is no meaningful mandate for any controversial policy however much ministers continue to bluster.

Second, what does it mean for a government to have a specific mandate?

The Oxford Concise Dictionary of Politics suggests that "If a particular issue dominates a successful election campaign, then it might reasonably claim to have a mandate to pursue that issue." Not even the government could claim that its plans to further develop private surgical and other facilities with public funds were widely aired at the hustings. In no way did they dominate discussions.

It might be argued that a government has a specific mandate if its particular plans were clearly laid out in its manifesto. In general terms, Labour made much of its 'detailed' manifesto but what, for example, do the 12 pocket­book pages on health tell us about Patricia Hewitt's "reform...to deliver a

patient­led NHS"? The short answer is ­ very little that is specific.

For instance, it means (without explanation) "fundamentally reforming the NHS to meet new challenges..." Or, "We will deliver...by using new providers where they add capacity or promote innovation, and most importantly by giving more power to patients over their own treatment and over their own health." Significantly it adds "We promised to revive the NHS; we have. In our third term we will make the NHS safe for a generation." Within a week, the government had brought significantly more privatisation and ­ very important ­ destabilisation.

Sound planning, for which the NHS was once admired, is further jeopardised. The big bills that will eventually accrue from major planning errors along with the heavy 30­year bills from PFI schemes constitute an appalling legacy.

On bureaucracy there is the comment "by strengthening accountability and cutting bureaucracy, we shall ensure that the new investment is not squandered. We are decreasing the number of staff in the Department of Health by a third..." The reader would have no idea of Labour's ill­ advised earlier decision to keep the expensive bureaucracy of the Tory 'internal market' with all its current expensive ramifications to promote 'collaboration with the independent sector.' The Health Policy Network estimated that the original internal market cost no less than about 5% of the NHS budget.

Similarly, the cost estimates for the very heavy IT and staff time to run the controversial 'choice' apparatus are not given. Indeed, the opposite overall impression is fostered ­ of cutting bureaucracy and of "freeing up £500 million for front­line staff."

Involvement of the private sector is described in general terms and nowhere is

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7 there a recognition that relationships with vast health corporations can be highly problematic. "Expansion in NHS capacity will come both from the National Health Service...as well as from the independent and voluntary sector..." Nowhere are the growing NHS staffing levels given in terms of staff in relation to population and in comparison with levels in other developed countries. Nowhere is there a discussion of the need to strengthen measures to avoid stealing trained staff from poor countries.

To add insult to injury, commercial medicine is presented naively as a panacea ­ as the source of reform, innovation and 'contestability' as though innovation and comparisons within the NHS are worthless.

"We shall continue to encourage innovation and reform through the use of the independent sector to add capacity to, and drive contestability within, the NHS. We have already commissioned 460,000 operations from the independent sector...Whenever NHS patients need new capacity for their healthcare, we will ensure that it is provided from whatever source."

Critics might add "and without considering the medium­ and long­term consequences ­ developing commercial medicine is paramount not strengthening NHS weak spots". Even the few NHS Treatment Centres are to be put up for sale (Hospital

Doctor).

The Labour Party did not have even a 'manifesto mandate' for the post­election increase in private surgery ­ it had a manifesto smokescreen. And what little there was in the manifesto was not used as a basis to inform the electorate about Labour intentions.

The government in no way has a clear and specific mandate for significant privatisation of the NHS. However, as we can already see, Mr Blair, more desperate than ever to salvage a legacy ­ which seems to include breaking up what he insultingly characterises as the 'monolithic' NHS ­ is roaring ahead and has taken the chairmanship of the relevant cabinet committee. Would it make any difference if Gordon Brown became prime minister?

Robert Peston's highly acclaimed Brown's Britain strongly suggests it would. Peston reports Brown as judging that the health sector is inappropriate for markets ­ unlike Blair. Sadly, however, it looks as though Brown has retreated from his defence of the NHS from privatisation. All the more need for vigorous opposition to further privatisation wherever possible ­ the government has no mandate and we must make that crystal clear.

