Blog

  • Categories
  • Category Archives: Local Government

    In the context of whole person we need health services to be aligned with all the other public services. We need to focus on tackling the social determinants of poor health, investing in better health, and only the public service approach can do that.  Only local authorities can be the focal point for bringing public services together.  Only those who are accountable to us through a democratic process should be allowed to make decisions about how public funds are allocated and priorities set.

    But, the antipathy that exists within the health service to local government is matched only by the reluctance of most local authorities, already coping with austerity, to get involved in health services which are seen as shambolic.

    Whatever method is used to plan or commission should take into account all of the public services and the total of resources available.  It is incidentally an argument against ring fencing of funding for separate services.

    There are three reasons why local authorities ought to also have the strategic responsibility for the planning/commissioning of health services:-

    • it brings the democratic accountability we rely on for (most) other public services
    • it allows for total public funds for an area to be allocated to best overall advantage and for strategic investment decisions – population based decisions
    • it allows for economies of scale – especially in management, administration and support functions

    And arguably there is one further reason:-

    • Local authorities are better managed than health services (in terms of procurement, sharing services, service integration, commissioning) – they are many years ahead on the “best value” journey.  They are also far better at resisting vested interests and conflicts of interest – its one reason why we have democracy.

    Alongside the basic ideological case for democracy this is about how we get the greatest value from public funds. For most of the lifetime of our NHS public money flowed to the “providers” of healthcare based on history – just roll over what was used the previous year plus a bit. Long waits and restrictions on access balanced the books.  There was no planning, no sense of public involvement in decision making and no measures of value for money.  Two decades of commissioning by various flavours of NHS bodies have not managed to change things much and we constantly hear (for example) that the priority attached to acute care is detrimental to developing community care – care closer to home.  The biggest inefficiencies in our NHS are arguably no longer in providers being “inefficient” in delivery (although they are) – it is that we allocate spending on the wrong things.

    Responsibility and funding for social care is with local authorities and subject to means testing in contrast to free “health” care.  Sixty years ago this did not appear to matter much, now the fact that our care is split between two armed camps that do their best not to communicate and have huge cultural differences matters a lot.  Not to mention the issues around totally inadequate funding for social care impacting on health.

    Finally we can note that because funding streams are separate there are fewer incentives to cooperate, and even some perverse incentives to compete for funding.  If local authorities invest in better housing then health improves but it is the NHS that gets the gains. We have the current situation of one public body imposing fines on another – which should be a ludicrous idea but which has a twisted logic in the current fragmented set up.

    So does change require a reorganisation?

    The reality is that in many parts of the country the local authorities and the NHS are already working together – and where it works best is where the local relationships are good, informal arrangements are made and they ignore the complexities of governance and just do it.  That can be built on and encouraged but each locality has to be left to find its own way.

    We could start by a few simple measures:-

    • give Health and Wellbeing Boards the responsibility to sign off Clinical Commissioning Group plans (now rests with NHS England) – and to monitor delivery
    • and sign off on social care budgets and commissioning plans

    (both plans must explain how they took the other into account)

    • make a joint commissioning framework (and policies) mandatory as with Joint Strategic Needs Assessment and the area Wellbeing Strategy
    • strengthen governance of CCGs by having non executive directors to prevent conflicts of interest so that all of primary care (including GPs) can be brought into their local remit (currently with NHS England)
    • set financial limits above which agreement from the LA would be required (~£5m)

    and in a longer time frame

    • make CCGs and LAs coterminous (many CCGs are smaller than their  Local Authority)
    • integrate commissioning and other support functions
    • pool the whole budgets.

    None of that requires any major whole system reorganisation.  And it should not be done through top down imposition; each locality should be left to find its own way at its own pace so long as it delivered improving and better integrated care.

    6 Comments

    This consultation on local authority health scrutiny runs until 7 September 2012

    The changes proposed in this consultation will update the arrangements and regulations for local authority health scrutiny and help to ensure that the interests of patients and the public are at the heart of the planning, delivery and reconfiguration of health services.

    The consultation seeks views on whether health service reconfiguration and referrals should also include a:

    • requirement for local authorities and the NHS to agree and publish clear timescales for making a decision on whether a proposal should be referred
    • new intermediate referral stage to the NHS Commissioning Board for some service reconfigurations
    • requirement for local authorities to take account of the financial sustainability of services when considering a referral, in addition to issues of safety, effectiveness and the patient experience
    • requirement for health scrutiny to obtain the agreement of the full council before a referral can be made.

