sh0705

Socialism and Health, the magazine of the Socialist Health Association Spring 2007

Inside this issue:

Time for a change The retirement of Tony Blair gives the opportunity for SHA members to participate in the election of a new Leader and Deputy Leader of the Labour Party. In this mailing you will find your ballot paper. Each member’s vote counts, and the totals voting for each organisation will be published. If lots of our members vote that may increase our influence in the Party, so use your vote.

Lessons from the Past Paul Walker

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Letter to the editor LabOUR Commission

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Conversation Peace Paul Hodgkin and James Munro

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Life Chances at Birth Louise Bamfield

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We asked each candidate for the Deputy Leadership to respond to three questions:

Out Damned Spot Elizabeth Barrett

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Has Tony Blair saved the NHS? Martin Rathfelder

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1. How important is it to you that the next Labour Government reduces inequalities in health? How does that compare with the need to bring down waiting times in the NHS, to combat threats from terrorists or expand the economy?

Future events

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2. Are there public services which would not benefit from marketisation?

3. Would it be possible for a Labour Government to devolve decision making in the NHS to locally elected organisations and not interfere with local decisions, even when there are complaints about postcode prescribing?

The answers we receive will be enclosed with this mailing. Central Council decided on the basis of a quick poll to endorse Jon Cruddas, but the voting now is down to you At a time when the NHS is regarded as one of the key battlegrounds for winning back confidence in the Labour government, the SHA will be promoting its own way forward for the future.

Paul Walker is masterminding the production of a paper on an alternative future for the NHS which will go to Central Council in October

Jon Cruddas—a man to watch?

www.sochealth.co.uk

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Preparing for future disasters by learning the lessons from the past Paul Walker, Chair With the current concern about avian and pandemic flu and with the recent Bernard Matthews incident in mind I have been pondering how well the government is preparing itself and the country for the disaster of a flu pandemic.

For it is certain that there will be another flu pandemic; the only uncertainty is when it will occur.

Having just read two books describing the BSE saga (When Food Kills by Hugh Pennington, and BSE: risk, science and governance by van Zwanenberg and Millstone), it seemed appropriate to use this example as the litmus test of the government’s approach.

Disasters happen, of course, in all countries but how they are dealt with varies. On the basis of recent experience their handling in the UK has particular features that are probably unique and reflect an underlying pathology of our establishment processes. In particular, the mishandling of the BSE crisis raises fundamental questions about these processes which are a cause for concern. Here the delay in taking effective action to prevent infected material entering the human food chain and the further delay in accepting that the BSE agent could cross the species barrier and infect humans were both caused by a very British aversion to working and thinking outside the cosy confines of what has been termed the Establishment Thought Collective. Only members of this exclusive club were allowed into the magic circle of those who determined which hypotheses were accepted and what action should be taken.

The real experts and those prepared to challenge the Establishment view were kept outside.

They were regarded as mavericks and thus not heeded. If they had been many hundreds of thousands of infected animals would have been

prevented from entering the food chain and possibly many tens or even hundreds of cases of variant CJD would have been prevented.

The paradox is, of course, that the UK has consistently punched above its weight in scientific terms, witness its disproportionately large number of Nobel prize winners, simply because in our academic and research communities mavericks and maverick ideas have been positively encouraged. Within Establishment circles, however, they have been systematically excluded thus denying to the Nation the contributions of those most fitted to solve novel scientific and other challenges.

A key question is has the UK government learnt any of the lessons of the BSE disaster? It would seem that the answer is no, or at best, not many. Transparency is identified as one constituent of the remedy; yet the civil service remains incurably and pathologically secretive.

Accountability is another ingredient but scientists, increasingly in thrall to industry which funds them and buys their loyalty, tend to call the shots rather than accountable politicians.

At a more general level the central question is how can we understand the roles that science should play in policy making. Should science be subordinate to politics or the other way round? There is strong support for both views.

In fact real policy making is more complex than this but in an increasingly technological and science driven world it is difficult for scientifically naif politicians and their civil servants to compete with the scientist experts.

So, fast forward to avian flu and a human flu pandemic, we can but hope that government and its advisors have read these two books and have learned their lessons of total transparency, political accountability and the importance of breaking out of the magic Establishment circle to take on board views and suggestions that might seem off the wall.

The club is a British invention. The BSE story demonstrates that it is potentially a lethal one.

We need to be sure that the same closed mindedness and aversion to maverick thinking are not constraining the planning of the country’s response not only to a human flu pandemic but also to other possible disasters such as 9/11 type terrorist incidents and chemical, nuclear or biological attacks.

