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Socialism and Health, the magazine of the Socialist Health Association Autumn 2006

Editorial:

Inside this issue: Is our NHS the best in the world

2

USA falls behind Cuba

3

Labour Party Conference report

4

Conference Resolution on health

5

Regulating Health care Professionals

6

The War on Drugs

10

Does the Government have a mandate?

11

NHS on the operating table

12

Doctor’s Dilemma

13

Future events

14

The SHA raised its profile at the Labour Party Conference in Manchester. Our constitutional amendment to simplify Clause 4 of the Party Constitution is on the agenda for debate before and at next year’s Conference. And the initiative to organise a common venue for Socialist Societies was highly successful.

The SHA draft policy statement on the NHS circulated in draft at Conference and was further discussed at SHA Central Council in October. It will be presented in our next issue.

We include in this issue the SHA response to the consultation on Regulating Healthcare Professionals.

Dr Jackie Grunsell, GP and Huddersfield Save Our NHS councillor at the NHS Together demonstration on 1st November

www.sochealth.co.uk

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IS OUR NHS REALLY THE BEST IN THE WORLD? Paul Walker, Chair I was asked the other week to speak to this title by my Constituency Labour Party. I don’t imagine anyone seriously believes that the NHS is the best healthcare service in the world but it is I believe quite important to try and assess how good it is compared with those in other rich countries.

I am old enough to remember when the NHS was generally believed to be the best in the world, which begs the question “why?”

The answer I think lies in one of the statistical

annexes to the landmark World Health Organisation Health Report 2000 – Health Systems: Improving Performance. This shows that in that year at least the NHS occupied a unique position in that the direct out of pocket cost of the Service to individual users was much lower than even its nearest rivals because it remains more or less free at the point of use, unlike other countries where patients have to pay for rather more than prescriptions and dental care out of their own pockets. So, I posit, it is because the NHS remains “free” unlike in all other countries that it is still perceived as the best.

But this aspect aside how does our NHS stack up? The WHO report aims to assess the healthcare systems in each of its 191

member states on five criteria: 1.Overall good health (eg low infant mortality rates and high disability-adjusted life expectancy) 2.A fair distribution of good health (eg low infant mortality and long life expectancy evenly distributed across population groups) 3.A high level of overall responsiveness 4.A fair distribution of responsiveness across population groups 5.A fair distribution of financing health care (whether the burden of health costs is fairly distributed based on ability to pay, so that everyone is equally protected from the financial risks of illness) On the first criterion using Disability Adjusted Life Expectancy as the measure of health the UK ranks 14th with Japan at number 1 and Holland, Norway and Belgium its nearest neighbours. On the second criterion, using infant mortality as the only readily available relevant measure, rather surprisingly the UK ranks second after Chile with Japan, Norway and Poland as near neighbours. On the third measure the UK ranks 27th, with Ireland, Qatar and Andorra as its near neighbours and with the US ranked number one.

Looking at the distribution of responsiveness , the fourth criterion, where there were no hard data and ranking had to depend on the subjective assessment of a panel of experts the picture is not so clear.

The UK ranks third equal with at least 30 other countries including Sweden, Japan, France and Germany. The United Arab Emirates ranks 1st, Bulgaria ranks 2nd and the

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US does not appear in the top 37.

On the fifth criterion the UK ranks 11th with Columbia number 1 and Japan, Finland and Austria its near neighbours.

Ambitiously, the WHO has attempted to integrate these five criteria into a single measure of health system attainment, which shows Japan as league leader and the UK ranking 9th next to Holland and Austria. But it also attempts to rank the member states in terms of performance which they define as their attainment relative to the use of resources on healthcare.

On this measure France ranks number 1 and the UK ranks 18th behind Luxembourg and Holland.

When this study was published it caused considerable controversy because of both its methodology and findings.

There was a general view that to rank France as number one in terms of health system performance flew in the face of common experience; and undoubtedly some of the methodology is primitive and needs further work. But it was at least a start and the WHO has undertaken to improve its methodologies and data collection, and to publish updates of the 2000 Report.

It is interesting to speculate what these might show in respect of the UK bearing in mind the large increase in funding that has been applied to the NHS since 2000.

My hunch is that the NHS’ attainment will be shown to have increased but that its performance will have deteriorated, as it is difficult to believe that any healthcare system could absorb the extra funds allocated to the NHS in such a short period of time and deploy them efficiently.

So what is the overall diagnosis? No, not the best in the world but compared with the other largest global economies, better than the US and Germany if not as good as France and Japan.

US falls behind Cuba to finish 30th in 2004 Health Olympics The Human Development Report 2006 has released with the latest rankings of countries by life expectancy These are data for 2004.