US Health Maintenance Organisations – Are they the answer?

Gavin Ross The government has been impressed by claims that savings could be made by adopting the practices advocated by US HMOs, in particular a Californian organisation, Kaiser Permanente.

An article in the British Medical Journal in 2002 by Feachem, Sekhri and White (1) claimed that for a given outlay the Kaiser model outperformed the NHS in many respects. But these claims have been subsequently thoroughly refuted by Talbot­

Smith, Gnani, Pollock and Gray (2) in the British Journal of General Practice in June 2004.

Talbot­Smith et al show that it is quite fallacious to compare Kaiser with the NHS even though both organisations are of similar age and provide both primary and secondary care services. After correcting for some of the major differences the NHS is shown to be at least 40 per cent more

7 Promoting health and well-being through socialism

efficient than Kaiser.

HMOs are funded by voluntary contributions and by user charges, and provide care only to a small proportion of the US population.

Patients are selected as low risk, and conditions such as chronic mental illness are excluded, care of the elderly is variable, and some care for chronic illness ceases after 100 days. The financial comparisons are also flawed, excluding the costs to Kaiser of marketing and administration and inflating NHS costs. Currency conversion calculations are criticised, and non­ standardised data are used for key indicators. Important functions such as

health protection, education and training of healthcare professionals, and research and development are omitted from the model.

Criticism of US healthcare is well rehearsed on both sides of the Atlantic, and it would be disastrous if policies were introduced here on the basis of poor research and erroneous comparisons.

1) Feachem RGA, Sekhri NK, White KL. Getting more for their dollar: a comparison of the NHS with California’s Kaiser Permanente. BMJ 2002; 324: 135­143.

Talbot­Smith A, Gnani S, Pollock AM, Pereira Gray D. Questioning the claims from Kaiser. BJGP 2004, 54, 415­421.

FAILURE TO MEET CANCER TARGETS IS NOT AN OPTION NHS Press Release Health Secretary Patricia Hewitt has warned health managers that targets for improving cancer services and reducing waiting times for treatment must be met. The warning comes after preliminary data shows that some NHS Trusts are not making the progress expected on cutting waiting times.

The NHS Cancer Plan, published in 2000, set out two targets for cancer waiting times.

All patients with cancer who have been urgently referred by their GP should begin treatment within a maximum of 62 days of referral. In addition when a decision is taken to treat a patients diagnosed with cancer, treatment should start within a maximum of 31 days. There is clear evidence that diagnostic tests are currently causing delays which could prevent the targets not being met.

not targets for the sake of targets, but targets for the sake of patients. They are being achieved in some parts of the country and they must be achieved nationally. She stressed that redesigning services and introducing new, creative and more efficient ways of working are essential to the improvement of treatment and care of all patients. Achievement of the targets is reliant on Trusts working together to ensure that patients who are diagnosed in one Trust and treated in another are transferred quickly and efficiently.

She added: "Nobody is denying that meeting these targets for all cancer patients will be tough. We have a collective responsibility to maintain this momentum of reform, at both a national and a local level, if every cancer patient is to receive a service that compares with the best in the world."

Patricia Hewitt made it clear that these are

Whatever Happened to the Black Report?

Martin Rathfelder

The SHA is holding a 25th Anniversary Conference on the Black Report in September, because several of our members were prominent in setting it up and have been agitating ever since for action to be taken (for details see back page). In anticipation of the conference I have looked at the 37 recommendations for www.sochealth.co.uk

9 action. Much has changed in the last 25 years, but this article attempts to establish what, if anything, has happened in respect of each of them. The recommendations have been edited slightly.

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School health statistics should routinely provide, in relation to occupational class, the results of tests of hearing, vision, and measures of height and weight.

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Representatives of appropriate government departments should consider how progress might rapidly be made in improving the information on accidents to children.

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The Health Education Council should be provided with sufficient funds to mount child accident Prevention Programmes in conjunction with the Royal Society for the Prevention of Accidents.