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LabOUR Commission’s Interim recommendations The LabOUR Commission’s Interim recommendations presented here are based on the findings of the first representative study of Labour Party members’ views since Labour’s landslide victory in 1997:

b) Establishing a Charter of Labour Party Members' Rights, underwritten with the creation of a new post of Party Ombudsman, as part of a comprehensive approach to rebuilding membership and the Party's finances c) Extending democracy adoption of one minister 1. one vote procedures for all government places on internal Party bodies, and One member one vote elections (OMOV) for the constituency section places on the National Policy Forum as first steps to restoring open and transparent consultation, and policy making processes.

Angela Eagle MP, Chair

Letter to the Editor I have just read “A Fresh Start” and agree wholeheartedly with its contents, particularly with the PPI section.

Labour Party members have told us they want their voice back. After ten years in Government, the Party’s future ability to operate as an effective, broadly based electoral force is in question by both its members and former members. This Interim Report contains evidence that the Leadership's experiment to run Labour on an US style, command and control basis, ruled from Downing Street has failed.

2. From the outset the LabOUR Commission has seen mass membership, and active citizenship as central to restoring accountability, party and parliamentary democracy for Labour renewal. An important first step is reaffirming its federal structure and strengthening its internal processes of democracy.

3. Our interim recommendations are based on detailed research with past and existing members, as well as the experience of members of the LabOUR Commission. Our proposals include: a) Ending political patronage starting with abolition of the post of appointed Party Chair, and including interim measures to elect Labour nominations for the House of Lords, pending its further reform

We in Hemel Hempstead have experienced consultation documents which are “evasive if not downright dishonest”. The recent consultations have indeed been predetermined and a waste of time and money. We have never had an acceptable explanation of why Watford was chosen when they will have difficulty “shoring up the existing buildings” while a new hospital is built there, yet still pushing NW Herts there! Is there any likelihood that the forthcoming consultation will be any different? Our Chairman of West Herts Hospital Trust makes clear that consultation is a farce.

One additional fact that is omitted from the SHA paper is the position of non-executives on Trust Boards. They were supposed to hold the executives to account, on behalf of the public. But they raise only minor issues and simply endorse everything. If they object, as three did last year, they are got rid of. So could a paragraph be added about strengthening the role of non-executives, as well as making consultations have some significance.

Zena Bullmore, Hemel Hempstead, March 2007

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Conversation Peace Paul Hodgkin and James Munro The latest web technology has the potential to disrupt the NHS status quo - but it could transform our experience of healthcare The internet may be revolutionising banking and tearing the travel and music industries to bits, but so far the NHS - that great dowager duchess of the public services - has sailed on relatively unperturbed.

This, however, is about to change. The technology (known as Web 2.0) that drives sites such as Amazon, YouTube and My Space is as potentially disrupting to health services as Napster and peer-topeer file sharing have been for the recording industry.

Clips on YouTube of health service staff not washing their hands or of dirty NHS toilets are likely to become commonplace. Depending on how it is managed, such feedback could be hugely positive or it could become trivial, demeaning and unpleasant.

Web-based feedback by thousands of citizens about the care they have received is new. In the old days of the 19th century the world ran under an industrial information economy. It took a cast of thousands and a brace of millionaires to produce a newspaper or film. As a result, only elites had access to a public voice. But the new networked information economy has made

it easy for anyone to have a digital voice. You can blog or upload a clip to YouTube or post a comment about your recent hotel stay on Trip Advisor right now and at zero cost.

The searchable nature of the web means that those with minutely matched affinities can find each other.

If you have got renal failure, rheumatoid arthritis and have just lost your job, somewhere out there is an e-discussion group that will be filled with people who really understand you because they have experienced similar things.

And a problem shared is not only a problem halved, it is also, given the right circumstances, a problem transformed into a pressure group.

But having a voice is not the same as being heard.

For most people, YouTube is an anarchic cacophony, an ego-driven place that shouts: "Look at me." Unsurprisingly, it is hard for bureaucratic organisations such as hospitals to make sense of this new information. People may be posting pictures of the dirty toilets on ward 15, but what exactly are busy managers supposed to do about the posting once they have sent the cleaners in?

By contrast, surveys and focus groups - the classic tools used by organisations to find out what service

users want - are essentially about "you", about managers researching those mysterious people called patients. These two dialogues, one based on dissecting you, the other on shouting about me, are equally ill-matched for productive conversations.

What we need is to enable newly democratised voices to speak in ways that organisations can hear and respond to. What we need are dialogues about "us".