The rankings of the top 30 countries with their life expectancies are: 1 Japan 82.2 2 Hong Kong 81.8 3 Iceland 80.9 4 Switzerland 80.7 5 Australia 80.5 6 Sweden 80.3 7 Canada 80.2 8 Italy 80.2 9 Israel 80 10 Spain 79.7 11 Norway 79.6 12 France 79.6 13 New Zealand 79.3 14 Austria 79.2 15 Belgium 79.1 16 Germany 78.9 17 Singapore 78.9 18 Finland 78.7 19 Cyprus 78.7 20 Luxembourg 78.6 21 Malta 78.6 22 Netherlands 78.5 23 United Kingdom 78.5 24 Greece 78.3 25 Costa Rica 78.3 26 United Arab Emirates 78.3 27 Chile 78.1 28 Ireland 77.9 29 Cuba 77.6 30 United States 77.5 Just to give a sense of the magnitude of the difference between the US and Japan, consider that if we were to eradicate the leading cause of death in the USA, heart disease, and keep the other disease death rates the same, we would only gain about 3.2 years and still be behind the leader.

When I went to medical school in 1970, the US was about 12th, when I went to public health school in 1992, we were about 20th, and last year, 29th, the year before that 27th. I have no idea how much farther we will descend.

Stephen Bezruchka MD, MPH University of Washington

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Labour Party Conference 2006 Report by SHA Director, October 2006 The Labour Party Conference seems to have produced the desired result. The seven-point lead over Labour opened up by David Cameron went. Peace between the various leadership candidates has been re- established. The party website says “The most important part of conference are not the personalities involved but the policies being debated, the policies meeting the needs of the public and facing the challenges they and we face together.” – but it isn’t true. We are no longer allowed to discuss policies at conference because the sight of people disagreeing with each other alarms the voters.

Health, or at least the future of the NHS, was the subject of one of the few contentious debates at the conference. The National Executive Committee agreed a statement recommending that there should be discussions about “the different criteria that we should use to establish the extent and balance of diverse providers in order to achieve the best care for NHS patients”. The Health debate was set down for an hour and a half, combined with education, and half an hour of this was taken up with a discussion on a sofa between Pat Hewitt and

Alan Johnson and lovely front line staff telling the viewers about the wonderful work they were doing, so leaving little time for debate. There were two resolutions – one largely supporting the Government and one from Unison rather more critical (see page 5), So where does this leave the NHS? Is it safe in the hands of the Labour Party? The Unison resolution falls rather short of the position advocated by Keep Our NHS Public. It calls for reviews and reconsideration. There was a lot of fuss about NHS Logistics, which is actually being privatised, ie handed over to a commercial organisation, not just being made subject to a quasi- market as other parts of the NHS are, but in the end it is a warehousing and delivery organisation, so it did not raise as much feeling as a clinical service might have.

All the resolutions called for wider consultation and discussion, but are such discussions are possible? The Blairite faction are clearly convinced that market forces and competition are necessary to cope with the technological changes in health care and to ensure increases in efficiency.

The Keep Our NHS Public

camp takes for granted that public provision is inherently superior. Neither side seems very interested in considering evidence which might undermine their belief, and really convincing evidence is scarce. Both sides also believe that irreparable damage to the NHS will be done if their opponents get their way.

Of course these days much of the most interesting discussions happen outside the formal conference agenda, in the fringe meetings, which may eventually, as has happened in the Edinburgh Festival, come to overshadow the official event.

Both the Fabian Society and the Socialist Health Association had events on the theme of inequality, and both featured Prof Danny Dorling, from Sheffield, who pointed out that this was the first Labour Government under which inequality has risen. Delegates probably also reflected that this is the first Labour Government which has managed to win more than one General Election, and wondered if there was a connection.

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Proposed by UNISON, seconded by Oxford and Abingdon CLP, and passed by a large majority (all other resolutions fell): Conference notes with concern the Government’s announcement on September 5th that NHS Logistics, an award winning service, will be outsourced to DHL and its Texas-based Novation and the ballot decision on 11th September of NHS Logistics staff to take industrial action against this step. NHSL has won numerous awards for efficiency and service excellence and its dedicated and committed staff wish to remain part of the NHS public service family.

Conference also notes the appeal court decision of 23rd August 2006 regarding the awarding of a contract for GP services in Cresswell and Langwith in Derbyshire by the North East Derbyshire PCT to United Health Group Ltd. Despite the fact that investment in the NHS has increased substantially and will continue to increase under a Labour Government, immense damage is being done to some local services because of deficits and the breakneck speed of change. Private Finance Initiative projects, of which a fresh wave was announced on 18 August 2006, lock hospitals into long-term financial commitments and leave them unable to adapt to changing needs.

