POLICIES FOR THE NATIONAL PLAN FOR HEALTH
1. Introduction
- The SHA was founded in the 1930s as the Socialist Medical Association
to campaign for the introduction of a National Health Service. Following
that initial success, it has continued in existence to focus debate on protecting
and improving the NHS, and to campaign on issues of health and inequality.
The SHA seeks to bring fundamental and enduring socialist values to the
analysis and understanding of contemporary health politics.
- With the advent of a new Labour government it has been reviewing its role.
It recognises that it may now seem out dated to some critics, and aligned
to the forces of conservatism. This is, however, far from the case. While
retaining its commitment to the enduring values of the NHS, the SHA wishes
to be the "critical friend" of the Labour government. It will be welcoming
and supportive of the government's policies and achievements, while offering
advice and views on those issues that require more attention.
- The SHA has over 1000 members. They are interested in and active at all
levels of the NHS. They are doctors, dentists, nurses, and therapists, managers,
lay members and non-executive directors, they come from the voluntary sector
and the community health councils, and most importantly, they are service
users. Most of them are trade unionists and members of the Labour Party.
They constitute a wide-ranging and influential cadre of Party members within
the NHS who know how it works on the ground
- Distribution of the internal questionnaire was patchy, and ordinary Party
members have had little opportunity to contribute to the National Plan consultation.
The SHA is seeking to fill this vacuum by offering the means for a continuous
dialogue between the government and the Party on health and health care
issues
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2. Improving Health
- The key to achieving significant improvements in the health of the population
will be through reducing inequalities in health by cutting the excess death
rates and levels of chronic disability of those sections of the population
with the worst health. This must be matched by modernising the operation
of the NHS and the delivery of health and social care to achieve an efficient
and effective service that is equally accessible to every person in the
country
- Underlying the inequalities of health are inequalities in most or all
aspects of life, of which the most pertinent measures are the differences
between the richest and the poorest. Income inequality remains the single
most important determinant of health inequalities, although the links to
educational attainment, family breakdown, ethnicity and geography are also
understood
- To reduce inequalities, income inequalities must be reduced by redistributive
methods. Health inequalities internationally are greater where the greatest
income inequality is found. Recent comparisons between cities in Canada
and the USA have demonstrated that the typical mortality gradients described
in the Acheson report for the UK are also observed in the USA, but are much
less apparent in Canada. There, the combination of greater economic equity
and publicly funded health and social welfare services have made an impact
- The disposition of disposable incomes in the UK is skewed to the right.
Focusing solely on the proportionately small poor and socially excluded
groups on the left hand side of the distribution, while important as a social
goal, is insufficient to deal with overall inequality. Greater fairness
and equity will improve the health of society as a whole, including the
rich. There is evidence that growing inequalities in Britain, and particularly
the legacies of Thatcherism, have been disadvantageous to the health and
well being of all, including the affluent.
- The principles that underpin all the SHA's detailed policies are equity,
accountability, and quality. The government's strategies to address poverty,
particularly child poverty, are therefore applauded for their likely impact
on health, as well as for many other reasons. However, the government should
now extend these strategies to reduce relative poverty as well as absolute
poverty for maximum health gain
- The challenge of reducing inequalities in health must be tackled under
each of the five headings. In every case there are immediate actions that
can be taken now, coupled with the need to build up hard evidence-based
strategies for the longer term
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3. Prevention
- Primary prevention means tackling the wider determinants of health. The
underlying causes of much ill health and premature death lie in unemployment
and low income, occupational risks, poor housing and community environments,
poor educational achievement and social isolation
- Resource allocations need to be positively weighted to support disadvantaged
communities, as is happening through the Regional Development Agencies,
Health Action Zones, Education Action Zones and Surestart schemes. However,
all these schemes need to be centrally co-ordinated in a more explicit and
systematic way so that they add up to a coherent and purposeful political
agenda. There is risk in a bidding and lottery culture of allocation that
those in deprived areas miss out once again - audiences at the Royal Opera
House versus the population of Inner Manchester
- It is known that there are more barriers to be overcome for effective
preventive measures in deprived communities, and resources must be allocated
accordingly over a reasonable time. Where there are specific interventions
that will prevent disease and reduce inequalities, then government must
show leadership and the determination to introduce them. For example, if
the expert committee on fluoridation reports that it is highly effective
and safe, then it should be introduced as a water quality measure nationally,
with minimum and maximum levels. Local determination would be an obstacle
to achieving this as water companies are multi-national, with supply grids
that do not respect local authority boundaries. This would be an example
of effective determination for a government that is serious about reducing
health inequalities
- Investment is needed in disseminating existing evidence about preventive
and health promotion strategies that work for communities with the worst
health chances. Significant investment in identifying and evaluating new
possibilities, and in disseminating the results, is also required. There
will be no magic formula - what is being sought are small increments in
success across a broad field
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4. PARTNERSHIP
- Health
- The SHA recognises that the NHS alone cannot improve the nation's
health, but requires the support of a range of partners. Therefore existing
partnerships with local authorities, voluntary organisations and others
need to be strengthened at every level. These will be facilitated if
PCG/Ts and health authorities match one or more local authority boundaries.