Patient Opinion, a not-forprofit social enterprise, uses a variety of tools to do this. Patients and carers generate content by sharing their stories on the site and by rating the service they have received.

Anyone can then view this feedback to find out what people thought about a particular department, ward, service or procedure. To make the system into a genuine conversation, Patient Opinion then offers several new Web 2.0 twists: opinions can be directed (using frequently updated digital RSS feeds) to the relevant manager as a weekly email digest; and a wide range of people (from patient groups to MPs) can be given the right to respond.

This mixture of constrained openness seems to produce a more useful dialogue than the unarmed combat that passes for discussion on many blogs and e-groups. Comments

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and suggestions from patients are typically small scale, easy to rectify and highly important to the experience of care. Examples include: "The ward orderlies never knocked," or "My father could only eat liquids but was at the end of the ward and the soup was always finished by the time they got to him."

Real change These things are central to good care. The NHS concentrates on efficacy and efficiency but these are aesthetic aspects of care.

Questions such as: were you included in decisions?

Did staff make you feel precious or worthless? are just as important. Too small to be dealt with by formal contracts, they gain some bite by being voiced on the public space of the web. Add comments from patient groups, and feed these conversations back to hospitals and primary care trusts, and the small voice of the individual can become the kernel of real change.

Running Patient Opinion has convinced us that the state or public sector providers themselves are likely to be poor hosts for these conversations. Citizens are likely to instinctively distrust government websites, suspecting them - rightly or wrongly - of spin. They may also be reluctant to give email addresses to a feedback platform owned by the NHS when they may be users of its services in the future.

And, of course, health abounds with controversies, be it hospital closures or herceptin rationing.

In our view, the NHS will find it easier to handle such firestorms if they are hosted on a platform that is clearly independent of the main players.

These arguments are about to be put to the test with the development of the NHS Choices website, which is due to go live this summer and has been funded by the Department of Health at a reported cost of ÂŁ8m. It is a welcome attempt to provide a single site where patients and citizens can find all the information they require about health and, among other things, includes a "patient voice" section where patients will be able to give feedback about their care at hospitals.

It will not be long, then, until we will have a choice of feedback platforms one owned by the state, another run by an independent, not-for-profit social enterprise. Having different models is important because no one yet knows how this new class of webdriven feedback about public services should be developed. Beneficial outcomes are not guaranteed - just ask the teachers who have been traduced by pornographic voiceovers on YouTube.

Research suggests that people are more likely to invest their trust in a site if it is independent and has

transparent values and motivations. Such trust has to be earned. Governments are liable to be suspected of spin, and advertising may be inappropriate - the most profitable advertisers for a site patient feedback site could be ambulance chasers and purveyors of therapeutic snake oil.

So testing different models and debating their merits is important. As webbased feedback grows, it will become a powerful quality driver and a major factor in how the public perceives services. It will take time for professionals to accept that their "clinical gaze" is now returned by the insouciant stare of thousands of users looking - and commenting - back at them. Yet, if we get it right, we could devise routine ways to aggregate our collective experience and wisdom, and perhaps find many of the solutions that we will need to survive the 21st century.

Honing the raw techniques into useful tools for civil society will require vision and persistence. The motivations and incentives behind any national patient feedback platform will determine whether the great potential of such citizendonated feedback is realised or thrown away.

Paul Hodgkin is a GP and chief executive of Patient Opinion. James Munro is director of research at Patient Opinion.

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Louise Bamfield Senior Research Fellow Fabian Society Making the positive case for improving life chances at birth In recent months, a new ‘prebirth’ agenda has begun to emerge in government, with a new commitment to allow women to claim child benefit during pregnancy for the first time,i and with the piloting of an intensive health-led parenting support programme, based on the US Nurse Family Partnership programme, targeted at pregnant women most at risk of poor pregnancy outcomes.ii Although the latter proposal in particular has attracted controversy, a strong and positive case can be made for government action to improve birth outcomes, in order to narrow the gap in life chances of children from more and less advantaged backgrounds.

The problem is that the positive case has not often been made – or heard – in public, being drowned out by hysterical media headlines about the targeting of future criminals.

In developing these proposals, the government has responded to mounting evidence of early health inequalities, beginning before a baby is even born, which can have long-term negative consequences for a baby’s life chances. As highlighted in our recent Fabian report, Born Unequal, a baby’s size or weight at birth is a particularly important indicator of healthy foetal development, since low birth weight (under five and a half pounds) is strongly associated with a range of health and developmental prob-

lems in infancy, childhood and in later life. Worryingly, children from different social and ethnic backgrounds continue to face significant inequalities at birth, with poorer parents and pregnant women of Bangladeshi, Pakistani and Caribbean origin having a much greater risk of having an underweight baby than other groups.