    New rules already provide local authorities will no longer be obliged to have an overview and scrutiny committee through which to discharge their health scrutiny functions, but will be able to discharge these functions in different ways through suitable alternative arrangements, including through overview and scrutiny committees.  It will be for the full council of each local authority to determine which arrangement is adopted;

    Main proposals:

    The application of the NHS failure regime is exempt from scrutiny. There will be  a new intermediate referral stage for referral to the NHS Commissioning Board for some service reconfigurations;

    Local authorities will have to:

    •  publish a timescale for making a decision on whether any proposal will be referred;
    •  take account of financial and clinical resources when considering a referral;
    •  involve the full council of a local authority to make  a referral.
    It is proposed to formalise the arrangements for joint health scrutiny committees

     

     

     

     

    Tagged | Comments Off on Consultation on local authority health scrutiny

    Summary

    The welfare reform agenda in 2011-2017 from government will combine with unexpectedly austere economic conditions and associated cuts to the voluntary sector and legal aid. Over 100,000 existingWolverhamptonwelfare claims will be converted to a new super-benefit, many existing payment levels being reduced, and all capped at £500 per household per week.

    A total sum of between £70million and £120million per year, every year, will be lost from the city economy by 2017. Large family households, headed by a lone parent, will face considerable pressures. The effects will be economically felt much wider than just the claimants’ households.

    Recommendations – summarised

    There are 12 itemised recommendations at the end of this paper. Principal themes amongst them are:

    • The need to see the welfare reform programme alongside other relevant economic factors, such as future financial fragility in the mortgaged sector
    • Creation of a working forecast of all the forthcoming factors, a “Wolverhamptonway”, which can better inform different agencies in planning for and reacting to events, and creating new mitigation plans
    • Identifying particularly vulnerable groups, such as workless lone parents with a large family in a heavily mortgaged property
    • Asking the private sector firms delivering the prevention agenda contracts to join in partnership work
    • Identifying which voluntary sector resources need defending
    • Obtaining research from theUSAexperience since 1996 on (perhaps unfamiliar) issues such as behaviour change and mental wellbeing

    1.0 Background

    Government is committed to transformative welfare reform, to change behaviour and deduct £18 billion from the cost within 4 years. A quarter ofUK public spending (13% of GDP) is today on welfare, although 40% relates to pensioners who have been comparatively protected. There is widespread public support and largely cross-party agreement. The familiar if complex benefits system redesigned by Norman Fowler in the mid 1980s, and variously adjusted by Labour administrations, will be transformed around these driving themes:

    • stronger work incentives (to make work pay and redefine claiming welfare as a temporary status)
    • responsible life choices (especially the size of family when claiming)
    • support for pensioners and those “genuinely” incapable of work, but less so for many other groups

    New legislation has survived a contentious parliamentary passage and will soon replace a plethora of current mainstream benefits (such as Housing Benefit) with one simplified “super benefit” (Universal Credit, UC) starting in October 2013, for claimants who are in or out of work, or moving between. The benefits being abolished are currently supplied by Local Authorities and civil service agencies. This scale of change is ambitious under any circumstances, but set against a double dip recession, high unemployment, a weakened voluntary sector and lowered future growth forecasts, it is an unprecedented programme. InWolverhamptonchild poverty has risen from 17.9% in 2004 to 33.4% in 2011. In the USA, somewhat similar policy changes, starting in 1996, have cut welfare claims by 58%, but in doing so created sub cultures of people who simply fell out of the system, including a category described as “floundering mothers” who cannot keep in work but are simultaneously debarred from claiming state aid, resulting in controversial policy debates about the many children affected by such complex household consequences.

    2.0 Current Position

    a)    Welfare change issues only

    [Indicative figures in this report will be rechecked in forthcoming weeks]. In Wolverhampton there are well over 100,000 live claims to be changed into UC over a 4 year period: Housing Benefit (25,869), Income based JSA (12,108) other out of work benefits (29,700), plus Working Tax Credit and Child Tax Credit are received by 65% of Wolverhampton’s families. Each year even more customers start and stop claims. UC will be applied for by digital default (online) and paid one month in arrears to a bank account. It will be administered by a remote national agency rather than local offices. Direct payments to landlords will cease, meaning the concept of an “earned monthly wage”, with all the responsibilities for the household, is created. In a recent DWP guide it was stated that, until they get a job, a claimant’s job is to get a job.