This will enable joint policy development, and reduce the emerging mismatch
in England between NHS registered populations in primary care organisation
and local authority resident populations
- Looking to the future, mechanisms are needed to ensure that local
authorities and health authorities work effectively together to draw
up and implement Health Improvement Programmes that will improve health
and tackle health inequalities. The requirements are not sufficiently
robust at this stage, and leave room for local authorities inimical
to the government to do as little as possible to progress the government's
modernisation agenda. Performance review systems within the NHS and
local government need to reinforce joint planning mechanisms such as
Community Plans, Joint Investment Plans and Health Improvement Programmes
- In addition, the government should use its considerable skills to
bring others on board for better health, including business, industry,
leisure, food and catering, the press and other media. Areas such as
combating exposure to tobacco smoke, alcohol availability and abuse,
promoting the availability of healthier food, and alternatives to car
travel immediately spring to mind, but there are limitless other possibilities.
The SHA would welcome involvement, for example, with the trade unions
and the co-operative and labour movement
- Health and social care
- The SHA believes it is sensible to combine the delivery of health
and social care, since recipients of these two forms of care do not
recognise the boundaries. This would also help to abolish 'cost shunting'
when local authorities move patients into health, where care is provided
free at the point of use, whereas local authorities must means test
service users and make up shortfalls through Council Tax. Local government's
role in HImPs offer one short term medium for engaging local democratically
accountable organisations in the health agenda
- If the delivery of health and social care is combined, it will also
be necessary to take cognisance of the size, range and complexity of
the resulting organisation and the issues it will be dealing with. This
would need to be broken down, and a balance struck between a national
drive to improve the delivery of care, and the need for local flexibility
to address local problems
- However, if social care moves to health, there will also be an additional
democratic deficit to address. The democratic deficit at all levels
of health care planning and provision is a serious blight on a service
that the public otherwise holds in high esteem. It is therefore necessary
to develop a model of representation of the public interest in the NHS
that ensures that there is public ownership of the government's modernisation
proposals as set out in the National Plan
- At the moment, the only organisations with the statutory duty to represent
the public interest in the NHS are Community Health Councils. However,
care must be taken when considering the role of CHCs. If they are to
be a substitute for democratic accountability, then their own membership
structure will first require radical reform, and they will have to be
properly resourced and independent of the NHS
- No new constitutional settlement for the NHS will work unless it reflects
the will of the people. The government should therefore consult the
public widely on the future structure and governance of the health services.
This would be a natural progression from the government's current consultation
on the National Plan
- Issues that this consultation could address include:
- the type of public body that the New NHS should be
- how the relationship between the day to day running of the NHS
and the Secretary of State's responsibilities for overall policy
direction and delivery will be defined
- the shape and content of a new Patients' Charter based on clear
and easily enforceable rights
- fairer and more efficient allocation of resources, both financial
and human, to the provision of health care
- The SHA would welcome the opportunity to provide a thoughtful and
detailed contribution to this debate, but does not wish to be too prescriptive
in advance of that consultation
- In the meantime, and as long as NHS bodies are quangos, they must
show evidence of serious involvement with local government and other
local democratic structures and local communities, so that they have
some means of delivering local accountability
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5. PATIENT CARE
- The inverse care law, which states that the availability of good medical
care tends to vary with the need for it in the population served, is not
a law of nature. It can and must be challenged
- The amount, quality, accessibility, appropriateness and affordability
of health care available for those with the worst health must be improved.
Proposals for improved health care must address the current problems of
unequal access to health care. This will require additional resources and
training for all health services in deprived areas. A particular and urgent
priority is to accelerate the development of well-resourced, multi-disciplinary
primary health care teams. These will have salaried GPs with links to centres
of excellence. This seems the only option if the primary care deserts found
in some urban and rural areas are ever to be transformed
- Professionals working in deprived communities have a more difficult task.
