We’ve been discussing health policies for 85 years now. When we start thinking about what policies we should be putting forward now it seems sensible to review the policies we already have to see if they are still relevant.
Public health issues don’t change as rapidly as issues around the provision of services, so we will start with them.
In 1942 we said:
- Health is a national asset and its preservation must therefore be a state responsibility.
- The aim of the health services should be the achievement of optimum health for the whole population, the prevention of disease, relief of injury and sickness, and restoration of health after either.
- The public must be encouraged to play an increasing part in the maintenance of health.
Then in 1946, in the agitation around the form of the proposed NHS:
A Health Service is required now and probably always will be; it necessitates the education of the public in the meaning, preservation and promotion of health.
In 1953: “After five years of experience of the N.H.S. we are becoming increasingly convinced of the need for closer integration of the preventive and curative aspects of medicine.”
Industrial Health Cover was one of the demands in 1962.
The Socialist Charter for Health, published in 1965 wanted to see “proposals for a preventive health service as opposed to a purely curative one” and for the medical profession to undertake collective responsibility for the health of the nation, and more precisely for every group of doctors to assume collective responsibility for the health of the community or unit of population they serve.
The 1984 Charter for Health had a bigger section on prevention:
Prevention of illness
4.1 Self help groups are an important development in the democratic process. They also provide support for people with special needs, and so help to prevent illness. Health Authorities should give practical assistance when groups have been set up by local initiative.
4.2 DHSS as health watchdog. All health workers must be aware of every opportunity for health promotion, through an understanding of the harmful effects of unhealthy practices e.g. ‘junk’ foods, lead in petrol, unemployment, smoking, excessive drink, poor housing etc.
4.3 Health promotion teams should be set up by every Health District. Their annual reports would be reviewed not only by the DRA, but by the DHSS inspectorate to ensure that more than lip service is being paid to prevention.
4.4 Health Visitors are the only ‘outreach’ part of the NHS. They are ideally placed to bring the Service to those most in need of it, but, as the Black report showed, are the least likely to take it up. In particular:
- numbers of Health Visitors will have to be increased to allow small enough case loads for the extra work of going out to look for those in need
- attachment to GP group practices needs to be speeded up
- more motor cars are needed for health visitors to visit their patients.
4.5 Cigarette smoking has to be attacked:
- outside the Health Service
- by making all hospitals no smoking areas
- by providing a counselling service in every Health District.
4.6 Screening programmes are best done in general practice, using a register of patients by Age and Sex. The register makes it possible to identify and contact people at risk e.g. the elderly, men liable to high blood pressure and women in the age range for pre-cancer of the cervix. The new DHAs, which will have Family Practitioner responsibilities, should be instructed to assist all GPs to set up Age/Sex registers, and to give encouragement and the necessary financial support to carry out these programmes.
4.7 Well people sessions. The list of categories is longer than most of us realise. Well Woman and Well Baby clinics are familiar, but there is a need also for Well Men, Well Elderly, Teenagers and People with Disablements. To these clinics, Health Districts should add Antenatal, Family planning, Sexually Transmitted Disease and Chiropody. The minimum number needed for each type can be calculated per head of population. The DHA should then ensure that there are the right number of sessions being held, preferably in Health centres or GP surgeries; failing which in separate clinics. Domiciliary services will be required to follow up non-attenders who often have the most need.
4.8 Child health – in the community as proposed in the Court report requires principally:
- developmental surveillance at key ages for all children by properly trained workers. These may be health visitors, family or clinic doctors.
- schools must be drawn in to these assessments. DHAs must work with Education authorities to make the school a focus for community activity.
- Encouraging closer family life is not mere sentimentality. The Court Report emphasised how essential for the proper development of each child it is to have a secure family. We must recognise that children can find that security in parental structures which are not just the traditional married mother plus father. Departments of Education, Health, Industry and Employment all have roles in encouraging men and women to lead a flexible enough life that they can be involved with their growing families.
4.9 Child health – in the school. The role of the School Health Service in health education of children requires further debate. The responsibility for teaching basic health education lies with the teachers, after appropriate training.