Across the country patients are finding themselves facing cuts in valued local services and in staffing levels as some local Trusts struggle to balance their books.

Clearly, where such cuts are being made, local services are suffering. Moreover, staff morale across the NHS is being damaged as they feel their

Text of Composite 8 on Health views are not being listened to and there is growing public concern that the NHS is once again in crisis. The party needs to listen to the concerns of those communities.

Conference recognises the widespread and spontaneous reaction of local communities as they respond to news about their local NHS with protests and demonstrations. In Cornwall 400 Royal Cornwall Hospital staff have received redundancy “at risk” letters, and services at the Royal Cornwall Hospitals Trust’s two smaller hospitals are being curtailed (with possibilities of outright closure not excluded).

A resolution of the South West Regional Labour Party for an independent review of the RCHT’s affairs, promoted by this CLP last March, when the Trust’s declared deficit stood at barely a quarter of its present level, has received no response for the Secretary of State.

Compulsory payments to independent treatment centres can impoverish local NHS facilities; in Oxfordshire, NHS trusts were forced to pay Netcare hundreds of thousands of pounds for cataract operations which were never carried out because local hospitals could already cope, driving them further into deficit. “Cinderella” services such as mental health are particularly hard hit, and though the south-east is considered affluent, there are pockets of deprivation and disadvantaged individuals who are suffering and look to labour for support.

Conference understands that the issues underlying some of these problems are complex, varied and often long-standing.

But the major cause of the current crisis is a direct consequence of the move to a competitive, market-based system, the continued use of PFI and payment by results.

The paper issued by the Department of Health on July 13, “Health reform in England: Update and Commissioning Framework” defines the key drivers for improvement through commissioning to the “contracting, contestability and service redesign,” (para 2.4).

This flatly contradicts Labour’s policy agreed at the last round of Partnership in Power (Britain is Working, 2004, p.117) which stated “Labour will develop an approach that builds on collaboration, not competition.”

The Health Select Committee Report in July into independent sector treatment centres has demonstrated that the NHS is not benefiting for the involvement of the private sector and that cuts in hospital services may come about as a result. The recent decision to freeze the expansion of payment by results is welcome, but many areas already covered by the national tariff have seen their finances destabilised by this system.

It is the rapid move from collaboration to competition which is forcing individual accounting units within the system to have to achieve “financial balance” in unrealistic timescales.

Moreover, this is being demanded at the same time as other substantial changes are being introduced, some very welcome such as the new emphasis on prevention and the shift of resources to primary care.

Conference believes that the sheer pace and weight of change is in itself causing damage, and that such major changes should be carefully trialled and evaluated before considered for wider application.

Regulating Health Care Professionals and the regulation of the nonmedical Healthcare professions Response by the Socialist Health Association to The regulation of the non-medical healthcare professions: a review by the Department of Health, and Good doctors, safer patients: Proposals to strengthen the system to assure and improve the performance of doctors and to protect the safety of patients July 2006 1.We welcome the general direction of these two reports, but were saddened that there had to be a separate one for doctors. We also felt that they could have gone further, although we recognise the complexity of the issues involved, and the need to address many conflicting interests and concerns. Despite the manifest inadequacy of the existing systems of regulation and the immense sums of money which have been spent on repeated enquiries resulting from their failures the changes proposed are less fundamental than appears to us to be appropriate. Despite its length Sir Liam’s report is short of logic to justify its proposals. Harold Shipman is frequently mentioned but there seems no clear link between the findings of the report into his activities and the proposed course of action. As far as one can tell Harold Shipman was a competent and popular doctor who would have had no difficulties with anything now proposed. In any case we do not think it is sensible or practical to set up a system of regulation which is partly designed to catch a clever psychopathic professional in the absence of any evidence that there are more like him. We want a single system of regulation which applies to all health and social care professionals and is governed by one set of legislation

across the whole of the UK and which can be easily understood by everyone. We believe that the roles of workers in both the health and social care sectors are increasingly overlapping and becoming more fluid so there should be a single system of regulation.

There would be economies of scale to be made, and it might be possible to devise a system of fees on a basis which related to the earnings of the various professions. Many of the recent failures have been a mixture of weak, or nonexistent, local arrangements, and confused understanding of who would take action. A single system would be much better able to cope with problems arising from the development of new professions and of specialisation within existing professions. Simpler legislation would be easier to understand and could be made more flexible as is needed in an era where professions and specialisms develop and mutate quickly. It is not necessary for each profession to have its own Act of Parliament in order to demonstrate its autonomy.

2.Given the free movement of labour within the EU & the mutual recognition of EU professional qualifications it would make good sense to have a single EU-wide regulator for all health and social care professionals. It is certainly no longer possible for the UK to conduct its regulatory system as if it were selfcontained. Nor is it politically acceptable for us to recognise European qualifications and experience but discount experience and qualifications gained outside Europe.