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Consideration be given to development of the National Food Survey into a more effective instrument of nutritional surveillance in relation to health through which various at risk groups could also be identified and studied.

In the General Household Survey steps should be taken to develop a more comprehensive measure of income, or command over resources, through either (a) a means of modifying such a measure with estimates of total wealth or at least some of the more prevalent forms of wealth. such as housing and savings or (b) the integration of income and wealth, employing a method of, for example, annuitization.

The importance of the problem of social inequalities in health and their causes as an area for further research needs to be emphasized.

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Resources within the National Health Service and the Personal Social Services should be shifted more sharply than so far accomplished towards community care particularly towards ante-natal, postnatal and child health services, and home help

Although data is collected about babies and breast feeding in relation to social class there does not appear to be comprehensive data about hearing, vision, height or weight. Consensus appears to be that routine monitoring of the whole population is not cost effective.

School nurses are beginning to make a comeback, but are likely to be more focussed on children with problems and less on monitoring. It may be time to revisit the costs and benefits of routine monitoring of all children. Perhaps information about the physical condition of pupils in the school could be correlated with academic achievement.

Information seems to be much better. It is well established for example that children in the lowest socio-economic group are over 4 times more likely to be killed as pedestrians than their counterparts in the highest socio-economic group. In Wales there is an almost comprehensive system for collecting accident data including on children from all A&E departments.

The HEC bit the dust a long time ago. England had a National Task Force on Accidental Injury and The Child Accident Prevention Trust was established in 1981. One of the key health targets established in 1999 is to reduce the death rates from accidents by at least one fifth and to reduce the rate of serious injury from accidents by at least one tenth by 2010 The National Food Survey seems to have been taken over by the Food Standards Agency and become the National Diet & Nutrition Survey.

The General Household Survey continues to cover income, but measures of wealth are notoriously difficult in every sense.

The Health Variations Programme was a research programme focused on the social determinants of health inequalities funded by the Economic and Social Research Council from 1996 to 2001. It was followed by the Acheson report in 1998.

This still seems like a good idea and governments of all flavours have pledged to do it. Progress in achieving these shifts has been minimal because of the immense power of hospitals to attract funds.

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and nursing services for disabled people.

We see this as an important part of a strategy to break the links between social class or poverty and health.

The professional associations as well as the Secretary of State should accept responsibility for making improvements in the quality and geographical coverage of general practice, especially in areas of high prevalence of ill-health and poor social conditions. Where the number of general practitioners is inadequate we recommend Health Authorities to deploy or redeploy an above-average number of community nurses. The distribution of general practitioners should be related not only to population but to medical need.

We recommend that the resources to be allocated should be based upon the future planned share for different services including a higher share for community health.

A non-means-tested scheme for free milk should now be introduced beginning with couples with their first infant child and infant children in large families.

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Areas and districts should review the accessibility and facilities of all ante-natal and child health clinics in their areas and take steps to increase utilisation by mothers, particularly in the early months of pregnancy.

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Savings from the current decline in the school population should be used to finance new services for children under 5. A statutory obligation should be placed on local authorities to ensure adequate day-care in their area for children under 5 and a minimum number of places the number being raised should be laid down centrally.

Further steps should be taken to reorganise day nurseries and nursery schools so that both meet the needs of children for education and care.

Every opportunity should be taken to link revitalised school health care with general practice and intensify surveillance and follow up both in areas of special need and for certain types of family.

An assessment which determines severity of disablement should be adopted as a guide to health and personal social service priorities of the individual and this should be related to the limitation of activities rather than loss of faculty or type of handicap

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Distribution of GPs in poor areas has not improved very much, although the various schemes for salaried GPs and PMS seem to be potentially a more effective mechanism for effective action than previous efforts.

Funding arrangements have changed, but despite widespread agreement that community health is effective and needs more resources there is little evidence that the proportion of expenditure absorbed by hospitals has fallen.

