Category Archives: Local Government

I can’t recommend this film – which focuses mainly on older political activists campaigning for the NHS – too highly.
(Statement of competing interests: I feature briefly in the film)

Pensioners United

Directors: Phil Maxwell, Hazuan Hashim

Country: UK

Running Time: 75′

Year: 2018

A potent account of a passionate group of pensioners who unite together to fight for a better life for themselves and those who will follow them. Starring Jeremy Corbyn, Harry Leslie Smith, the late Tony Benn, and thousands of inspirational pensioners from across the UK.
~ Allyson Pollock

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You may find this video of a meeting held in Birkenhead Town Hall on September 27 of interest. The meeting set the current situation in Wirral, of an accountable care system at a fairly advanced stage, in its national context.

The meeting began with a short contribution from a local GP, Dr Mantgani, who has in the past worked closely with Virgin; he expressed his concerns regarding the threatened closure of five walk in centres.

I then spoke – about 12 minutes into the video – about the historical and current context of NHS cuts, rationing and privatisation.

After a very interesting Q and A, there was a contribution, starting 56 minutes in, from Yvonne Nolan, a former director of social services in Manchester who now lives in Wirral. Yvonne described her work in Manchester, which in effect involved a long period setting up the de facto accountable care organisation which now operates across Greater Manchester. She related this to the current situation in Wirral.

This was followed by further questions and comments; all in all, a fascinating session

https://www.facebook.com/groups/defendournhs

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Can I appeal to everyone, individuals and organisations, to get solidly behind the judicial review as loudly and forcefully as possible.

I’d like to see all of us highlighting and publicising the judicial review in our various communications and campaigns. We are trying in Wirral.

If the review succeeds entire awful council/CCG edifices of pooling and dissembling come tumbling.

If the review doesn’t raise the required £18k we’re all doomed no matter how vocal our local and national campaigns!

Come on! The price of a few glasses of wine/beer/flat white.

https://www.crowdjustice.com/case/justice4nhs-stage5-courtofappeal/

Cheers

Kevin Donovan

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Dear chums

As you may have heard the Wirral Clinical Commissioning Group (CCG) has announced that it wants to close five local NHS clinics because Wirral residents “were confused about where to get help with urgent care”. The CCG, which is the local arm of NHS England, says it wants to “move care closer to home”.

Are YOU confused? Will YOUR care be closer to home if they close centres which are used by THOUSANDS of Wirral residents every week of the year?

Eastham Clinic; Victoria Central, Wallasey; Miriam Medical Centre, Birkenhead; Parkfield Medical Centre, New Ferry; Moreton Medical Centre

All these are due to close. Will a proposed ‘urgent treatment centre’ at Arrowe Park be closer to YOUR home?

You can find a petition from Defend Our NHS here:

https://www.change.org/p/defend-our-nhs-save-our-wirral-walk-in-centres?

Please sign and share with friends.

Thanks

Kevin

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The introduction of Accountable Care Organisations – or whatever they are called this week – brings a lot of talk not only about integrating health and social care, but also about local accountability.  The accountability seems to be more about accountants than about democracy, but in principle local elected councillors could have a voice in the working of health services  which they haven’t had for many years.  We asked our members how health had featured in their local election campaiogns.

Of course we were looking mostly at how local Labour parties dealt with health – but some of our members reported that the Green Party had more to say about the NHS than Labour.

Enfield Labour Party

Their manifesto said they had  IMPROVED HEALTH:

  • Increased fitness with 12 outdoor gyms and outdoor playing spaces
  • Opened a world class sexual health clinic
  • Cut smoking prevalence by 6% since 2012
  • Helped cut the life expectancy gap between the rich and poor and cut teenage pregnancy rate in the borough

and pledged that they would:

  • launch a Borough Poverty and Community Fairness Commission
  •  tackle discrimination based on sex, race, disability, age, sexual orientation, gender reassignment, religion or belief, marital status, or pregnancy and maternity
  • oppose Tory policies that drive division and disadvantage in our community and tackle the causes of childhood poverty giving every child a good start in life
  • develop our holistic approach to adult social care meeting needs in housing, advocacy and support
  • continue to oppose the privatisation of our NHS
  • campaign for more GPs and better surgeries
  • put public health at the heart of policies for improving the quality of life of residents by promot-ing healthy lifestyles and physical activities
  • continue to subsidise leisure facilities and services for older people
  • give mental health the same priority as physical health
  • support increased integration between the NHS and Adult Social Care to meet residents’ needs and cut bureaucracy
  • reduce air pollution through clever design and screening of roads
  • crackdown on illegal tobacco and cigarette selling
  • ensure food safety standards and hygiene in business premises

Hertfordshire Labour Party

Hertfordshire leaflet

Colchester Borough Labour Party

reported they had redesigned two outdated sheltered housing schemes to provide fully accessible 21st Century older persons’ apartments.