The extension of child benefit into pregnancy is an important move, signalling as it does the government’s willingness to address financial barriers to good health which currently exacerbate health gaps. As Prime Minister, Gordon Brown will need to go further still to improve financial support, however, especially for the groups of women, including very young mothers, most at risk of experiencing poor birth outcomes. To this end, we call in Born Unequal for an end to the age disparity in income support for young people under 25, to provide additional financial support for some of the most vulnerable pregnant women and parents-to-be. In the longer term, government must be prepared to increase adult benefit rates, both to improve adult health and to protect children yet to be born from the effects of poverty.

Besides increased financial support, more needs to be done to reduce social inequalities in access to maternity care. Investment is

needed to increase the number of specially trained midwives, health visitors and family support workers to help meet the needs of vulnerable groups such as teenage mothers, women from more deprived ethnic minority groups and pregnant asylum-seekers and refugees.

As indicated, the government has already started to explore new ways of improving pregnancy and birth outcomes for the most vulnerable mothers and infants. As set out in the Cabinet Office’s Action Plan on Social Exclusion last September, the government has set up pilots in ten areas to explore the efficacy of a programme of intensive pregnancy and parenting support provided by specially trained health visitors. The Department of Health’s Family Nurse Partnership project will help build up the empirical research base in this area, something which is especially welcome given the current dearth of robust research evidence on what works to improve pregnancy and birth outcomes.

But doubts remain about the sustainability of the programme. In the first place, the long-term viability of the pilot project is uncertain, since funding has as yet been secured only for the first stage of the study, which will last until March 2008. Concerns are also expressed about the affordability of a national pro-

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gramme of intensive health-visiting for the most vulnerable groups of women. Whereas health visitors in the pilot study have a caseload of 25 parents, this diverges widely from the current situation, where the average ratio is 1 health visitor to 400 parents (and reaches a ratio of 1 to 1,600 in the worst areas). Even assuming that the funding can found to facilitate a roll-out of the project across the country, the question remains of where the health visitors would come from to provide support at these kinds of levels, and whether it will be possible to expand the project without diverting funds and staffing capacity from the universal health-visiting service.

Perhaps the most pressing concerns, however, are about the political posturing that has accompanied some of the policy announcements so far. While the Action Plan on Social Exclusion contained some sensible proposals for piloting new ways of supporting the most vulnerable pregnant women, coverage of the Action Plan was overshadowed by hysterical headlines warning of ‘baby asbos’, while subsequent updates on the pilot programme have been presented as a ‘crackdown on criminality’.iii By framing proposals for early intervention around the notion of anti-social behaviour, the government risks distorting the message it sends about the purpose and rationale of these programmes. This threatens to alienate members of the public who might otherwise

accept the case for positive pre-birth intervention, whilst stigmatising the very people that the proposals are intended to support.

Instead of emphasizing the risks to society of future anti-social behaviour, government needs to make the positive case for improving children’s life chances at birth, to enhance their prospects for a full and flourishing life. Gordon Brown can and should make inequalities at birth an important theme of his premiership, building on the proposal to extend child benefit to pregnancy already announced. But to get this agenda right, he needs to ditch the posturing and punitive language which has characterized presentation of the issue so far, and concentrate instead on making the positive case for improving baby’s life chances at birth.

i In his pre-budget review in December 2006, Gordon Brown announced that pregnant women would be entitled to claim child benefit from the 29thth week of pregnancy, beginning in 2009. ii Proposals to pilot the new programme were set out in Reaching Out: an action plan on social exclusion, published by the Cabinet Office in September 2006. 10 pilot areas have been chosen to take part in the project, which is being led by Kate Billingham, deputy chief nursing officer at the Department of Health. iii Hennessey, P. (09/10/2006) Daily Telegraph; Ward, L. (16/05/2007) The Guardian.

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Out Damned Spot Dr Elizabeth Barrett When patients were asked, at one of our local District General Hospitals, about shifting dermatology to primary care, they thought it was a wonderful idea to 'use GP skills'. The question to be asked is 'what skills?'. Dermatology is a highly specialised area, which is inadequately taught in medical school, and afterwards. It involves a lengthy process of learning pattern recognition and judgement, and constant exposure is required for the development and maintenance of good skills. Inadequate experience is not safe and patients will get a duff service.

don't always understand clinical issues. The assumption that clinicians should respond enthusiastically to every new managerial initiative is as mistaken as the assumption that managers are always wrong.