3.We see a continuing role for each profession to establish standards of professional competence across Europe

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within its sphere of expertise and to decide, if necessary, whether entrants to the profession or those who competence is called into question have reached the necessary standard. We do not want to see the standards of professional competence in any profession determined by the state. But there must be involvement of lay people and patients in setting the standards and in monitoring those standards both in practice and in educational institutions. We do want to see a system which ensures that the standards espoused by leading members of each profession are translated into systems which are reliably enforced.

4.There should be one appointments process for all members of the UK professional regulatory bodies, both registrants and lay, which should be handled by the NHS Appointments Commission, or another independent body. Both registrant and lay members should be appointed, not elected. Appointment should be against a set of criteria. There should be no need for alternates for registrants if they are appointed rather than elected. Much more effort needs to be devoted to ensuring that decision making bodies represent the diversity of registrants and that the lay members represent the diversity of the population.

5.There is little mention in either of these weighty documents of the systems for dealing with patients’ complaints or those for involving patients and the public. (We use the word patients throughout to mean those, however designated, at the receiving end of the work of a professional).

The impression is still that the systems of regulation are pro-

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vided for the benefit of the professional staff, not for the patients.

6.It is apparent that few complaints by patients come to the attention of the regulatory bodies. Most of their work is generated by other professional staff. In our view this is not because patients have no complaints, but because the procedures established to deal with patient complaints are impenetrable and have no real link with the regulatory system. We accept that patients may make unfounded, illinformed or inappropriate complaints, but this is not a good reason for ignoring the possibility that their complaints may be well founded.

Complaints should be encouraged if there is a genuine desire that the health service should learn from them. At present most patients do not complain when it appears that things have gone wrong either because they are afraid that their subsequent treatment will suffer (and there is evidence that such a belief is well founded, especially in primary care) or because they think it is a waste of time. We should aim for a system which regards an increase in the number of complaints as an indication that the system is working properly. Patients who are disadvantaged are less likely to make complaints than those who are better placed, although they are probably more likely to be on the receiving end of poor practice.

We would like to see monitoring of the social and ethnic characteristics of complainants (and also of those subject to complaint) and measures for increasing the proportion from disadvantaged groups.

7.The systems for dealing with concerns that things have gone wrong, whether or not they are described as complaints or clinical negligence or something else entirely

must be joined up. If this means reducing the number of separate organisations with responsibilities in this area then that should happen. Too often when we meet a person who has been on the receiving end of some unfortunate episode the process of trying to work out which one of a myriad of organisations was the most appropriate to deal with the problem, and the Byzantine complexity of pursuing a complaint, has been as damaging to them as the original incident.

8.We do not see a good reason for treating the regulation of doctors as something entirely separate from the regulation of all other professionals. The days when doctors were entirely autonomous and all other staff were subservient to them have gone. From the patient’s point of view the doctor is part of a team. When things go wrong this is often because of poor communication between professionals.

We would want to see systems which permit investigation of all those involved in an incident if things go wrong. It is clear from the findings of the various enquiries that while doctors were culpable there were often other professionals implicated, if only for inaction. We would like to see some link in this area to the Ombudsman and the Principles of Good Administration.

9.We suggest that there are many areas across all health and social care professional practice, including that of doctors, in which common standards apply. We would like to see a common code of ethics and conduct established which could apply to all caring professions and common procedures for dealing with breaches of that code. It should not be necessary for each profession to decide individually whether it is acceptable for its members to ex-

ploit or abuse patients or to make racist remarks about their colleagues. This code should be incorporated into person specifications and job descriptions for all professionals and staff, as it will enable employers to deal more effectively with unacceptable behaviour in annual appraisals and other best human resource practice. Implementation of these procedures will support the evidence gathering processes undertaken by the regulator if a case has to be referred to them.

10.The idea of a separate process of fact finding which could be carried out locally and quickly is attractive. This is a difficult task which is best carried out quickly by people who are not closely involved in the institutions involved. We do not see that members of professional bodies necessarily have forensic skills.

The present processes for dealing with professionals who have needed investigation are often slow and cumbersome and this is bad for both patients and professionals. A single local process for establishing the facts of a case which applied to all health and social care professionals would make it a lot easier for patients to see how they could complain. In some cases it is quite clear on the basis of admitted facts that the person can no longer practice, but decisions are often delayed for years while other processes are carried out.

We think that there is merit in adjusting the standard of proof, if facts are in dispute, in the light of the seriousness of the allegations and their consequences.

We are not convinced that placing more reliance on employers to carry out investigations is likely to be a successful strategy.