Milk went through a bad time because of its high fat content. Resources are going towards fruit in schools, although milk is still available for poor families. It has recently been rehabilitated and milk is being provided free of charge to all children in some schools as a result of the cheap EU scheme.

There has been very little work done in this area in the last 25 years. Rachel Rowe and Jo Garcia carried out a literature review in 2003.

(The innovative work of Boddy et al in the Grassmarket in Edinburgh aimed at making antenatal care accessible to deprived populations does not seem to have been replicated widely which is a pity).

Sure Start is one of the Labour government’s major successes. It seems to work at least partly because it departs completely from the top down prescriptive approach recommended by Black, but it is on the way to achieving the same results. Part-time education is available for all 3 and 4 year olds for 12.5 hours at present and this is planned to rise to 20 hours a week.

More than half a million childcare places have been created.

The evolution of Children’s Trusts is intended to produce more integrated and responsive services.

There has been some progress in joint assessment and in considering limitation of activities both in health and in Social Security.

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A Working Group should be set up to consider: i. the present functions and structure of hospital residential and domiciliary care for the disabled elderly in relation to their needs in order to determine the best and most economical balance of future services; and ii. whether sheltered housing should be a responsibility of social services or of housing departments and to make recommendations;

There has been a long debate about long term care for the disabled elderly. Few long term wards remain in hospitals. Sheltered housing is now provided mostly by housing associations.

Extra care sheltered housing is the new model which has the potential to significantly improve the community care of the elderly and the elderly disabled. There is still debate around the future of “Supporting people”, which is likely to restrict funds to the most needy.

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Joint funding should be developed to encourage joint care programmes. A further sum should be reserved for payment to authorities putting forward joint programmes to give continuing care to disabled people - for example post-hospital follow-up schemes, pre-hospital support schemes for families. and support programmes for the severely incapacitated and terminally ill.

Criteria for admission to or continuing residence in residential care should be agreed between the DHSS and the local authority associations, and steps taken to encourage rehabilitation and in particular to prevent homeless elderly people from being offered accommodation only in residential homes. Priority should be given to expansion of domiciliary care for those who are severely disabled in their own homes.

The functions of home helps should be extended to permit a lot more work on behalf of disabled people; short courses of training, specialisation of functions and the availability of mini-bus transport, especially to day centres. should be encouraged.

National health goals should be established and stated by government after wide consultation and debate. Measures that might encourage the desirable changes in people's diet, exercise and smoking and drinking behaviour should be agreed among relevant agencies.

An enlarged programme of health education should be sponsored by the Government. and necessary arrangements made for optimal use of the mass media especially television. Health education in schools should become the joint responsibility of LEAs and health authorities.

Stronger measures should be adopted to reduce cigarette smoking. These would include:

Joint work between health and social services has become more common, even though joint funding as known in 1980 is now uncommon. There has been substantial investment in intermediate care. Support for disabled and terminally ill people often comes from voluntary organisations and hospices.

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This is a battle largely won. All parties now advocate helping people to remain in their own homes as long as possible, even though this is sometimes difficult. The residential home industry is declining.

Extra care sheltered housing is a breakthrough here as is the new focus on intermediate care. However, generally speaking rehabilitation remains very much the Cinderella element of the NHS even though its importance was recognised by Beveridge himself in his blueprint for the NHS. Role enlargement in home care is recognised as important in supporting disabled people in their own homes; and is being increasingly practised. More significant, and not envisaged by Black, is the development of Direct Payments, enabling disabled people to decide for themselves what help they need.

The Public Service Agreement targets specifically address inequalities in mortality and life expectancy.

Measures to reduce smoking and improve diet are shortly to be implemented. There has been very little agreement about measures to increase exercise or reduce drinking.

Health education has been out of favour, but seems to have been rediscovered in the White Paper “Choosing Health”. Health promotion / education in schools is the joint responsibility of LEAs and PCAs and is seen as very important in achieving sustained lifestyle change.