Manifesto commitments:  A Labour-led council would improve the health and wellbeing of the Borough and its residents by:

  • Continuing to question whether the merger of Colchester and Ipswich Hospital Trusts is in the best interests of our residents and communities;
  • Demanding a greater say in the NHS Sustainability and Transformation plans and programmes for our area, which means objecting to one Clinical Commissioning Group run from Suffolk;
  • Involving the Borough Council in the integration of health and social care provision;
  • Lobbying the government to significantly increase spending on the NHS;
  • Providing more sheltered, supported and extra care accommodation by working with a range of partners across all sectors;
  • Campaign on easy accessibility for all public buildings – especially the Work Capability Assessment centre;
  • Instigating more Changing Places toilets.

Manchester Labour Party

Put Health and Social Care at the front of their campaign – as perhaps is appropriate when Manchester is said to be leading the way.

Manchester people made caring for those most in need in the City their number one priority so it is the number one priority for Manchester Labour. By taking control of our health and care services we will protect our NHS and help Manchester people live longer, healthier, happier lives.

We will:
● Increase pay for homecare workers to at least the Manchester Living Wage
● Employ more people to support vulnerable residents to stay in their own homes using the 1.5% Council Tax increase raised for adult
care
● Begin construction of at least 200 homes for older people at social rents as part of our extra-care schemes
● Invest to improve local access to community mental health services

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Alan Hall

Speaking the truth to power is always a risky business.  No more so than when considering how millions of pounds of public money should be shovelled into developments and contracts.

Local government overview & scrutiny has been with us since the Local Government Act 2000 and the advent of the cabinet system and executive mayors. In the case of executive mayors –  a single politician making the decisions to spend millions of pounds of public money albeit with the advice of officers and an appointed cabinet – it is easy to see how local councillors could feel disempowered if they are not allowed a proper say on the decisions taken. Overview and scrutiny committees can provide a proactive, pre-decision mechanism for proper political involvement and public engagement. This scrutiny system improves and refines decisions, weeds out poor proposals and advances evidence-based policies.

Good council scrutiny can also allow for challenge to government too. Following the roll-out of austerity and public spending cuts led a review of the London Borough of Lewisham’s emergency services which reported in 2013.

The review showed that significant funding cuts had put services under severe strain, with an impact on preventative services and areas like probation too.

The process allowed for proper scrutiny of these changes both by the council and external public agencies and, during the review, Lewisham Council successfully challenged Jeremy Hunt, secretary of state for health over the proposed closure of Lewisham hospital’s A&E department.

An example of proactive scrutiny came after the tragic Grenfell Tower fire. All housing authorities rightly reviewed their housing stock and hopefully their policies. As a matter of urgency, I wrote to Barry Quirk the then chief executive of Lewisham council to ask that a fire and risk assessment be made of all tall buildings and I invited the borough’s fire commander to address us to give the public and the council the assurances it needed.

Party politics will, of course, play a part in any local government setting and it is naive to think that elected politicians forget their party in scrutiny. But, as a recent Communities & Local Government Select Committee report on local authority scrutiny says, council leaderships have a responsibility to foster an environment that welcomes constructive challenge and debate. I have always held that scrutiny meetings can provide a platform to explain and publicise good policy initiatives and challenge assumptions or ‘group think’.  Let’s imagine the alternative – complete, untrammelled power of the executive.

Instructing scrutiny members how to vote and threatening them with the whip does not foster the constructive challenge we need. Scrutiny committee members need to be able to hold their cabinet colleagues to account.

But if proper scrutiny is to play a full part in effective local government, we will need a culture shift.  The scrutiny process – sometimes seen as the trainspotting of the council world – needs to be valued every bit as much as executive decision-making. This parity of esteem should mean getting access to the resources needed to do the job – including professional and independent advice.

The Financial Reporting Council and the Institute of Chartered Secretaries & Administrators advise that a company’s board should make funds available to their audit committee to enable it to take independent legal, accounting or other advice when the audit committee reasonably believes it necessary to do so. However, scrutiny committees have no such right. Indeed I have requested independent legal advice in the past and an eminent QC has given an opinion supporting a refusal of this request. I believe this change would help proper scrutiny when a council’s legal officers are advising the executive on hugely complex and controversial developments and contracts. It would solve an inherent conflict of interest.

Meanwhile, the government has responded positively to the select committee’s recommendations that overview and scrutiny committees should report to their full councils and not just the executive and that officers should provide impartial and professional advice. That after 18 years of local government scrutiny these recommendations need to be made at all is telling. There is a long way to go before there is anything like parity of esteem between the executive and scrutiny functions.

I helped pilot scrutiny arrangements in Lewisham in 2001 and more recently I am pleased to have had the endorsement of Lord Kennedy – and, somewhat to my surprise a government minister Lord Young – when I led the questioning of a compulsory purchase order around Millwall Football Club’s ground in South East London. The lesson I have learnt is that scrutiny is best when gathering evidence from beyond the usual officers and paid advisors. In the words of an Ofsted inspector who I gave evidence to recently: “Triangulate – don’t only listen to your officers.”

Council scrutiny is a crucial part of our local democracy. It benefits councils and residents alike, contributing to better decisions, better use of public resources, better public engagement and – ultimately – better services.

this article was originally published by The Fabian Society

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In recent days there has been a storm about the recently announced 2016/17 local government grant settlement from central government. The creation of a new £300m relief fund will mainly be used to help Tory-run councils, like David Cameron’s Oxordshire County Council, with Labour leveling the accusation that this is to buy off Tory MPs.

