Introduction
The Socialist Health Association welcomes the Labour Party’s consultation document Health 2000 — the health and wealth of the nation in the 21st century. The following points, many of which are made in Health 2000, should in our view be spelt out in any subsequent policy document, dealing with health and social care.
A national health strategy
The SHA believes that the determinants of health include social, economic and environmental factors. Therefore a strategy for health needs to address poor housing, unemployment, poor diet, low income, environmental pollution, low educational attainment and inadequate training. This requires an intersectoral approach and will include policies toward full employment, investment in housing, reducing income inequalities, an integrated transport policy and banning tobacco advertising. Leadership of a national health strategy requires Cabinet level involvement, and also needs to take account of international dimensions such as the European Community, World Health and the threat of war.
The NHS
The NHS should be a democratically accountable, comprehensive, national health service. It should provide equal access to care which is free at the time of use and funded from general taxation.
Financing
The SHA believes that, despite the NHS delivering relatively good value for money, the service has always been comparatively underfunded. Labour should adopt a target to fund the NHS at least to the level of comparative European economies (8% GDP) within the first term of government. The morale boosting effect of investing in the NHS to provide new hospitals and health centres, to tackle unmet health needs and to address low pay would be enormous.
Values
Health for All principles include the right to health care, the development of personal skills community participation and government policies which support health. We believe that the NHS should be managed in a way that reflects the underpinning values of equity, efficiency, effectiveness, appropriateness, accessibility and responsiveness. These are all useful principles which should be weaved into a general political statement of purpose and values by Labour.
NHS Users
The SHA acknowledges that users have too often been regarded as passive recipients of services controlled by professionals. It supports the promotion of a genuine partnership between users and providers of health services. Components of this will be: Sharing of information including patients held records; informed patient choice over place and course of treatment; involvement of users in the planning, management and evaluation of services.
Prevention
Labour should acknowledge that health care programmes must include elements of health promotion, disease prevention and anticipatory care in addition to diagnostic, treatment, rehabilitation and continuing care. We believe that health promotion will involve other agencies contributing to the health strategy and where there are effective programmes that these should be comprehensively disseminated. Anti poverty strategies to enhance maternal and child health and teaching parenting skills in schools are examples of interagency prevention work.
Primary and community care
The SHA recognises that the acute secondary care and specialist services were comparatively better funded than primary care and care for priority client groups. Labour policy should ensure that the NHS develops a well resourced and strong primary care base from which services can be delivered most effectively and which ensures appropriate use of secondary care services. There should be no shift of emphasis between care services without first ensuring that there are adequate resources to support such a change.
Needs led services
The NHS should be “needs led” and should develop a process of objective needs assessment that takes into account the views of users.
Purchasing and providing
The separation of strategic and operational functions does not need to have anything to do with a health care market with its emphasis on increasing the private and for profit providers, commercialising the NHS and encouraging opting out and fragmentation.
The full implications of the purchaser/provider split are still unclear. However the role of a commissioning or purchasing agency is quite clear; to assess the health needs of a population and contract for provision of the necessary services to meet that need within a strategic framework and using available resources to maximum benefit. These agencies need to have effective public health information and monitoring mechanisms and be linked to local authorities.
Providers, where the bulk of the NHS workforce are employed, are there to develop and provide locally accessible, efficient, effective and responsive services. The people who work in the NHS should also share in the planning process.
Democratic accountability
The SHA believes that there should be more democratic accountability within the NHS. We believe that there are five levels which need addressing:
- The centre through the Secretary of State needs to be accountable to Parliament.
- An intermediate regional tier based on recognisable and geographically consistent boundaries which have coterminosity with local government structures. These should be the location for regional government and the NHS strategic functions be part of their responsibility. They will also have a developmental and regulatory function (including NHS providers)
- Local NHS commissioning and planning needs to become part of a revitalised local government function and derive their local democratic accountability through locally elected Local commissioning would be constrained by a basic ring fenced NHS budget determined by a national formula and the responsibility to work within the national NHS framework and attain minimum quality standards.
- Hospitals and Community Units will need to be run by boards which have representatives of local government, health professionals, user groups, staff and other relevant interest groups.