What is needed is intelligent dialogue where all particpants are honest about their assumptions and have a genuine re-

spect for each others' position.

Shifting dermatology out to primary care cannot be achieved by just asking GPs to do more dermatology, or providing some brief training, therefore. One suggested solution is to use people like me as 'intermediate' dermatologists.

But we then cease to be GPs if we spend our working days going round other surgeries. If we simply act as referral redirection services (looking at letters and sending back or redirecting), some ghastly mistakes will be made,.

If we are going to shift dermatology into primary care we have to shift the expertise with it, and this includes all the connected staff, including admin, and not just our old, resistant friends, the doctors. Sometimes there are good clinical reasons for not changing behaviour in response to managers' requests. Managers may be great at managing, but they

We have had this before - specialists coming out to primary care to see the patients of certain GPs. This is inefficient and also discriminatory. We had an ENT surgeon who came to our surgery every 4th Friday. The patients loved it. The surgeon loved it, too. He was away from his secretary; noone in the hospital knew where he was; there were no 'extras', no overbooking and no-one knew where to phone him.

Most of us multi-task at work.

If I do a child health clinic, even in the building next door, I am taken out of my complex working environment (phone, computer, ad hoc requests, interruptions, messages, and paperwork etc) and immediately become less efficient. I have, effectively 'disappeared'.

It is physically impossible for specialists to visit all GP surgeries. If you ask patients to

come to a particularly large, central surgery, or even to some other building, then you might as well ask them to go to the hospital - at least there is a public transport infrastructure around hospitals, whereas there is no such connections between surgeries.

'Anywhere except the hospital' is not going to lead to joined up clinical care. Seeing patients in an off motorway industrial estate is not 'care closer to home' and may simply fragment care. Pathologists and Dermatologists work closely together, for instance.

Specialties cannot be taken in isolation on a medical level, and clinicians should have opportunities to meet each other, at least sometimes.

Some GP minor surgery is highly cost-effective, and very satisfactory for patients, but the term hides a very wide range of operations. Some GPs, especially ex-surgical registrars, will be able to carry out quite complex procedures but I can't see that sort of thing having a major budgetary impact. For most GPs claiming minor surgery payments, the surgery they do is very minor indeed - often the stuff that patients can't even be bothered going the hospital for. Savings need to be balanced against perverse costs of GPs claiming for things that the hospital wouldn't do. The most important skills in surgery are a) knowing the diagnosis and b) knowing when something shouldn't be removed, because

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most patients are blissfully unaware of the risks of scarring, and inadequately experienced doctors may be, too. Being able to confidently explain why you are not doing something is one of the important jobs of a clinician.

I think it is fair to say that melanomas are never intentionally excised by GPs. The problem is that some are very difficult to recognise and they can masquerade as benign moles, seborrhoeic warts and sometimes can look quite banal. In general practice, melanomas are removed by mistake. The best hope is that, at very least, all specimens are sent for histology, so that the patient has the opportunity for an MDT opinion, as per skin cancer guidelines, if it turns out to be nasty. It is actually not the end of the world for a melanoma to be excised by a GP, as long as the specimen reaches a histopathologist.

Crucially, failure to send a specimen to histopathology is seriously legally actionable, in the event of a missed melanoma. Most GPs are terrified of missing a melanoma, anyway, a fear that results in vast amounts of two-week wait referrals for all sorts of benign lesions. None of this is an easy business.

So what, exactly, is wrong with the system of 'hospitals'?

What is wrong with the idea of secondary care? What is wrong with the concept of tertiary care? And how are we going to ensure standards if everything is dumbed down one rung of the ladder? Who is going to check quality, and how? How much will all that cost? Where

Smallpox are the calculations?

I think the real prize of care closer to home is the care of the elderly, with complex needs, who become overtired by hospital visits, or admissions. Ensuring adequate social care, better communication between health and social care, addressing dysfunctional funding policies between health and social budgets, and creating collaborative working structures which put patients' needs at the centre is a realistic aim, though it may not come as cheap as is hoped. Good, anticipatory, social care can't come cheap, and identifying 'high risk' patients for extra care is an inexact science, but this is well worth working towards.

One other thing we really do have to be concerned about is the experience of patients in residential and nursing homes.