I will leave it to others to form a view on whether this is fair or not. But this whole storm did get me thinking about the scale of the cuts not just for this year, but over the past few years, since the Tories came to power.

So I grabbed hold of the 2011/12 figures for “council spending power” and compared them to the recently announced 2016/17 figures and worked out the percentage cut in spending power for each council. I picked 2011/12 as a base year this was the first full council financial year the Tories were able to fully influence after being elected.

I decided to look only at the 152 County Councils and Single Tier Councils (e.g. London Boroughs, Unitary Councils, Metropolitan Boroughs etc) as they make up over 93 per cent of all council spending. There are 201 district council but they make only about 7 per cent of total council spending. Hence looking only at the “Upper Tier” councils as this made the analysis more focussed.

The thing I wanted to test was the theory that the most deprived councils were worst hit. So I took a trip over to the Office of National Statistics (ONS) English indices of deprivation for 2015 website. Here I got the Index of Multiple Deprivation (IMD) average score breakdown by council areas and then  used the rank of the average IMD score to plot percentage change in revenue spending power using versus the IMD average score rank.

Below is the very telling plot of this data. Note councils with low ranks on the IMD (those plotted to the left) are the most deprived and those with high ranks on the IMD (those plotted to the right) are the least deprived.

Upper Tier Council Cuts versus IMD

This graph shows a strong and clear relationship that the councils that are serving the most deprived communities have suffered the largest cuts over the past five years. This very strong relationship is evidenced by the high R2 value (or coefficient of determination) of 0.81. A value of 1 would indicate a perfect fit on the line of best fit, and a value of 0 would mean the data does not fit the line in any way. A value of 0.81 shows a strong and clear fit/relationship.

So there you have it: the numbers don’t lie. The poorest and most deprived have suffered the largest percentage council cuts. The poor have been robbed to subsidise the rich.

If you want to check the data and my calculations you can download it here.

First published on Ravi’s own blog More Known Than Proven

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Integration. Prevention. Personalisation. The buzzwords that indicate the reforms our health and care system needs are as widely recognised as they are overused. So too are the problematic features of current service provision: fragmentation, barriers and silos. The challenge is not one of rhetoric, but of moving beyond words to practically forge a system that works for people – and enables us all to live healthier, happier lives.

The context is a challenging one  – on this there is also widespread consensus. People are living longer, and many more with long-term, complex conditions. The medical advances and increased life expectancies we can all celebrate mean that demand for services has evolved from the point when the National Health Service was first established in 1948. A hospital-based model set up to treat illness when life expectancy was 65 is now being required to tackle challenges it was not designed to cope with. Pressures are created as a consequence of this: A&E wards are struggling to cope with too many crises that could have been avoided if appropriate care was in place, and hospital beds are over-relied upon because community based infrastructure is insufficient. The funding cuts to local government of 40 per cent over the last parliament have had an inevitable impact on social care provision: the coalition government’s approach to salami-slicing Whitehall budgets without reform exacerbated the situation.

Against this backdrop, the announcement that responsibility for health and social care would be devolved to statutory organisations in Greater Manchester was certainly a bold move. The circumstances of the announcement months before the general election distracted from much of the substance of the proposed framework, which was to enable joint decision-making on integrated care to support physical, mental and social wellbeing. The intervention also exposed some of the fault lines that exist in debates over health and care reform: between centralist and localist perspectives, and between the medical profession and the local government sector.

As a consequence there are a few myths around the content and the implications of the Memorandum of Understanding which set out the terms of the devolution deal in Greater Manchester that need to be addressed, prior to a realistic appraisal of the measures. Some media coverage referred to the agreement as a local government “takeover” of the NHS. In fact, the frame – work was developed between Greater Manchester partners together  – 12 NHS clinical commissioning groups (CCGs), 15 NHS providers and 10 local authorities  – and each will retain their existing statutory responsibilities. The parties to the agreement are the Greater Manchester CCGs and local authorities (collectively known as GM), and NHS England. The mischaracterisation of the approach reflects precisely the obsession with professional hierarchies and sector-based territorialism that true integration needs to break through for new arrangements to be more than the sum of their parts.

Fears have been expressed in some quarters that the measures herald the end of the “N” in the NHS. However, the first principle of the agreement is clear that “GM will still remain part of the National Health Service and social care system, will uphold the standards set out in national guidance and will continue to meet the statutory requirements and duties, including those of the NHS Constitution and Mandate”. The charge that the creation of new models of inclusive governance and decision-making would equate to the dissolution of a national system is ill-founded. The NHS has always been delivered in practice by local units such as primary care trusts, which lacked strong public accountability or visibility but worked within geographic and bureaucratic boundaries to make decisions about resource allocation and service provision. When considering the ‘N’ in the NHS, we need to be clear how this fits with the aspiration to craft a system suited to whole person needs, which are by definition different. What balance should be struck between national ‘one-size-fits-all’ rigidity on the one hand, and responsiveness to the needs of people and places, on the other? A public service reform discussion about the role of the national and the local very often quickly alights upon the phrase ‘postcode lottery’ in the negative  – this is interestingly most often used with respect to local inputs rather than variations in outcomes nationally. The postcode lottery that people living in Greater Manchester should be most concerned about is the fact that they can currently expect to live nine years less than the average person in England. This is the motivating force behind the new framework being created by GM partners: tackling the existence of some of the worst health outcomes in the country  – outcomes which have emerged and persist under a centrally-accountable national system.