4.10 Child health – and child abuse. All families on child abuse registers should be offered intensive help to build constructive relationships in Family Day Units. Units at present do exist, run by the NSPCC or the occasional NHS psychotherapy centre, and these should be the models for all Health Districts.
4.11 Fertility control. Prevention of unwanted children leads to less stress in the parents, less mental breakdown in the family, less child abuse in the unwanted child and fewer disturbed adolescents growing up. Adequate services should be available equally in all parts of the country to allow people to control their fertility, and to choose when to have a baby. In many areas facilities for contraception are poor. Regional variations in NHS abortion services penalise women with less money who may be forced to continue with an unplanned pregnancy which a more wealthy person could pay to have terminated. Some women are not offered sterilisation when they ask for it, and then have to go through with a pregnancy which they do not wish to terminate, even though they may be at high risk due to age and many previous pregnancies DHAs must be required to provide adequate Family planning, Abortion and Sterilisation services.
4.12 Back pain is a huge contributor to distress and reduction of useful activity. Prevention involves education on how to avoid it. The Health and Safety at Work Acts could ensure that police, firemen, nurses, farmworkers and others are taught correct lifting techniques. Where furniture, car seats and so on are being made in local factories, Health Education Officers will need to be able to advise on design.
5. Topics for special emphasis
5.1 Health Education should
- be expanded into schools, the workplace, and other places where people meet e.g. centres and groups for the unemployed and residents’ associations.
- take on a wider role than simply telling people how to look after themselves. The more we are informed of the wav that uncontrolled commercialism and pollution damage health, the more pressure there will be for change.
5.2 Alcoholism. Control of advertising of alcohol will be as for tobacco (Environment para 4). Attention must be paid to underlying provoking factors which create stress, like poor housing, poor education, and unemployment.
The 1988 Policy Digest had three relevant sections:
PROMOTION OF HEALTH
i) Believes all government policies should be designed to prevent illness and create a healthier Britain.
ii) Believes that local authorities, in conjunction with their health authorities, should produce an annual audit report on their districts health to be used in policy development and resource allocation.
iii) Believes that many claimants fail to take up their full entitlement, and urges local authorities and health authorities to provide facilities for continuous in-service training to maintain a level of awareness and update information on welfare rights.
NUTRITION
i) Believes the provision of school meals should be compulsory in all state schools and adequately funded to ensure that nourishing meals are available.
ii) Calls for healthier nutrition in all schools, NHS and social services institutions. Managers and staff should be given training in preventative health; and a low fat, low sugar, and low salt diet should be the goal in all schools, colleges, hospitals and other institutions.
SMOKING
i) Calls on DHSS to ban smoking by staff, patients and visitors in all NHS premises. Where it may be considered necessary to allow certain categories of patients in hospitals to smoke, this should be allowed only in a self-contained room set apart for the purpose. Cigarettes should not be sold in any NHS premises.
ii) Opposes the sponsorship of sport and the arts by tobacco manufacturers.
iii) Calls on the Labour Party to recommend to its membership that smoking be banned at all LP meetings and conferences.
iv) Calls on all Labour DHA members to get their own DHA to prohibit smoking by all staff whilst on duty at NHS hospitals.
Our submission on the The National Plan for Health 2000 started by emphasising that “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” and went on the say “Greater fairness and equity will improve the health of society as a whole, including the rich. Focusing solely on the proportionately small poor and socially excluded groups … is insufficient to deal with overall inequality.”
We wanted to see more emphasis on prevention in the plan, and in particular – “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……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.”
Sadly leadership and determination were not very evident when it came to prevention. We called for :
“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.”
The Policy we advocated for the second term of the Labour Government 2001 started with a public health approach, including the development of a policy on food and nutrition for the whole population. Our response to the 2002 Labour Party policy consultation stressed that “Public health is bigger than the just NHS, and includes other areas, such as housing, education and transport. Responsibility for public health should therefore rest with a minister who is both of Cabinet status and quite independent of the responsibility for healthcare.”
In our response to the Big Conversation on Health in 2004 we went a bit further, saying: “Targets for improving the health of the population should take priority over targets for treatments, waiting lists and operations and they should be integral to the role of senior managers and members in local and regional government as well as in the NHS.”