Employers have their own interests to consider and struggle to deal fairly with senior staff who are subject to investigation. Managing underperformance, or dangerous practice by professionals and ensuring compliance with employment legislation and regulatory procedures is a highly

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Regulating Health Care Professionals (continued skilled task, and most Directors of Nursing and Clinical Directors will only have to deal with a few cases in their professional lives. Support to undertake this work appropriately (such as that offered by the National Clinical Assessment Service) must be made more widely available particularly as more and more health professionals will be employed outside the NHS. Some employers send cases to the regulatory bodies because they cannot manage the situation themselves. If we have a more diverse range of providers the capacity of employers to manage will also become more diverse. It should also be noted that some professionals appear before their regulatory body because of systems failure, or inappropriate demands by employers which present conflict with their code of conduct. In these cases sharing of information both in the collection of evidence, and in the judgement of the facts with the HealthCare Commission for instance, should be encouraged to ensure fairness to individual registrants, but also to protect patients and the public.

11.As far as adjudication goes we suggest that the regulators should fund the Council for Health Regulation Excellence to manage the adjudication process with the hearing panels being drawn exclusively from a single central pool trained by CHRE and working to common rules, procedures and sanctions. The fees charged to registrants might relate to the numbers of costs of hearings in their particular area of expertise. The regulators would have a clear role in working with CHRE about their own registrants to ensure that the evidence was judged against the competen-

cies agreed by the regulator for that particular area of practice. This separation of function would ensure that the regulators focused on their key roles of setting standards for training, and placing people who have achieved the standard on the register which in effect is the licence to practice in that profession. The regulators should also be ensuring that they have systems in place to keep up to date with rapidly changing practice in the workplace, and that they have working relationships with organisations and employers so that high standards can be maintained and developed. Their role in continuing professional development and re-validation (however this is done) will be crucial so that the public can have confidence that people who have been placed on the register and whose registration is regularly renewed are competent and safe to practice. This would also end the involvement of members of the professional councils in the judgement of fitness to practice cases which can take up an inappropriate amount of their time, and, at the moment, we do not have the evidence that council members have the necessary forensic skills to undertake this work.

12.The regulation of health and social care professionals must be separated from the management of the National Health Service. We do not want to see different standards or different procedures depending on who employs the staff. We cannot see any good reason for separate regulatory procedures for staff who are not employed by the NHS or for different procedures reflecting the increasing divergence across the NHS in the four different nations.

13.We want to see an end to the system which excludes professionals, doctors most commonly, from the normal processes of performance management. No-one should have the right to prevent information about their performance at work being subject to scrutiny. The appraisal arrangements for doctors as well as other professional staff should be used for performance management. A professional may be inefficient, uncooperative, wasteful or lazy without bringing his or her fitness to practice into question. But this does not mean that continued employment should be guaranteed.

Many patient complaints are concerned with this sort of poor behaviour which should be dealt with as an employment issue, just as it would be with unqualified staff.

14.If continuing training, professional development and reaccreditation are to become mandatory it will be necessary to ensure that an external body is in a position to insist that it happens and is prepared to prevent people from practicing if they do not comply. This cannot be done by the employer because we know that employers will use training budgets to tackle other more pressing problems if they can. There will be substantial costs to be borne and it is not clear who is expected to carry them. We would like to see a system of revalidation developed which can be applied to all health and care professionals. Reaccreditation and professional development belong to the regulators, with the CHRE being used to bring together core elements to maintain consistency about team working, communication skills, and all the general standards of a professional, while

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the individual regulatory body deals with the specialist nature of the particular profession. This is and should be their key role and it is one where far more time, resource and effort should be placed. This is not only important in terms of protecting patients, but is also a resource issue. If high standards for training leading to a licence to practice are not in place then incompetent and unsafe practitioners will continue to put patients at risk, or cause distress by their behaviour, and employers and colleagues will spend time and resource trying to manage them. The cost of removal from the registrar is high in terms of staff morale, employers' time and money and costs to the regulators in terms of legal fees and other resources. Any system of revalidation needs to take account of the realities of professional life. It needs to be flexible enough to cope in particular with staff who move and work across international borders.

It is high time we abandoned the fiction that professional experience is only valid if it takes place in Europe or America. A person employed as a cardiologist, or as a speech therapist specialising in work with small children needs to be accredited in their current area of expertise (and possibly restricted from straying outside it). Information about revalidation and areas of expertise should be made available in public registers.

15.The role of the National Clinical Assessment Service should be developed to deal with all concerns about impaired fitness to practise across all regulated professions. An underperforming nurse or therapist should not be denied help which is made available to doctors.