The devolution agreement, while not in itself an automatic shift to positive outcomes, presents real opportunities for transformation beyond the existing baseline. Taking the starting point of making an analysis of whole population health needs across Greater Manchester, partners can work towards the twin objectives of closing the health inequalities gap – moving from having some of the worst health outcomes to having some of the best – and aligning provision to prevent ill health and promote well-being, from early age to later life.

For the first time, strong democratic accountability puts local people at the heart of the emerging new framework. Where previously decisions would be taken by remote bureaucracies or distant Whitehall departments, they will now be taken involving democratically elected representatives. This can inject a new responsiveness to the local system which will be driven by stronger direct incentives to evolve to meet people’s demands: good access to high quality, joined up services which provide the right care at the right time. GM partners are already focussed on ensuring early, tangible benefits for people which also begin a shift to wider systemic reform, such as proposals to offer seven days a week GP access by the end of the year and a Greater Manchester-wide plan to join up fragmented dementia services.

While the devolution deal does not bring with it any more or less funding – the £6bn package identified refers to existing resources – a more strategic approach across Greater Manchester can seek to make the best use of these by allocating them more efficiently and effectively. Full place-based commissioning and delivery can ensure public investment is committed on the basis of shared intelligence and is geared to provide the right balance between medical intervention and social support. The GM framework is an opportunity to develop a more coherent long-term strategy to ease pressure on hospitals, while building up services in the community that bring health and social care closer to people’s homes. This will mean removing funding ring fences to make sure funding goes where it is needed locally, identifying duplication caused by service silos, and strengthening formal collaboration between providers. New budgeting models such as year of care funding can be developed, which begin to engineer a system-wide shift away from a focus on single episode and crisis treatment towards longer term preventative care. This can all create space for precisely the innovation and adaptation healthcare systems need: a research, innovation and growth strategy is a major strategic thread through GM partners’ joint work and they are prioritising the early implementation of an academic health science system.

Creating a preventative whole-system approach that shifts from treating illness to promoting wellness involves recognising individuals not as patients but as people. In a different relationship with statutory services, individuals have responsibility for their own health outcomes but are also given the right support. Traditionally, building-based health services like hospitals and GP practices focus on treating illness and operate largely in isolation from wider provision that impacts on good health outcomes such as employment and housing. There is now a real opportunity to align priorities across services and within communities. For example, poor health is too often a barrier to sustained employment, so another early implementation priority from the GM partners is a new programme to help people with mental health conditions get back into work.

Stakeholders in Greater Manchester are continuing to develop the relationships, trust and mutual respect between the professions and services involved. Nonetheless, there are real risks to the new approach which will need to be recognised and managed as the process evolves.

First, the funding context within which the GM partners operate is something of a burning platform. It won’t be until the new Conservative government’s first comprehensive spending review that partners will have confirmation of what resources they have to work with, and how longterm a settlement they can predicate their plans on. A strategic business case will be developed by the end of the year which will need to find a way to bridge financial gaps, which will be no small challenge in the context of further austerity.

Second, the huge ambition set out in the early Memorandum of Understanding was matched by an extremely tight timetable for the translation of these principles and framework into action and outcomes. Partners are already part-way into a ‘buildup year’ ahead of full control of health and care budgets in GM by April 2016. While a roadmap and delivery plan are to be developed and agreed between the partners and wider stakeholders, governance arrangements will be agreed in parallel. A careful balance will need to be struck between moving forward where possible while also ensuring that effective system-wide leadership is forged. Governance arrangements will need to simplify accountability rather than add to complexity. They must be robust enough to realign accountability for the use of public resources sufficiently to meet the huge ambition of the framework.

A priority within all of this is to ensure constant and substantive public engagement and involvement: both in the process of devolution itself, and on an individual level in relation to health needs. There will be a new responsibility for local politicians to articulate the ambitions of the GM partnership and ensure that public dialogue focusses not simply on institutional arrangements but on health outcomes. The latter must remain a driving force for partners as well as a measure of their success. Public engagement shouldn’t happen solely through democratically elected institutions but that a new transparency and accountability is created across the whole health and care system so that people have greater opportunity to become genuinely more involved and engaged in decisions which affect their lives.

GM partners are not complacent about the scale of the challenge they face. As the business case is developed they will need to identify the risks and ensure plans are in place to mitigate and overcome them. There is a shared recognition that they have a unique opportunity to move beyond traditional ‘vertical’ organisational silos and pioneer the development of ‘horizontal’ arrangements across a place which have more potential to tackle demand pressures and create more responsive services. The ultimate prize motivating all involved would be to overturn the trajectory of health inequalities which a centrally accountable system has failed to. Then words like ‘integration’ and ‘prevention’ would move from being just aspirations to standard practice.