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a. legislation rapidly to phase out all advertising of tobacco products (except at place of purchase); b. sponsorship of sporting and artistic activities by tobacco companies should be banned over a period of a few years. and meanwhile there should be stricter control of advertisement through sponsorship; c. regular annual increases in duty on cigarettes in line with rises in income should be imposed; d. tobacco companies should be required to submit plans in consultation with Trades Unions for the diversification of their products over a period of 10 years with a view to the eventual phasing out of sales of harmful tobacco products at home and abroad; e. a stronger well presented warning should appear on all cigarette-packets and such advertisements as remain. together with information on the harmful constituents of cigarettes; f. the provision of non-smoking areas in public places should steadily be extended, and g. a counselling service should be made available in all health districts. and experiment encouraged in methods to help people reduce cigarette smoking.

In the light of the present state of knowledge we recommend that screening for neural tube defects (especially in high risk areas) and Down's Syndrome on the one hand, and for severe hypertension in adults on the other should be made generally available.

We recommend that the Government should finance a special health and social development programme in a small number of selected areas, costing about £30m in 1981-82.

As an immediate goal the level of child benefit should be increased to 5½% of average gross male earnings or £5.70 at November 1979 prices.

Larger child benefits should be progressively introduced for older children after further examination of the needs of children and consideration of the practice in some other countries.

The maternity grant should be increased to £100.

An infant care allowance should be introduced over a 5 year period beginning with all babies born in a year following a

Now achieved To come into effect, finally, this year.

Was implemented but further increases are inhibited by the threat of smuggling from lower duty areas. Needs to be tackled on a Europe wide basis.

Tobacco companies did not embrace this suggestion.

Has been implemented, and further gory illustrations are about to be introduced.

To be implemented in government buildings in 2006 and in everywhere except pubs without food in 2008 Extensive investment in smoking cessation, and particularly in nicotine replacement therapy.

Screening is much more widely available – although there are still doubts about the cost and benefits.

Screening for neural tube defects and Downs Syndrome is now routine and well attested. Widespread use of folic acid is also reducing neural tube defect. Screening for severe hypertension is practised by GPs now on their practice populations Health Action Zones by another name? Targeted funding – Neighbourhood renewal etc. – is now one of the major programmes for tackling inequalities. This approach is open to the criticism that inequalities within areas are as significant as inequalities between areas.

Increasing Child Benefit was one of the first acts of the Blair government in 1997. Now £17 per week for the first child and £11.40 for other children, although this is only about 3.5% of average gross male earnings.

Child Tax Credits play this role, but are means tested.

The universal maternity grant has been abolished, but the Sure Start Maternity Grant, which is means tested, is now £500. Paid maternity leave is now about £1400, and there are proposals to increase it next year.

No progress on this, although rates for young children in means tested benefits were increased very significantly by the first Blair government.

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date to be chosen by the government.

Provision of meals at school should be regarded as a right. Representatives of local authorities and community dieticians should be invited to meet representatives of parents and teachers of particular schools at regular intervals during the year to seek agreement to the provision and quality of meals. Meals in schools should be provided without charge.

A comprehensive disablement allowance for people of all ages should be introduced by stages at the earliest possible date beginning with people with 100 per cent disablement.

Representatives of the DHSS and DE, HSE, together with representatives of the Trade Unions and CBI should draw up minimally acceptable and desirable conditions of work.

Government Departments, employers and unions should devote more attention to preventive health through work organisation, conditions and amenities. and in other ways. There should be a similar shift of emphasis in the work and functions of the Health and Safety Commission and Executive and the Employment Medical Advisory Service.

Local Authority spending on housing improvements under the 1974 Housing Act should be substantially increased Local authorities should increasingly be encouraged to widen their responsibilities to provide for all types of housing need which arise in their localities.

Policies directed towards the public and private housing sectors need to be better coordinated.

Special funding on the lines of joint funding for health and local authorities should be developed by the Government to encourage better Planning and management of housing, including adaptations and provision of necessary facilities and services for disabled people of all ages by social services and housing departments.