For many of our vulnerable elderly, the standard of nursing and care in some of our privately run homes is truly dis-

mal. Staff may be badly paid, poorly trained, and work excessively long shifts. There are policies of recruiting nurses from abroad, and many of them don't have English as their first language, which the elderly, muddled and deaf can have great difficulty with. Understaffing makes for excessively regimented and depersonalised regimes and inadequate social input. Perhaps, with all this attention on caring for people in the community, some attention needs to be focussed on this Cinderella of private provision for some of our most heartbreakingly vulnerable patients.

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Has Tony Blair saved the NHS or ruined it?

We still have a National Health Service – now in four different flavours, one for each country.

It consumes immense amounts of money. £105 billion, 9.4% of Gross Domestic Product in 2007-08 more than £2000 each. And perhaps it gets too much attention. After all the NHS is a means to the end of improving the health of the population. It has become an immense institution – a national religion. There are other ways of improving health which may be cheaper and more effective. The endless attention given to the NHS by the Blair Government has helped to foster the illusion that the means are more important than the end. Certainly much more political attention is given to concerns about the workings of the NHS than to concerns about health. Life expectancy in some Glasgow constituencies is under 60 for men. For women in Kensington it's over 80. Conservative voters on average get to vote in two more General Elections than Labour voters.

The NHS has changed a lot since 1997. Fundholding was abolished because it was an evil emanation of a Conservative market in health care and has been replaced – eventually – by Practice Based Commissioning, which is, of course, much better and entirely different. Local health authorities were abolished and have been replaced, eventually, by PCTs which often seem be covering the same areas, have similar functions, and operate from the same buildings. A similar pat-

tern of changes has taken place at regional level in England.

But the devolution of power to Scotland and Wales – and now Northern Ireland - has been a very important and significant change, although little remarked in England. Constant reorganisation has not allowed the government to claim credit for previous reforms, because the implication must be that they have failed or they wouldn't need changing again.

One big change is that under Blair the Department of Health has become more than ever the Department for Managing the English NHS. Almost entirely staffed by NHS managers there is little consideration of health policies across the UK and little impression that health policy is determined by the Department, which is dominated by target delivery. Policies seem to come from Downing Street and the Treasury. Richmond House concentrates on delivery and the pressure it exerts on local NHS bodies means that their opportunity to make their own decisions is severely restricted.

seems quite possible that the target to bring total waiting time for planned treatment from GP referral to start of treatment under 18 weeks in England will be met sometime in 2008 – although it will be challenging, previous targets have largely been met. The market for private healthcare is drying up. Premature deaths from circulatory disease (CHD, stroke and related diseases) in people under 75 have fallen by almost 36% in the past decade. The NHS is on target to achieve a reduction of at least 20% in cancer deaths by 2010. The new GP contract includes targets for management of many chronic diseases, the like of which has not been seen anywhere in the world.

Annual investment of over £1.5bn has resulted in 700 new mental health teams in the community, increases in all main staff groups, increased patient satisfaction and record falls in suicide rates, (although that owes more to public health measures like reducing the availability of poisons) meaning that the World Health Organisation now rates England's mental health services as the 'best in Europe'. Psychiatry was starting Service delivery to patients has from a low base however, and improved amazingly. Not only there seems to be more dissatisfaction with the state of services have large numbers of shiny from both patients and staff than new hospitals been built (mostly using PFI but patients in physical medicine. The NHS Confederation Mental Health Secdon't seem to object to that), tion has started its life by issuing but there are enormous numan apology to the patients it's bers of extra staff, better paid members have failed. In particular and so less likely to abandon talking therapy still seems very the NHS for a job in Tesco, and many more machines that hard to get, despite Prime Ministerial promises about increasing go ping. Waiting lists have evaporated under heavy down- availability. However one of the ward pressure and the threat of Blair Government's most imprescompetition and choice. It sive achievements has been to

Martin Rathfelder unite the whole mental health world in opposition to its efforts to reform the mental health legislation.

Some things have not changed. Most importantly the principle that NHS care is largely free at the point of use has been resolutely defended (mostly against doctors, some of whom still think charging the patients is a good idea), to the point where even the Conservatives seem to have abandoned their proposals to interfere with it. Even the dog's breakfast which constitutes the charging system for prescriptions, teeth, eyes and providing help with fares to hospital has escaped reform – except in Wales where prescriptions have just been abolished.

The patients seem to be happier. There has been an extensive programme of patient satisfaction surveys, independently operated by the Picker Institute, and on almost every area patients satisfaction is rising steadily. They report that the things patients care most about are: ·Fast access to reliable health advice ·Effective treatment delivered by trusted

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professionals ·Involvement in decisions and respect for preferences ·Clear, comprehensible information and support for self-care ·Attention to physical and environmental needs ·Emotional support, empathy and respect ·Involvement of, and support for, family and carers ·Continuity of care and smooth transitions.