This was first published by the Fabian Society

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The Chancellor of the Exchequer has announced a £200 million in year cut to the public health budgets in England and the Department of health is holding a snap consultation over the summer how to axe the budgets.

Councillor Alan Hall, who sits on the governing body of London’s Kings College Hospital and also chairs Lewisham Council’s public scrutiny function, said: “This is a cruel conjuring trick that will directly damage public health services. The Chancellor has slashed them to the bone and now he’s cutting through the bone itself.

“Because he’s transferring the services from the NHS to local authorities he thinks that we won’t notice. But they are still the same services and public health will suffer.

“We have had scarlet fever in children at record levels this year and this is the work of public health clinicians locally. Most of Lewisham Council’s health budget is tied up in NHS contracts and axing £1.5 million in this financial year will affect services.

“He’s cutting preventative health care and so will inevitably put greater strain on the NHS. This damages not only the poorest communities but it damages all of us that benefit from preventative health services. It’s a cruel con-trick that will backfire on all of society”

The Public Health budget was directly run from the NHS but transferred to local councils in 2013 with child health service budgets transferring this year. The public health budget  funds many direct NHS services such as sexual health clinics in local hospitals, health protection, drug and smoking healthcare and children’s health programmes like promoting vaccinations and breast feeding.

Local authorities up and down the country are waking up to the consequences of the announcements by the Chancellor of the Exchequer on 4th June 2015. The Department of Health launched a four week consultation on 31st July what it describes as a technical consultation on how to cut £200 million in year from England’s public health budgets previously agreed for this financial year 2015-16.

The consultation document called: Local authority public health allocations 2015/16: In-year savings reveals that Lewisham is earmarked for an ‘in-year’ cut of £1.5 million pounds.

This was first published on Alan Hall’s own blog.

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The transfer in 2013 of significant public health responsibilities and funding for the over fives was, rightly, heralded as one of the best local government-related decisions of the last Parliament (although, to be honest, there weren’t that many to choose from). And since that time we’ve been working hard to negotiate the follow-on 0–5 healthy child programme, included within it the Coalition Agreement priority of an enhanced Health Visitor resource, personally mandated by the PM.

At an otherwise pretty grim time for councils, we celebrated the “coming home” of responsibilities that had, more than 150 years ago, first defined local government as being principally about the health and wellbeing of our citizens and their communities. Indeed, we even took in our stride the otherwise anathema-like criterion of the money being subject to a ring-fence.

And we lauded this progressive change not just for its potential to enable all our functions to be redefined and reworked in the light of these new “health of the public” duties, but we loved the unexpected and increasingly rare opportunity to salvage something of our commitment to prevention and early intervention which was being undermined by the swingeing reductions being made to other key sources of “early help” revenue (notably the DfE’s “hot knife through butter” approach to the EIG).

So, the recent announcement by the Chancellor that £200m is to be swiped in-year from our grants, just a few months before the 0–5 transfer, has left us – and apparently the Department of Health and Public Health England – deeply troubled. The sense of disbelief and, amongst the more melodramatic, outrage wasn’t just because we thought we might have balanced our books in 2015-16; no, it was because we picked up a rumour that the cut was to be made both deliberately against non-NHS activity and also specifically against this grant. Local government, and only local government, must take the hit. Whether or not the latter is true, it is clear that the former is accurate – protection for the NHS is to be ensured.

Or is it?

As we work our way through the likely implications locally with our health colleagues (possibly £6.4m for Birmingham, by-the-by) – who are equally bemused and angered – what is clear is that pretty much all of the 2015-16 allocations are tied up contractually. And large numbers of those contracts are – you guessed it – with the NHS, notably Community and Mental Health providers.

So, this cut has three consequences attached to it: it will, as seemingly intended, permanently reduce the DH’s DEL as it pertains to the public health grant and, consequently, further impair councils’ ability to invest in upstream interventions. But it will also put more pressure on the NHS at a time when it least needs it.

Why would the Government want to do this? Well, we know that deficit reduction is the fig leaf for an appetite to shrink local government, so perhaps there is no real surprise in yet another cut – although, clearly, the rules of the funding game are that there are no rules and, if this is the case, we should expect further in-year reductions to play havoc with our attempts to plan and set budgets.

But what councils and their partners really don’t get is why it makes sense to anyone to introduce this kind of cut when it clearly undermines the otherwise ferocious determination to protect the NHS. Maybe, along with much else that we are seeing in the early legislative programme of the new government (for example, in the Housing Bill), decisions are being implemented that were never intended to get this far. Obviously, it is bizarre that anyone would bring forward ideas that they wouldn’t really want to put into practice in the first place; but this is not as strange as then seeing them through anyway. Let’s hope that this is just an early phase of cognitive dissonance and that, as Parliament progresses, there will be no more cutting off of noses to spite faces.

For now, however, it does seem that a paradise only recently regained is to be a paradise lost.

This was first published on Mark’s own blog.