Providers will be part of the NHS and account able upwards through the regional authorities and to their commissioning authorities. - Community Health Councils should be strengthened by developing their statutory rights in obtaining information and providing a regulatory role. Their boundaries should be
coterminous with relevant local government and health authority boundaries. They also need develop links with neighbourhoods where local organizations and people can be involved and
NHS staff
The SHA recognises that too many NHS workers are low paid and relatively undervalued. We believe that training, equal opportunities and good terms and conditions of work are an essential component of a healthy and adequately staffed NHS. Racial and sexual harassment should be dealt with vigorously. National agreements should determine pay and conditions. Giving a voice to staff together with ending low pay and market testing in the NHS should be a key policy objective.
Efficiency and Effectiveness
We believe that the NHS should be concerned that it obtains the maximum benefit from its resources. We support the idea of an efficiency unit.
The SHA accepts that knowledge is poor on the effectiveness of many treatments provided in the NHS. We welcome the initiatives encouraging the critical review of current practices. We believe that proven and effective therapies should be given priority and a national R & D strategy including health service research be promoted.
Drug companies
The NHS drug bill is relatively high at 10% of NHS expenditure and rising at over 10% each year. The current drug pricing negotiations have been too lenient, guaranteeing overall drug company profitability despite the recession and without reference to individual companies performance. We believe that there should be further limits to the amounts spent on drug promotion and on the proliferation of “me too” drugs. The large sums of money spent on “educational events” by the pharmaceutical companies should be channelled through the NHS educational systems to support professional development and the use of formularies. Marketing of new drugs and other health technologies needs to adhere to ethical principles. We would recommend that negotiation for provision of more high quality generic drugs, which the NHS would promote, and stop the abuse of the NHS by commercial practices such as transfer pricing. Monitoring and control on prescribing should continue with the emphasis on rational and cost-effective prescribing.
Competition from a major publicly owned production and research unit, producing both for the NHS and the world market, would benefit the UK pharmaceutical industry as a whole. This former Labour policy should be restored.
Greening the NHS
It is the responsibility of a large organisation such as the NHS to be seen to act in an environmentally sensitive manner. As a major employer and purchaser, the NHS should consider its policies with regard to their environmental impact. Areas to consider are supplies, waste, energy use, transport and estates management.
Specific comments on document chapters
- Introduction
1.5 Agree that there is a risk of privatisation of Trusts and a challenge to the universality and equity of the NHS.
1.8 Agree that the GP fundholding scheme will be ended. Existing fundholders will be transformed as we develop primary care led local commissioning and clinical resource management in primary care.
1.14 The problem of strategic planning in London needs to be addressed by a democratically elected London wide authority.
1.16 Management costs do need to be controlled but the NHS was traditionally undermanaged and the party should avoid “bureaucrat bashing”.
- The Tory legacy
2.14 Agree that the NHS principles of equity of access and treatment according to need should be maintained and so prevent a “two tier system” obtained by some fundholders.
2.16 Accept that there have been enormous changes in the NHS reorganisations and that Labour should be wary of threatening more wholesale organisational change.
- Developing an economic and social
policy
3.2 Agree that absolute and relative deprivation affect health and a health strategy must therefore also address economic factors and the distribution of wealth.
3.6 Agree that intersectoral collaboration from the highest level of government is an important method of delivering a health strategy.
- Prevention is better than cure
4.4 Working to deliver the health curriculum alongside a schools national curriculum will be a vital element in a health strategy. This input should be co-ordinated from the early years through primary and secondary Accessible youth services are also an important element in a matrix of services.
4.5 Banning tobacco advertising and addressing EC subsidies to tobacco growers is a welcome
4.6 The SHA strongly supports the strengthening of the powers and role of the Health and Safety Executive and the policy of improving people’s access to sound occupational health
4.10 While welcoming occupational schemes we would warn against screening tests which have not been shown to be effective e.g. multiphasic BUPA testing.
4.12 Restoring the NHS ophthalmic services such as the free eye tests and encouraging glaucoma screening in high risk groups would be a highly popular policy at comparatively low cost.