    Because of the scale of the changes there will be 4 years where de facto 3 different welfare benefits systems co-exist: those already on UC, those still on the legacy benefits package, and those waves of claimants in transition. Alongside this is a parallel change from Disability Living Allowance (DLA) into the newly stringent Personal Independence Payment. This will require a fresh claim for all of the existing 15,700 disabled DLA claimants inWolverhampton. Cuts were made to Housing Benefit in 2011, and more are now occurring. There is also a new Benefit Cap of £500 per week per household.

    The Stoke on Trent municipal information team are suggesting a loss to that city of £106.4million a year, every year. A simplistic per capita assumption aboutWolverhampton’s population compared to the national cuts sum produces a not dissimilar range.

    What are the wider consequences of these changes? Housing Benefit (HB) is in reality a rent subsidy which funds landlords. InWolverhamptonthe housing supply is 7% private sector landlords and 25% the ALMO. Rent arrears are expected to grow as some claimants cannot or will not make up the shortfalls caused by HB reductions. The amount of housing related enquiries coming to the CAB inWolverhamptonhas already increased from 7% in 2008 to 18% in 2011.

    The Benefit Cap is a novel fixed ceiling on all household welfare income, irrespective of family size. Early government estimates predict circa 70,000 households will be affected at an average loss of £83 weekly from April 2013. 56% are in the private rented sector, 69% have more than 3 children and 52% are lone parents. The Black Countryhas an unexpectedly high volume of such households and preliminary letters are already going to them. £83/week is £4312 a year. DWP staff work to “vulnerability” triggers but need claimants to engage, and are not knowledgeable about housing stock quality or local rent issues. Initial claimant responses are apparently defeatist. If 500 families lose the average modelled sum, this equates to just over £2million in Wolverhampton.

    b)   Economic background issues

    A fair wind does not exist for welfare reform:

    • youth unemployment is high and inadequate numbers of good jobs exist to move claimants into
    • flat wages are being eroded because of rising costs of living
    • fuel and food inflation is especially high
    • increasingly bold marketing of “pay day loans” at extortionate interest rates (4000% APR from one popular mainstream company) are flourishing, and local CAB evidence suggests a growing negative trend
    • Enquiries at Wolverhampton CAB for “threatened homelessness” have continued to rise year on year since 2008: 141, 286, 625, 743, and these are before the welfare cuts have really started

    Other more currently favourable phenomena will drop away:

    • there is a small temporary effect of PPI claims (for mis-sold payment protection insurance) coming back to local people, possibly £2million pa
    • the standard variable rate of mortgages has been held low for 3 years, offering up to £300 a month interest relief on an average priced Wolverhampton fully mortgaged property of c£126,000 – this could end in 2013/14, and if only 10,000 properties were affected this would still drain £36million pa from the city. 60% of local property is owner occupied
    • cuts of freely available discrimination casework in 2012 and to legal aid in January 2013 will remove all publicly funded assistance to low income households in the subjects of discrimination, employment and welfare benefits law, and most debt advice too; the cuts have been opposed because £1 spent on legal aid is reliably estimated to save at least £4 to the tax payer. This means 1,400 fewer cases to be run inWolverhampton(and 12 key jobs lost at the CAB), or about £1.2million more cost to the local public purse.

    And a particular concern lurks concerning owner occupied housing stock in future and the number of children in households accepted as homeless:

    • it is widely forecast that a rush of mortgage repossessions will occur at the end of the downturn, as the national economy and housing market recovers, and interest rates rise, but unemployment lingers locally. Repossession figures for Wolverhampton postcodes to date for 2007 to 2010 inclusive are 535, 655, 320 and 285. This shows how effective the post credit crunch support responses have been locally (the MRS, CAB and City Council activity), plus mortgage lenders not viewing repossession as attractive in a depressed market, and the protective effect of the low Bank of England led SVR. In 2012 the CAB continues to advise over 500 households annually with serious mortgage debt, and reschedules most onto the low SVR. Once that SVR changes, all of these recently stabilised cases unravel afresh, and simultaneously
    • recent figures from Housing Options inWolverhamptonshow that of 175 families accepted as homeless last year, 473 children were involved

    c)    Prevention services

    One of the hopes of the government agenda is a real appetite for prevention work, and the use of bank levy money (“polluter pays”) to fund a national debt advice scheme (rather than tax payer income) is a long overdue reform. The heavily funded Work Programme and Troubled Families schemes also seek to combine to reduce obstacles to job hunters or families on welfare and the new Money Advice Service offers basic guidance on financial planning and awareness.