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As the 2010 Marmot Review (and before that the 2008 WHO report on Closing the Gap) makes clear, significant improvements in population level health, as well as reductions in health inequalities, require actions that tackle the social determinants of health. However, traditional public health policy has tended to focus on modifying individual lifestyles, rather than addressing the more fundamental causes.

The suggestions so far put forward as the SHA’s submission to the Labour Party’s Public Health Policy review also largely focus on these downstream determinants. This review process is an ideal opportunity to put forward more upstream, social determinants based suggestions.

Based on the social determinants of health, and my knowledge of the public health evidence base, I would like the following policy suggestions to be considered by SHA council on 26th April, with a view to including them in our submission to the NEC.

Whilst not all of these policies will be seen by everyone as being “politically possible” in the current climate, however, the SHA is a broad coalition and a range of ideas should be put forward in our submission to the NEC. As Maggie Winters pointed out in her recent post – the NHS and the welfare state were set up in much harder circumstances.

The evidence supporting these interventions can be provided to Council on request.

1. Improving control at work

Studies have shown that employees of all grades with higher levels of control over their work (in terms of content, pacing of tasks, decision-making, etc.) have better health. Low control at work is associated with higher rates of heart disease, musculoskeletal pain, mental ill health and mortality – even when other risk factors (such as smoking) are accounted for.

Interventions to improve control at work (for example rotating tasks, flexible working, employee participation in making company decisions, employee ownership/shares) have been found to improve health – with no detrimental effects on productivity.

The last Labour government introduced flexible working for parents and carers, and Ed Miliband has talked about potentially having employees represented on company boards to influence the remuneration of executives. The health literature suggests that these ideas should be extended to involving employees in other areas of the business so that job control is increased. In other European countries, such as Germany, “worker’s councils” are common place in businesses.

2. Enhancing access to public transport

Access to public transport is an important social determinant of health as it is vital in terms of enabling access to employment opportunities, health care, and other services such as leisure services, food banks etc. However, it has decreased since privatisation due to the costs of travel, and the reduction in bus routes. Local government budget cuts have also led to reductions in the subsidies paid to support less popular routes. This is particularly an issue in rural areas, and for lower income groups.

The last Labour Government introduced free bus passes for the over 60s. These should be extended to the unemployed and workless to enhance employability and job search. Central government should provide funds to local authorities to ensure that public transport is continued to be made available in rural areas to connect communities with services.

3. Introducing 20mph zones

Traffic accidents (non-fatal) are higher in more disadvantaged and urban areas (particularly amongst children and outside schools) – perhaps due to the higher volume of traffic in such areas. There is a strong evidence base that shows that reducing traffic speeds from 30mph to 20mph results in a reduction in accidents. Such interventions are relatively low cost (changing signage) but can lead to a 15% reduction in injuries. Targeting interventions outside schools with high accident rates may be particularly beneficial.

4. Creating healthy places

Geographical research has shown that communities with higher rates of obesity also have a higher prevalence of fast food outlets. Gambling is associated with higher rates of debt, as well as with mental ill health. Betting shops, as well as high-cost credit shops, are more prevalent in poorer areas. There have been big increases in the prevalence of betting shops, fast food joints, and high-cost credit shops in local high streets and town centres since the 2007 financial crisis.

Current planning law does not enable local authorities to properly control the number of such businesses in their local areas because health is not currently a reason to turn down planning requests. A Labour Government should increase the power of Local Authorities to shape local high streets by adding health as factor in planning decisions.

5. Implementing a Minimum Unit Price

The connection between ill health and high levels of alcohol consumption are well known. The Marmot Review advocated a minimum unit price to reduce mortality and morbidity associated with high levels of alcohol consumption. Econometric modelling as well as comparative data from countries such as Canada suggest that a Minimum Unit Price could be a very effective intervention and one that is proportionate – impacting most on the consumption behaviours of those most at risk.

6. Reducing Ill-health related worklessness

Rates of receipt of incapacity-related benefits (e.g. Employment Support Allowance) have increased rapidly over the past three decades and approximately 7% of the UK working-age population is now in receipt of such benefits. Policy has traditionally focussed on reducing the benefits paid to such groups, tightening up eligibility criteria or making employability programmes compulsory. There is almost no evidence that such interventions have been effective. This is because policies have seldom tackled the route cause of such worklessness – ill health.

People in receipt of health-related benefits have multiple and complicated long term illnesses and so tackling underlying health issues could be the first step to successful return to work. NICE guidance recommends a ‘health first’ approach (combining traditional vocational training approaches, financial support, and health management on an ongoing case management basis) to improving the health and employment of people with a chronic illness. The evaluation of a pilot ‘health first’ intervention in County Durham, also suggests that taking a more health focused approach can be beneficial in improving the health of Incapacity -related benefit recipients and thereby putting them in a better place to engage in mainstream job-search activities.

7. Healthy Housing Policy

Housing is one of the major determinants of health – indeed in the Atlee Government, Bevan was Minister for Health and Housing. The quality of housing (e.g. damp) impacts on health, as does tenure (with private occupiers usually exhibiting better health than renters). The cost of housing – both in terms of purchasing and renting – has increased well-above inflation in the UK since the early 1990s. Rents are now considered to be extremely high and in some areas simply unaffordable for large swathes of the population. Much of this increase has been taken on by the tax payer in terms of housing benefit – a subsidy to private landlords.