Greater co-ordination between Government Departments in the administration of health related Policies is required, by establishing inter-departmental machinery in the Cabinet Office under a Cabinet sub-committee.

Local counterparts of national coordinating bodies also need to be established.

Jamie Oliver is working on this one, and there is a campaign, particularly in Scotland, for universal free school meals – which are already available in Hull.

Disability Living Allowance was introduced in 1992 with this intention, although it does not assess disability with a percentage system.

The Labour Government introduced the minimum wage, and the EU has laid down rules about hours of work and holidays but neither has been inclined to get involved in details about acceptable conditions of work.

The workplace as a key setting for health promotion is now recognised including in the English Public Health White Paper. And HSE is increasingly interested in wellbeing at work as well as the traditional health and safety issues. Stress at work is HSE’s current top priority for action. Unions are still demanding action on Corporate Manslaughter.

It fell. Housing is an area where government intervention has considerably reduced, although the imposition of the Decent Homes Standard has made a considerable impact on the living conditions in social housing.

Local Authorities now have a strategic role in housing and look at all local needs in their Housing Strategies.

But they no longer build houses.

The intention is clearly to reduce further the role of local authorities in the provision and management of housing.

In the more mixed housing economy there is better coordination in some places, especially in regeneration areas Joint funding as it was has gone, but pooled budgets and cross-sector working are at last becoming widespread, especially in respect of disabled people, mental health and children’s services.

There is a Cabinet committee on Public Health, but reports of its activity are sparse. Having a Minister for Public Health is a small step in this direction but might be more effective if of cabinet rank. Still little articulation at the highest level that everything that central government does impacts directly or indirectly on health and wellbeing. There are now plenty of local co-ordinating bodies, but the centre is lagging behind.

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A Health Development Council should be established with an independent membership to play a key advisory and Planning role in relation to a collaborative national policy to reduce inequalities in health.

We had a Health Development Agency – just amalgamated with NICE. And we do have policies to reduce inequalities in health.

HEALTH MANAGERS CHALLENGED TO LOOK AT SERVICE GAPS From an NHS Press Release In a move to develop a more holistic and joined up health service focused on patient need, Sir Nigel Crisp, Chief Executive of the NHS, has challenged senior managers to get personally involved to experience what it is like living in the gaps between services. As an action plan for the year he has asked that they each identify a patient with a long-term condition or some sort of more complex need who lives in the community and uses one or more services. He made it clear that this should not be someone who is absolutely dependent and might be looked after by a community matron, but someone with more intermittent needs. He then wants them to follow the experiences of the person throughout the year and at the end of this monitoring to report to their own Boards on what they discovered. This, he believes, will give Boards a different perspective and maybe help them think and act a lot differently.

As an explanation of the challenge he described the case of a man in his70s. He is diabetic, recently widowed, wants to give up smoking and has a problem with his knees. No one apart from his daughter was concerned about his whole health. No one communicated between all the services - it wasn't the responsibility of the GP nor of the nurse in the diabetic clinic.

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nts should be sent to Gavin Ross, 21 Connaught Road, Harpenden, Herts AL5 4TW, Tel/ Fax 01582-715399 or by e-mail to .15Deadline fo

FORTHCOMING EVENTS Socialist Health Association Members are very welcome at these events, but please let us know you are coming, in case arrangements change

Friday 9th September 2005 Manchester Town Hall

Black Report 25th Anniversary Conference on Health Inequalities

Speakers include Bev Hughes MP, Minister for Children ( pictured below with Mr Oscar Rathfelder ­ tbc) Prof Richard Wilkinson, Dr John Ashton, Dr James Munro and Dr Alex Scott­Samuel

Saturday 17th September 2005 Birmingham Central Council Meeting with Melanie Johnston discussing the Nanny State Labour Party Annual Conference fringe events at La Trattoria 12 Kings Road Brighton:

Health Outside Hospital Wednesday 28th September 6.30 pm Fuel Poverty Tuesday 27th September 6.30 pm

15 Promoting health and well-being through socialism