The introduction of Patient Choice doesn't seem to have had much impact on this except where it has helped reduce waiting times. The choices on offer (between different hospitals) are not generally choices patients care much about, the information available about choices is pretty limited, and choice only really works for non urgent referrals in urban areas. The Expert Patient Programme seems to have been a major success for those involved in it, but the spread of the Internet has probably done more for patient autonomy and support for people with chronic conditions than any thing the NHS has done.

However the staff, especially the doctors, are very unhappy. “is a strong sense among doctors that government policy reflects a loss of faith in the NHS and public sector.” 1 This seems to be because of the impact of more aggressive management techniques and a more competitive environment which has at last begun to impact on doctors – 23 years after the introduction of General

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Management into the NHS. A consultant complained on TV last week that he was forced to process patients “like widgets”. Substantial pay rises do not seem to have made doctors happier. They feel their autonomy is threatened and they are uncertain about what the future holds. The endless reforms seem to lack any obvious endpoint. And many staff are uneasy that the service is moving from one which is "needs based " – ie professionally defined - to one which is "rights based" and even "wants based" – leaving them in an uneasy position between the consumer and consumer dissatisfaction.

lish Foundation Hospitals as self-governing and competitive entities has resulted in 65 Foundation Trusts at the time of writing. The process of establishing them and bringing NHS accounting and contracting more in line with the outside world has been quite painful exposing a good number of trusts as not viable and many others as having long running financial problems. And it is not clear whether the Information Technology which is supposed to hold the system together can be delivered and made to work.

Along with a market based approach there has been a significant increase in regulation of various kinds. The most politically significant is probably the National Institute of Clinical Excellence, (not strictly speaking a regulator) which has largely taken the heat out of the rationing debate (having recovered after suffering a body blow during the Herceptin affair). The Healthcare Commission, under its redoubtable Chairman, Sir Ian Kennedy who delivered the report on the Bristol heart surgery scandal, is implementing a progressively more demanding quality regime for NHS trusts. Having recently taken over the administration of second tier complaints it is now tackling this problematic area. At the same time the National Patient Safety Agency is the key to efforts to improve the safety of patients, who are increasingly aware that hospitals are not safe places and that the chances of contracting infection in hospital is significant. The General Medical Council and the other professional regulators came under intense scrutiny following a series of scandals of which the Shipman case was only the most dramatic.

The nearer the NHS gets to being a consumer provision the harder it will be to tell people that they cannot pay for what they want if they can afford to but the NHS does not provide. NHS Management has historically been based on principles of social administration, ensuring efficient local delivery within a fair and equitable national system, and is now being asked to be more commercial and entrepreneurial. Managers vary in their attitude to this change, but quite a few are unhappy. The idea that if you have external regulators, then you can liberate market forces to keep the NHS increasingly efficient and effective is not supported by very much evidence, and does not seem to be leading us towards a position of stability. Indeed there are a number of influential people calling for “creative destruction” and the like. Even if their theory is soundly based it seems unlikely to win us many friends Public and Patient Involvement has not been a success. in the short term.

It is still unclear why Alan Milburn decided unilaterally to abolish Community Health Councils – as part of an Nurses are not so unhappy – their pay has not NHS plan which otherwise was marked by widespread risen to such astronomical heights, but they have consultation and a consensus approach. The Patient Fobeen allowed to develop more responsibility. rums which followed have had an uncertain life and are There is a great deal of anxiety about what is still dues to be abolished and replaced by something labelled as “creeping privatisation”, but in real- which looks a bit like ... a Community Health Council. ity the proportion of the budget spent on nonThere has been a lot of talk about the importance of NHS providers has only risen from 3.2% (1996) public involvement, but when challenged the Departto 5.8 (2006), and most of this has been on new ment of Health has gone to court to defend the right not provision rather than moving services out of the to consult people. The consultations operated by indiNHS. But it is certainly enough to worry people, vidual trusts are often transparently shallow and time and some at least has been forced through by the wasting. It remains to be seen whether the present proDepartment of Health in the teeth of local oppo- posals will turn out to be either credible or lasting. sition. There are signs that people both inside and outside the NHS are worried about the effect There is also still considerable evidence that complaints of private sector provision on their local hospi- systems in the NHS are neither effective nor credible. tal, especially in more rural areas where if the Patients find them complicated and confusing, and local hospital were to close the alternative is a many are afraid to use them for fear of reprisals. Unforlong way away. In England the efforts to estab- tunately reprisals are not uncommon. The National Pa-

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tient Safety Agency is generally rated a success but it has a long way to go to establish a culture where staff can report incidents without fear, and until it does then the complaints system will continue to be ineffective.