Evidence suggests that making homes warmer can lead to improvements in health. Improved energy efficiency can reduce fuel bills, freeing up extra money to spend on essential items such as food. High rents also take money away from households. Rent regulation could also improve the wellbeing of vulnerable households by again increasing the amount of money available to spend on other items such as food and clothing.

Restoring rent controls would be an efficient way of reducing the housing benefit bill, whilst protecting tenants. Other policies, such as the welfare cap, merely penalise benefit recipients and have no impact on landlord behaviours.

The quality of private rental properties varies widely, but also follows a social gradient with the poorest renters inhabiting the lowest quality properties. Proper local regulation of housing standards would reduce the ill health burden of substandard housing conditions.

The Labour Party has already made a commitment to abolish the Bedroom Tax – these further housing reforms would make a fuller healthy housing policy.

8. Making work pay

Low income is the most important determinant of poor health. One of the great achievements of the last Labour Government was the introduction of the minimum wage. Despite cries from the opposition, there have been no detrimental economic effects, and for a significant minority of the workforce, it represented a large increase in pay. However, it is well known that the minimum wage is not yet a living wage and that in work poverty is still significant: 46 per cent of adults in working families in poverty are in families where at least one earner is paid below the living wage. There is little scope for these adults to work more hours to escape poverty; they will need higher pay. A Labour Government should pass legislation that sees the minimum wage become a living wage.

9. Minimum Income for Health Living (MIHL)

The Marmot Review proposed a minimum income for healthy living so that everyone – whether they are in work or on welfare – would receive enough money/vouchers/support to ensure a healthy lifestyle. This was the only recommendation of the Marmot Review that the Coalition government did not endorse. Research has shown that the value of out-of-work benefits paid to the unemployed can be important factors in whether unemployment leads to an increased risk of ill health. This means that there is a need to improve the value and accessibility of benefits from a health perspective. This has led to calls for a minimum income for healthy living (MIHL) which will ensure that there is a right to a certain standard of living for those on benefits. A Labour Government should examine how to implement the MIHL.

10. Decreasing debt

Although unable to access mainstream credit, many people on low incomes require credit to ‘get by’ and therefore turn to alternative lenders, generally high-cost credit sources (e.g. doorstep lenders, pawnbrokers, and payday loans). In low income households, credit is used to get by as welfare benefits and/or wages are not sufficient.

Debt has also been linked to suicide, poorer self-rated physical health, long term illness or disability, back pain, obesity and health related quality of life.

Credit unions offer low-rate, small loans, and can have a positive influence on the financial capability and wellbeing of their members. To decrease the health problems associated with debt, the Labour Party should look to supporting Credit Unions as well as capping the loan rates of commercial providers.

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This is reproduced by kind permission from the wonderful  Municipal Dreams blog.   @MunicipalDreams

The pioneers of the Socialist Medical Association started by taking over the health functions of the London County Council, and were deeply committed to the idea of Health Centres

‘Salus populi suprema est lex’. Cicero said it fourteen centuries earlier but Southwark Borough Council translated the phrase into English and bricks and mortar and placed it proudly above the entrance of the new Walworth Clinic opened in 1937.

Tablet

The state, by then, had come to recognise some responsibility for the welfare of its citizens but this had been a tortuous and piecemeal process.  Regularly employed male workers might enjoy National Insurance or trade union and Friendly Society benefits.  The poorest were stigmatised still by their dependence on charity or the Poor Law and its vestiges.

In 1929 the Local Government Act turned over remaining Poor Law services to the counties and boroughs.  It was an opportunity for progressive councils to build on functions already acquired – in maternal and infant welfare and tuberculosis care and prevention – to develop comprehensive healthcare programmes for their population. In this way, they would prefigure the National Health Service created in 1948.

Local health centres – such as those already examined in FinsburyBermondseyand Woolwich  were an important element of this programme and would be models for primary healthcare in the new post-1948 service.

Walworth in 1946 from www.britainfromabove.org.uk. Image EAW000645 © English Heritage

Walworth in 1946 from http://www.britainfromabove.org.uk. Image EAW000645 © English Heritage

Southwark first came under Labour control in 1919 when the Party swept to victory in local elections across the country. In the same year, the Maternity and Child Welfare Act was passed.  The new Council took up the cause, investing, for example, in a municipal store to supply cost-price or free milk and medicines to expectant mothers.

Southwark Labour lost power in 1922. The Municipal Reformers – antagonistic towards anything that smacked of ‘municipal socialism’ and jealous guardians of the ratepayer’s purse – scaled down these efforts.

But 1934 saw Labour back in power and committed to further reform. A Public Health and Sanitary Committee was established, a ‘complete investigation of the public health problems of the borough’ set under way.  The Medical Office of Health, William Stott, was asked to specify the premises he needed to deliver local health services.