16.The question of whether people can speak English is

distinguishable from their professional competence and should not be dealt with by the same procedures. The present systems for testing English language are part of a racially discriminatory system which has been very successful in ensuring that black people are kept out of high status jobs and that professional experience outside Europe is devalued. They also ensure that many of our citizens are denied access to a professional who speaks their language.

That is not to suggest that ability to communicate with colleagues and patients is not critical, only that we can no longer assume that all concerned speak English. It is not acceptable that people who speak Latvian are to be accepted as suitable for employment despite their lack of command of English, but people who speak Somali are prevented from practising here despite a clear need for their expertise in their community.

The procedure for European nationals should be followed in respect of all other applicants for professional recognition: “Member States may require migrants to have the knowledge of languages necessary for practising the profession. This provision must be applied proportionately, which rules out the systematic imposition of language tests before a professional activity can be practised. It should be noted that any evaluation of language skills is separate from the recognition of professional qualifications. It must take place after recognition, when actual access to the profession in question is sought.”

17.Lay people should be in a majority in all decision making bodies, including the CHRE. They should be treated as equal in all respects as compared with registrants.

They should be enabled to meet separately if necessary

and given support to ensure they are not disadvantaged as compared with members of the profession concerned.

Consideration should be given to linking lay people in the regulatory system into the national organisation for patient and public involvement which the Government is contemplating. We see important roles for patients and carers which are distinct from the roles ascribed to lay people in general, and these could be developed in any local decision making.

18.We do not want to see the concept of professionalism and the associated costs of regulation extended too far.

Professional regulation is necessary to deal with the imbalance of power and expertise between patients and those who to whom they submit themselves for treatment because they hold themselves out as having special expertise. The work of care assistants, cooks, porter, cleaners and other unqualified staff is equally important, but we do not need protection against their possible incompetence or inadequacy in the same way because lay people can understand what they are doing and if necessary question it in a way which most of us cannot do with professional staff. The problem here is that patients are generally vulnerable, and often alone and powerless. It is not clear to us how regulation of these staff would help.

It will certainly not be possible to protect the title of “healthcare assistant” by ensuring that only registered staff can use it. If regulation is extended to health and social care assistants then it may be that very different practices are needed to deal with these very large groups.

Fringe meeting organised by the SHA “ The War on Drugs – Another unwinnable American adventure?” - Paul Walker A small but interested audience attended the Drugs Fringe on Wednesday, 27th September in the Friends Meeting House. The line up of speakers comprised : Danny Kushlick – Director of Transform Drugs Policy Foundation Geof Rayner – Health Policy Analyst and former Chair of UKPHA Dr John Ashton – formerly Regional Director of Public Health to the NW Region Danny Kushlick provided the context for the debate on legalisation, namely the current global prohibition of drug use mandated by a series of United Nations Conventions on Drugs starting in 1961. Most of the 192 UN member states are signed up to these so preventing them from having independent domestic policy and legislation on drug use though some states such as Portugal and Mexico seem to have found ways of interpreting the Conventions more liberally than most. Prohibition was introduced into the UK in 1971 with the passage of the Misuse of Drugs Act. Just as prohibition of alcohol had not worked in the US in the 1920s and had spawned a massive rise in criminal activity, so the prohibition of drugs was not working – drugs were more available now and cheaper than at any time in recent history – and drugs related global criminal activity was estimated to be of massive and growing proportions.

It is evident that many UN member states – but not the UK yet – are pressing for an end to global prohibition and it is anticipated that by 2020 a new UN Convention on Drugs will abandon prohibition in favour of legalisation within a tightly regulated framework.

Geof Rayner called for a consistent approach to all psycho-active substances including alcohol and tobacco and referred to the recent Parliamentary Science and Technology Select Committee report, “ Drug Classification: Making a Hash of it?” which calls for a major overhaul of the system currently in use in the UK for categorising drugs. A key point made by the Committee is that any classification system based on harm done must include tobacco and alcohol which together cause about 40 times the total

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number of deaths from all illegal drugs combined. On the basis of a new categorisation system proposed by the Committee, based on harm done, alcohol would probably be listed as a class A drug, the fifth most harmful, and tobacco as a class B one, the ninth most harmful.

Geof further pointed out that the UK hosted both the biggest drinks manufacturer in the world and some of the biggest tobacco firms too.

John Ashton suggested that the use of psycho-active substances such as drugs and alcohol was part of the human condition and had to be accepted as such. So legal supply and use was the only sensible and pragmatic approach albeit within an appropriately strict regulatory framework to ensure purity of the product and the protection of minors backed up by health education programmes to warn people of the dangers of use and particularly of misuse.

My own take on the issue was that a health impact assessment should be carried out on the current policy compared with legalisation.