The plan to abolish child poverty by 2015 is very ambitious and may not be realised, but putting it on the political agenda is a very bold move. Household disposable income has gone up from £9050 in 1996 to £13302 in 2005, and this of course makes the realisation of the target – which is defined in terms of proportion of average income – more difficult.

The smoking bans, already in force in three parts of the UK may represent the Blair Government's most important legacy to public health, although the impression was given that they had to be persuaded to actually implement it. Much like other public health initiatives where the impression is repeatedly of uncertainty and timidity, which has denied the government any political credit among those who should be its supporters.

FREE BOOK GIVEAWAY – FREE SLAM NHS TRUSTS has print run of IS FULL OF

by Dolly Sen given to sercarers and

CHARITABLE sponsored a THE WORLD LAUGHTER so it can be vice users, mental health staff.

“This book started out as a possible suicide note and ended up a celebration of life”, writes the author. The result of her work is an outstanding memoir about surviving childhood abuse and severe mental illness in South London that has inspired readers to say the book has positively changed their lives.

"Raw, harrowing and compelling. This is a worthy addition to the new genre of mad memoirs."Robert Dellar , Mad Pride

Health inequality has been a very difficult problem for Labour. Life expectancy has improved – a woman aged 65 could expect to live 19.4 years in 2005 – a year more than in 1997. For men the figures are even more striking – an increase from 15 years to 16.6. But the evidence seems to be that life expectancy – and other measures – are improving more quickly for the rich than for the poor. Across most government departments there has been a significant amount of activity related to tackling health inequalities, but the impression is that the forces generated by widening economic inequality, fuelled by unprecedented growth have outstripped the relatively small scale programmes.

“The frankness and ironic humour kept me turning the pages. This is the book I’ll give to people who want to know what madness is really like.”– Liz Main , Mental Health Today

All this can be regarded as Blair's legacy, but it is unclear how much actually depended on his personal contribution. Of course other ministers will be keen to claim credit for successes – success has many fathers, but failure is a bastard. Brown seems a bit less enthusiastic about markets and a bit keener on public health. He has personal familiarity with the NHS in a way which Blair hasn't. It may be some time before we see if a change of leader means a change of direction in health. We can only hope that a new leader can be persuaded not to embark on another programme of redisorganisation.

Available now in paperback and E Book. For more info go to http://www.chipmunkapublishing.com

“Thought-provoking, stark, brutal and exhilarating”– Anne Mathie, Mind Out “Dolly’s powerful and moving memoir tells her terribly difficult story in an astonishingly frank and honest way which, don’t ask me how, somehow manages a streak of irony and dare I say it, even humour. It is an incredibly honest and determined account to record her personal struggle with mental illness.” - Barry Watts, Mind.

Dolly is willing to give free talks, readings or workshops to discuss her mental health experience, her book, or how writing and art can be a route to recovery.

If you are interested in taking part, contact Dolly on 07906 936 365 or email dollysen70@hotmail.com

Future Events Health of Black and Ethnic Minority Communities Tuesday 12th June 10am-4pm Toynbee Hall 28 Commercial Street, London E1 6LS Cllr Patrick Vernon LB Hackney, Jazz Boghal, Regional Public Health Group London, Dr Saffron Karlsen Department of Epidemiology and Public Health, UCL, Conor McGinn, Health Development Officer, Federation of Irish Societies Public Involvement in the NHS - is LINKs the way forward?

25th June 10am - 4pm Coventry Dr Richard Taylor MP, Ruth Marsden, National Association of Patients' Forums, Sally Brearley, Healthlink Local Democracy & the NHS 9th July Newcastle Friends Meeting House Sir Jeremy Beecham, other speakers tbc.

Future of Primary care 14 July Socialist Health Association Council – Derby Dr Bess Barrett th

Devolution and Health 19th Sept Edinburgh Scott L. Greer School of Public Health, University of Michigan, Professor D J Hunter, Professor of Health Policy and Management, University of Durham, Dr Kate O'Donnell General Practice & Primary Care, University of Glasgow 24th Sept Labour Party Conference Bournemouth – Is the NHS safe with Labour?

8th October Manchester Obesity and Exercise Costs for events vary but are reduced for SHA members (and delegates from affiliated organisations, such as Amicus and Unison).

Further details will be at 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 Autumn 2007 edition is 30th September.

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