The Centre in 1937

The Centre illustrated in 1937 with white stone parapets now disappeared

The result? Three years later, Southwark was ‘the first borough to have the whole of its health services in one building’ – a building which Councillor Gillian, the chair of the Committee, claimed ‘beats Harley Street’.(1)

The Council took the view, Gillian stated,  that :(2)

Cllr AJ Gillian

when the health of the people, and particularly the poorer classes of the population, is involved, only the best equipment and the most modern scientific devices would suffice.

The Walworth Clinic, built at a cost of £50,000, would be  in form and content a practical fulfilment of these principles.

The building itself, designed by Percy Smart, still has a strong presence on Walworth Road.  Architecturally, according to English Heritage who listed it Grade II in 2010, it’s notable for its ‘strong massing, brick elevations, and jazzy details…a hybrid of Modern Movement and Art Deco styles’.

The Lancet was complimentary: (4)

The borough council have wisely decided that the building shall have a pleasing appearance and by the brightness of its interior give a cheery welcome, so that the inhabitants may be encouraged to make full use of an institution devoted to the improvement of their health.

As shown in the opening programme

Statuary group as shown in the opening programme

Easily missed but powerful when viewed is the statuary group, by an unknown sculptor, at the top of the building. A woman and three children of varying ages, the figures are both allegorical (the woman is holding the healing rod of the Greek god Aesculapius) and recognisably ‘real’ with their modern hairstyles and the child’s doll. These were: (3)

Statuary groupdesigned to symbolise the functions of the new building with relation to family health – motherhood, various stages of childhood and the spirit of healing.

But if these externals were important – and they were for the combination of dignity and accessibility they offered to the priority of the people’s health – you can feel from the contemporary descriptions that it’s the facilities and equipment that really excited the professionals.

The Centre today

The Centre today

The side and rear of the building from Larcom Street

The side and rear of the building from Larcom Street

Southwark, in the best form of one-upmanship, listed its innovations – the ‘first maternity department in the country to have an illuminated colposcope’ (you can look it up), the first to install an X-Ray department, and the only borough to have a ‘complete full-time chemical and bacteriological laboratory’.  The building was air-conditioned too.

Artificial Sunlight and Radiant Heat Clinic

Artificial Sunlight and Radiant Heat Clinic

X-Ray clinic

X-Ray clinic

The Centre, the Council stated, marked ‘a further great step’ towards its goal – ‘the betterment of the health of the people of Southwark generally’.

That meant administrative offices and qualified personnel (including a ‘Lady Sanitary Inspector’ and ‘Lady Assistant Medical Officers’) too as well as the vital front-line services – a dispensary, a TB clinic and solarium, a dental clinic, regular maternity and child welfare clinics, of course, and a weekly clinic for women over 45 ‘subject to illness and disease peculiar to this age period’.

P1010790The basement contained a ‘Tuberculosis Handicraft Centre’ where unemployed TB sufferers could learn craft skills which might lead to employment or might, at least, provide a useful hobby.

Rheumatic clinics and breast-feeding clinics were planned for the future.

And the Centre was only part of a programme which the Council understood quite clearly as a comprehensive assault on poverty and its causes. When rats overran one part of Southwark, the Council built a new sewerage system, costing £70,000. Opened just three months after the health centre, it too aimed to raise ‘the health of the people’.

Whereas Southwark once had the highest death rate in London and one sixth of its houses had been declared unfit for human habitation, Councillor Gillian could assert in 1937 that: (5)

Coat of ArmsThis two-fold evil was being resolutely dealt with …Slums were being cleared, overcrowding was being overcome by new housing plans and Southwark was now one of the healthiest boroughs of London.

Over seventy-years later, the Elephant and Castle down the road is being redeveloped again and the centre itself looks slightly forlorn. There’s still an NHS clinic on the Larcom Street side but, as the signs in the contemporary photograph indicate, the building is to be let as office space. It’s a sad decline for a building which started with such bold and practical ideals.

In fact, the Walworth Clinic was a model superseded by the NHS a little over ten years after its opening.  There were plans for local health centres – based on these London examples – in the original NHS blueprint but the 162 envisaged, serving population centres of 20,000, were implemented only sporadically .

There was a loss here of democratic initiative, impetus and control that might have served the NHS well.  No-one would wish a return to the haphazard localism of the pre-NHS era but reforming and ambitious councils represented and practised the ideal of a community’s responsibility to safeguard and support its sick and vulnerable. The Walworth Clinic reminds us of that.

Sources

(1) Quoted in the Daily Telegraph, 17 September 1937 and South London Press, 1 October 1937, respectively

(2) Programme of the Opening of the New Health Services Department by the Worshipful Mayor of Southwark (Cllr CJ Mills) on Saturday September 25th 1937

(3) Programme of the Opening of the New Health Services Department…

(4) The Lancet , October 2 1937

(5) The Times, September 27 1937

Other detail and analysis comes from Esyllt Jones, ‘Nothing Too Good for the People: Local Labour and London’s Interwar Health Centre Movement, Social History of Medicine, vol 25, no.1 , February 2012.

The historic images come from the superb collection of photographs held by the Southwark Local History Library and Archive.

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