This would almost certainly show that the current policy had a greater tendency to increase health inequalities both domestically and globally than a new policy of regulated legalisation.

Implications for SHA I don’t think we learned anything new at the Fringe except that there is clearly growing discontent both domestically and internationally with the current US inspired UN Convention on Drugs. It would seem appropriate for the SHA to state its commitment to legalisation and to add its voice to any domestic campaigns aimed at speeding up the process of changing the UN Convention – to me at least, the year 2020 seems a very long way away.

I have been invited to become a member of the Drugs Health Alliance a group of mainly voluntary bodies campaigning in favour of legalisation which meets quarterly in London. I think it would be useful to keep SHA posted on developments.

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. The NHS should be built up now that significant public funds are at last available, not health corporations. In announcing controversial 5-year 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 determination to continue both the direction and the pace of reform set out by the prime minister and my predecessors to deliver the patient-led NHS for which the government has a mandate."

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 pocket-book pages on health tell us about Patricia Hewitt's "reform...to deliver a patient-led 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

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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 ÂŁ500 million for front-line staff."

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

The Labour Party did not have even a 'manifesto mandate' for the post-election 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.

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The NHS on the Operating Table, Suresh Pushpananthan

The appointment of David Nicholson as the new chief executive of the NHS in England is welcome by most of us working on the frontline. He has an impressive track record within the NHS and seems fully committed to its founding principles and core values. In his first interview as chief executive, he stated that a reconfiguration of emergency, paediatric and maternity services would be needed across the country. This is a controversial but necessary measure to enhance quality of care for trauma victims and children with complex health problems.

Medicine is changing fast. Specialists are becoming sub-specialists with advanced levels of expertise in treating the most complicated diseases for which there were few remedies just a few years ago. For example, one will now find sub-specialists in paediatric nephrology, paediatric cardiology and neonatal intensive care looking after new born babies who ten years ago would not have survived. To gain sufficient expertise, doctors need to treat these patients on a daily basis – rather than encountering them a few times a year. These sub-specialists can only deliver the highest quality of expert care if they cover a large population of patients.

As for trauma services, it has long been known that specialised trauma centres with immediate access to emergency specialist surgeons provide the best results for those with the most serious injuries. Immediate access to highly specialised trauma doctors such as neurosurgeons, thoracic surgeons as well as the general surgeons and orthopaedic surgeons that are present in every district general hospital leads to improved outcome for these patients.

So what is to become of A&E departments?

The majority of patients attending A&E are not critically ill. Most can be treated in walk-in centres and minor injury units or with improved access to their GP. Medical specialists such as cardiologists and respiratory physicians can deal with other emergencies such as heart attacks and asthma attacks possibly through a streamlined ‘Urgent Care’ department.

Advances in medical therapies coupled with proposals to treat more patients closer to home by expanding primary care will further add to the strain on district general hospitals.

These hospitals, caught between increasing community provision and increasing high-tech super-hospitals, may be forced into a diminished role.

The case for large teaching hospitals with ‘super-specialists’ catering for a larger population base is a strong one for trauma and paediatrics. Maternity services do not warrant reconfiguration. For the vast majority of pregnant women, very little specialist medical input is required beyond the midwife. It has been claimed that a consultant-led service is best. This is an over-reaction and an overmedicalisation of a normal part of life. This country can be extremely proud of its excellent standard of midwifery. The vast majority of pregnant women will not need a doctor when giving birth. In order to provide a 24-hour consultant obstetric service, maternity units may have to merge it has been suggested by Mr Nicholson. This is entirely mistaken and a very difficult line to sell to local people. Extra resources are needed to provide additional consultants in the district general hospitals where maternity services are successful, convenient and hugely valued by their local communities.

The future NHS should be leaner and more responsive to the needs of its patients. A modern NHS should have a greater role for large teaching hospitals with highly specialised doctors serving larger populations. It needs district general hospitals to provide most acute health care and services which is important to local communities such as maternity provision.

The electorate, already distrustful of Labour’s record on the NHS, will be sceptical about the apparent ‘cutting’ of services in the midst of media hype about a deficit ‘crisis’. Closure of local hospital services is a political hot potato.

Labour lost Wyre Forest in 2001 to Richard Taylor who stood on a ‘save our A&E department’ ticket. David Nicholson and the government need to clearly articulate that these proposals are about improving care rather than cutting costs. Labour risks losing its NHS trump card at the next general election unless it skilfully negotiates the changes that are necessary on the rocky road ahead.

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The Doctor’s Dilemma Gavin Ross, Editor, Socialism & Health

Bernard Shaw’s play, which celebrates its centenary this November, is relevant today not so much for his satirical approach to the variety of theories about medical treatment as for his farsighted views on inequality and public service.