4.18 We support the development of a national AIDS strategy and recommend that the Prison Health Service should also be taken into account when designing such a strategy.
4.19 We strongly support nutritional guidelines for school meals and the endeavour to increase the information on dietary ingredients and encouraging healthy choices.
4.20 The role of exercise is critical and should be encouraged within schools as part of the curriculum supported by sports teachers.
- Putting the patient first
5.2 Real issue is about empowering patients and developing a partnership. Information systems are important as is the involvement of carers. Rights to personal information and patient held records should be encouraged.
5.6 Protection of the public from poor practice is important and GMC powers despite recent changes remain inadequate. The GMC needs more lay involvement and the NHS needs powers to suspend professionals guilty of dangerous and poor standards practice.
5.13 We agree that in a public service such as the NHS that audit whether via the National Audit Office or the Audit Commission plays a vital role in improving efficiency, effectiveness and checking on probity. It is very important that these reports should be made public.
5.18 We feel that the Labour Party should develop a more detailed policy on drugs and the role of the pharmaceutical industry.
- Patient’s rights: democracy and
accountability
We feel that there are important lessons to be learnt from the organisation of Scottish Health Boards and the joint health and social services boards in Northern Ireland.
6.1 We feel that this section is about democracy and accountability and not about patients’ rights. There is also a confusion between management issues such as fundholding and private practice which is not about democracy. Democracy may be a good thing but it does not necessarily deliver “good”. Perhaps better to have a separate section dealing with the NHS changes.
6.11 We have put forward our case for democratic accountability in our initial statement. Trust boards would need some local authority nominations, nominees from the local community and organisations such as local businesses, colleges, voluntary sector etc. Worker representation should be dealt with by mechanisms of industrial democracy.
6.12 The SHA opposes private practice and feels that more control over the job plans of clinicians who do private work and the positive rewarding of full time NHS consultants should be explored. The merit award system requires review in order to reward those consultants with full time commitment to the NHS and those who work in shortage specialties providing high quality
6.24 We support a democratically elected London wide authority.
- Primary and community care — a vision for the future
7.5 We welcome the intent to develop a system of primary care sensitive purchasing but feel that resource management in primary care is also an issue.
7.11 Beware of Institutes of Primary Care unless they are tied into universities.
7.16 We agree with the need to develop community mental health services which address national objectives, standards and individual rights.
7.23 The treatment of tooth decay costs over £1billion and not £50 million. Implementation of the Coma recommendations that extrinsic sugar intake should be below 10% of total calories by year 2000. We urge the restoration of free dental checks.
7.24 We feel that the case for fluoridisation where local natural supplies are too low should be positively progressed, if necessary using We oppose the policy retreat from more definite policy statements in 1991 and 1992 LP documents.
7.25 We responded in detail to the policy development on complementary therapies and support the measured approach outlined in the policy document.
7.8 Uncertain about “specialist grades” in primary care.
- The family and the community.
8.8 We agree that palliative care services are very unequally spread and should be developed as a comprehensive service principally supporting people in their own homes and using hospice beds only when appropriate.
8.17 The issue of health/social care is vitally important and the means testing for social care. A charter of rights for users and carers is welcomed.
8.38 We agree that quality standards in the cervical cancer screening programme should be improved.
8.39 We believe that mammographic breast screening in women under 50 is not cost or clinically effective. On the other hand, there is a case for extending screening to older women up to 75 years.
- Finance and the NHS
9.4 We welcome the idea of an efficiency unit whose reports should be made public but wonder if this needs to be related to the Audit Commission’s work.
9.5 We support proper health technology assessments to ensure cost effectiveness and proper R&D.
9.21 We agree that policies on cost controls in the pharmaceutical industry should be explored, especially when the NHS is subject to transfer pricing, and cartelization.
- The NHS staff — a vital resource
10.1 Contracting out should be ended.
10.4 We strongly support a review of merit awards which should be public and accountable. Those who work exclusively for the NHS should be rewarded as opposed to those with large incomes from private practice.
10.11 The place of primary and community care underpinning the NHS should come earlier in the document with a higher profile.