This must be recognised, and remuneration and resources modified according
to need. The risk of a league table and Ofsted approach that is not sensitive
to these issues will alienate professionals working alongside these more
disadvantaged communities
- At the practical side of access, there is general public concern at the
difficulties and delays in securing appointments at GP surgeries as well
as unacceptable waits to receive hospital referrals, diagnostic procedures,
receiving reports and test results, and operations
- Achieving equal access is particularly difficult for many vulnerable people,
such as the elderly, people with physical and learning disabilities, members
of ethnic minority communities, especially those whose first language is
not English, users of mental health services, and substance abusers. In
addition, many people who should be accessing health care are unwilling
or unable to do so at the moment
- Steps to address unequal access to health care services could include:
- removing or substantially reducing patient charges
- providing specialist facilities in primary care settings to enable
more care to be provided within the community
- increased use of nurses and nurse practitioners in primary care
- increased use of salaried GPs and GDPs, and the phasing out of independent
contractual status
- re-establishing NHS dentistry based on lists of patients, with salaried
dentists responsible for General Dental Services
- changes to the consultants' contract to ensure that they are fully
committed to the NHS by rewarding full time NHS consultants, and making
all consultants' job plans subject to explicit annual review and monitoring
- mandatory ethnic and language monitoring accompanied by the effective
use of interpreters and advocates for vulnerable patients
- The SHA's continued opposition to patient charges reflects its commitment
to the anti-poverty agenda. Nevertheless, the SHA applauds government initiatives
that have already been taken to improve access to health care, such as NHS
Direct
- Another crucial step to improve access will be by empowering patients
to become equal partners in planning their own health care packages. The
socialist model is to think of health professionals and patients as being
co-producers of health, not as consumers and suppliers in a market framework
- An alternative role that could be considered for Community Health Councils
is to embed them firmly on the patient side of the NHS/patient partnership.
They could be given two clear and specific responsibilities. One would be,
independently and from the patient perspective, to monitor the delivery
of services, with a remit covering both primary and secondary care and any
private provider used for health care for NHS patients. CHCs should anyway
have the right to inspect all private premises in advance of them being
used for NHS care
- Their other responsibility would be to act as patient advocates, with
a clear remit within a modernised, responsive and effective NHS complaints
procedure. As stated above, however, the CHCs would need proper resources
and independent status to fulfil these roles effectively
- The private sector must also be better regulated, especially hospital
services that are currently part of nursing home registration guidance.
Private sector activity on all NHS patients must be properly recorded as
part of the NHS Information System so that there is a better picture of
need, demand and supply. This is especially important in areas where a very
significant proportion of elective surgery is undertaken in the private
sector
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6. PERFORMANCE
- Health
- Clearly, improvements in measures of health as the ultimate performance
indicators are necessary, but it must be recognised that these will
take time to achieve, and anyway may be less influenced by NHS activities
than by economic and social factors. More realistic and achievable performance
measures, including process targets, must be used as interim outcomes
for the NHS. Nevertheless, national targets to reduce inequalities will
help reinforce national government's commitment and enable it to be
seen in a more holistic way by relevant parties
- The Cabinet and all government departments, including the Department
of Health and the NHS, must undertake health impact assessments of their
policy options before they agree and implement priorities, and must
work with other agencies on health improvement assessments of their
policies. This should apply at every level - national , regional and
local - and should focus on how each policy impacts on those with the
worst health. The public health agenda must be heard at Cabinet level,
with national accountability for the health of the population being
through the Prime Minister
- NHS structures and Department of Health structures must assess the
impact on the local and larger environment of policies adopted, and
give the lead on green approaches to building use, power, transport,
waste disposal and other environmental issues. The government must also
sharpen the division between planning and commissioning, and put greater
emphasis on the need to improve the planning side of the process - coherence
and consistency versus overburdening the NHS with fragmented budding
processes
- Health Care
- The NHS must move from the position where performance management is
about identifying scapegoats when things go wrong to a situation where
it is used primarily to improve the delivery of care. The introduction
of clinical governance, and the establishment of NICE and CHI have gone
some way to address issues of quality. However, public confidence in
the Labour government's ability to manage and run the NHS effectively
will not be restored until it can demonstrate its intention to deal
rigorously and robustly with all the issues around quality and clinical
governance. Organisations with a memory consultation document make an
excellent start to linking clinical with corporate governance and the
development of learning organisations
- Performance monitoring should also be aligned with risk management
because of Shipman, the Bristol cases, cancer screening failures, the
laxity of GMC procedures in dealing with doctors associated with defective
care, and other concerns now being brought to the public's attention
almost on a daily basis. Patients want assurances that the care they
receive is not only appropriate, but does not expose them to dangers
and difficulties
- Although the public lacks the competence to judge the adequacy of
medical care, it is well placed to draw attention to adverse clinical
incidents. The main medium required is an effective and responsive complaints
procedure, and immediate steps must be taken to reform and strengthen
the existing procedure
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7. PROFESSIONS
- Health Care
- The SHA welcomes the consultation paper on workforce planning and
in particular its analysis of the problems with the current system.