The preface, which is nearly as long as the play itself, sets out, among other less relevant ideas, the case for a public health service, and for nonmedical measures to improve the health of the nation, whether by a minimum wage, better diet and hygiene and warm housing, better maternity services, or the education of women.

Shaw attacks the wealthy doctor who seeks to prolong illness in order to stimulate demand for his treatments. Meanwhile the few doctors willing to serve the poor were themselves hardly better off than the patients they treated for a pittance. He satirises the different theories prevalent at the time as equally ineffective, as they often were before the advent of penicillin. The “dilemma” of the title is whether to spend scarce resources on the treatment of Dubedat, the spendthrift but talented artist, or Blenkinsop, the worthy but boring slum doctor.

This hints at QALYS or of arguments as to whether to give a transplant to a politician or a tramp.

My grandfather (James S Ross) was a senior civil servant in the Ministry of Health in 1946, and his copy of Shaw’s play has interesting underlining of critical paragraphs in the preface, as if the play was required reading for civil servants to help them understand where these new Labour politicians got their ideas from. Of course Shaw as an early Fabian had helped to promulgate many of these ideas before and after 1906. But here are some of Shaw’s arguments which were noted in the Ministry: “When you are so poor that you cannot afford to refuse eighteen pence from a man who is too poor to pay you any more, it is useless to tell him that what he or his sick child needs is not medicine, but more leisure, better clothes, better food, and a better drained and ventilated house.”

(Penguin edn 1946. p.19) “The real woes of the doctor are the shabby coat, the wolf at the door, the tyranny of ignorant

patients, the work day of 24 hours, and uselessness of honestly prescribing what most of the patients really need: that is, not medicine, but money.” (p.72) “A popular but unstable remedy is to enable local authorities, when they are too small to require the undivided time of such men as Medical Officers of our great municipalities, to combine for public health purposes so that each may share the services of a highly paid official of the best class; but the right remedy is a larger area as sanitary unit.” (p.73) “The social solution of the medical problem depends on that large, slowly advancing, pettishly resisted integration of society called generally Socialism. Until the medical profession becomes a body of men trained and paid by the country to keep the country in health it will remain what it is at present: a conspiracy to exploit popular credulity and human suffering.” (p.75) “Here we come to the danger that terrifies so many of us: the danger of having a hygienic orthodoxy imposed on us. But we must face that: in such crowded and poverty-ridden civilizations such as ours any orthodoxy is better that laissezfaire. If our population ever comes to consist exclusively of well-to-do, highly cultivated, and thoroughly instructed free persons in a position to take care of themselves, no doubt they will make short work of a good deal of official regulation that is now life-and-death necessity to us; but under existing circumstances almost any sort of attention that democracy will stand is better than neglect.” (p.81) Nowadays we may regard Shaw’s strictures on vaccination, statistical methods, faith healers and surgery as slightly idiosyncratic. But we cannot deny that his outspokenness and burning passion were significant contributions to the formation of a popular movement for a National Health Service.

Future Events The New Deal on Patient and Public Involvement Abbey Community Centre 34 Great Smith Street Westminster London SW1P 3BU Tuesday 9th January 2007 10am - 4pm This event is designed for members of Patient Forums and people who want to be involved with the future of Patient and Public Involvement in England. It is intended to produce a response to the House of Commons Health Committee who have announced an enquiry into: • The purpose of public and patient involvement • The proposed establishments of Local Involvement Networks (LINks): their powers and make-up • Public consultation over changes to services in both primary and acute sectors (Section 11 of the Health and Social Care Act 2001) Dr Richard Taylor, MP for Wyre Forest (Independent Kidderminster Hospital and Health Concern), a member of the Health Committee has agreed to speak at the morning session.

Developing Labour Health Policy: Toynbee Hall 28 Commercial Street, London E1 6LS - nearest tube Aldgate East With Prof Nick Bosanquet, Consultant Director of Reform and Dr Jacky Davis, Keep our NHS Public 10am - 3pm Saturday 2nd December 2006 Golden Lion Hotel, Lower Briggate Leeds LS1 4AE 10am - 3pm Saturday 9th December 2006

Costs for the events above vary includes lunch and refreshments but are reduced for SHA members (and delegates from affiliated organisations, such as Amicus and Unison).

Further details will be on our website www.sochealth.co.uk or available from the office.

Articles, Letters, Announcements and Comments should be sent to the editor Gavin Ross, 21 Connaught Road, Harpenden, Herts AL5 4TW. The deadline for contributions to the next edition is 31st December.

Tel/Fax 01582-715399 or by e-mail to gavros.ross@btopenworld.com

Socialist Health Association 22 Blair Road Manchester M16 8NS Tel 0870 013 0065 admin@sochealth.co.uk