However, it also recognises that there will be difficulties in getting
the changes implemented
- One major challenge will be in ensuring that the workforce is properly
remunerated, motivated and allocated. The remit of the proposed National
Workforce Development Board will need to encompass all the factors relating
to the NHS workforce, including strategies on pay and access to affordable
accommodation, particularly in large conurbations
- The respective responsibilities of health authorities and NHS trusts
for workforce planning are not clear, and other things on the workforce
agenda need greater precision. For example, a revised structure on its
own will not produce more effective workforce planning. It needs to
be placed within an overall strategy for organising and running the
NHS that includes identifying the best organisational structure for
delivering it
- A human resources strategy that best serves the business strategy
is also needed, with an organisational structure matching authority
to responsibility. It must also be explained more clearly why health
authorities should lead on workforce planning, and what power they will
have to influence critical factors, such as the number of students and
trainees. The proposals give health authorities the responsibility for
workforce planning, but little capacity and authority to carry it out
effectively. For example, the boundaries for the proposed workforce
confederations and health authorities would need to be aligned. Skills
in workforce planning would also need to be strengthened throughout
the NHS, and in particular within the trusts and the English regions
- The proposed care group boards related to National Service Frameworks
will have to ensure that too much focus on specific diseases does not
lead to a fragmented approach to workforce planning that overlooks patients
falling into more than one care group. For example, trauma patients
with injury to many organs, elderly people with heart problems, chest
disease and a malignancy, and people with learning difficulties who
need treatment for psychiatric or physical problems
- This paper has already referred to the urgent need for general practitioners
to have attractive options for salaried employment in deprived areas.
Over time this should become the norm everywhere. The government must
also work towards the position where all consultants have normal contracts
of employment with clauses that preclude conflicts of interest, such
as may arise when private practice benefits from long NHS waiting lists
- Retention of staff who have worked for over 20 years in the NHS is
an important issue, as the number of older GPs and consultants taking
early retirement creates shortages. NHS employment policies on prolonged
study leave and sabbaticals would refresh those people who still have
a useful contribution to make. Occupational support for all NHS workers,
including ancillary staff, is an important input
- Health
- Although government policies depend heavily on services and policies
being governed by public health considerations, it is not clear how
this will be achieved. Management structures at regional, health authority
and PCG/T level must include senior public health professionals including
doctors, public health nurses, and other public health specialists such
as health promoters and public health dentists, with powers to give
direct advice to boards and other agencies, and a duty to report to
the public
- Public health professionals must be given the time and continuing
education to work strategically and across agencies, as well as to contribute
to current health policies and their evaluation. Different populations
at neighbourhood and PCG/T level, health authority and regional level,
and national and international level have different public health issues.
The concept of epidemiological stability and population levels means
relevant public health support is needed at all those levels
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8. FINANCE
- The National Plan will be unable to deliver any improvements unless the
financial underpinning of the NHS is correct. The SHA is therefore adding
a section on Finance to its presentation
- The SHA recognises that the government is moving in the right direction
on funding. The new money is a massive transformation, but should be set
to reach a target of 8% of GDP, to bring the UK in line with the best of
the European Union countries. The benefits of the new money will also take
time to become apparent, because of massive deficits and backlogs
- However, the challenge of capital funding must also be tackled. Funding
of all major capital replacement and developments should be reinstated as
an essential part of its year on year resourcing through the public purse.
The fabric of the service should be maintained and modernised on a consistent
basis, with the improving assets retained in public hands. This would avoid
the use of PFI schemes. PFI schemes mortgage the future through higher revenue
costs, and usually involve a reduction in the number of acute beds, which
would militate against the achievement of the 85% occupancy target of the
National Beds Inquiry
- Annual efficiency savings should not be required as a matter of course,
given their often deleterious effects on the level and quality of service
delivery. A standard costing system should also be introduced to ensure
a level playing field between trusts and transparent financial accountability
when trusts and health authorities are being held to account
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9. CONCLUSIONS
- The SHA welcomes this wide ranging consultation on the National Plan and
the opportunity it gives every citizen to participate in planning a National
Health Service for the 21st Century. It believes that the National Plan
must be an aspirational and inspirational Plan that describes a healthier
and fairer society. However the SHA also hopes that this is just the start
of the dialogue, and looks forward to joining future debates directed at
improving the nation's health and the delivery of health care services through
the development of a genuinely patient-focused NHS
- Every citizen has a right to be served by an efficient, effective and
accountable health service, and this will only be delivered by a Labour
government
SHA/23 June 2000