    As things stand these new nationally tendered contracts have all been won forWolverhamptonby private contractors such as EOS, Pertemps, In Training and A4e. Despite early meetings these firms are not currently participating in the established partnership frameworks, for reasons which are as yet unclear.

    d)   Big Society

    Another government ambition was to stimulate more local and informal sources of micro help and mutual support for those in communities. Unfortunately, due largely to other central government cuts, all of the recognised voluntary agencies in Wolverhampton able to help with the welfare agenda are today in far worse fettle than they were in 2010. The CAB has lost 24% of its funding and 21 (a third) of its paid staff in 15 months, due to 4 national schemes ending. It will have to downscale its offers at Bilston and Low Hill unless replacement resources for legal aid are found. The WVSC has suffered a similar range of cuts. The Asian womens’ advice agency AWAAZ closed in 2011, and the veteran All Saints local agency (the Haque Centre) closed in 2009/10. Only charitable free food outlets appear to be blossoming in this policy area, which are a genuinely welcome practical phenomenon, but treat the symptoms of need, not the causes.

    e)  Summary of current position and key concerns

    The scale of the welfare reforms, set against an austere economic outlook, as yet unproven prevention services, and rapidly deteriorating traditional sources of assistance, suggest that something in the region of £70million – £120million of year on year combined welfare cuts and economic strains could be felt in theWolverhamptoneconomy up to 2017. Amongst these are some emerging and especially local vulnerability issues:

    • lone parents, usually women, with low skills in larger households, especially with younger children
    • claimants for whom digital benefit applications and onerous conditionality obligations (90 minutes travelling to work) are problematic
    • those who are unaware of or do not access support services and are not flagged as vulnerable
    • those (from many backgrounds) who may become newly mentally unwell under the storm of negative pressures (such as spiralling debts and personal isolation)
    • some younger adults from Black and Mixed Black/White backgrounds already consistently show up as exceptionally vulnerable to personal indebtedness in CAB data
    • it is possible to forecast some families who will be exceptional losers under the changes: a workless lone parent with over 3 children in a heavily mortgaged property on the SVR could face both the worst of welfare cuts and the worst of the economic situation, and find less local support than ever before

    3.0 Way forward

    In a nutshell, it’s all going to happen. The questions are therefore not really about if and when, but exactly what tangible effects will occur in our city. Based on theUSAexperience, current government timetables and unavoidable forecastedUKfactors (like the national economic situation) the following expectations are presumed:

    • the majority of circa 100,000+ affected Wolverhampton claims (from a lesser number of local people) will adequately convert to the new welfare era, some less comfortably than others, although a higher proportion of rent arrears cases will result as landlords seek to reclaim unpaid rent
    • Wolverhamptonwill cope slightly less well than many other areas, due to longstanding local issues (the kinds of issues that have revealed a vulnerability to child poverty)
    • some households will lose over £4000pa via the Benefits Cap, many being lone parents and/or with larger families
    • less will be spent in the local shops and economy
    • from 2013/14 there could well be a rise in repossessions and more households presenting as homeless
    • a large number of extra enquiries will be brought to advice agencies, which will have less capacity to run legal casework
    • stress and mental wellbeing issues will increase to some degree across many groups
    • a hard to quantify rise in destitution and homelessness will occur for some vulnerable groups
    • a few harrowing cases will appear in the media, and increased lobbies will emerge from campaign and faith groups, but overall public support and political agreement for welfare reform remains strong
    • pockets of small-scale protest and anger may occur, for instance bailiffs at work being rebuked by local people
    • modest re-compaction of households, principally young adult people moving “back home”
    • the Local Authority will have greater overall responsibilities but little local control over the private sector prevention service contractors
    • child poverty is likely to creep higher, at least in the medium term, and safeguarding concerns may remain high
    • some increased disrepair as landlords’ income wanes and some mortgaged landlords are themselves repossessed, cascading unwitting tenants into homelessness

    4.0 Recommendations – specific

    1     Assess the total loss of income to the city from all causes until 2017

    2     Estimate where these losses will have an affect (ie by neighbourhood, or retail sector)

    3     Create an overall narrative for planning purposes, a “Wolverhamptonway”, that is broader than currently emerging agency by agency knowledge

    4     Arrange for DWP officers to liaise on the Benefit Cap with LA officers who possess intelligence on neighbourhoods, vulnerability and housing stock/rent levels

    5     Seek defined partnership engagement from the private firms delivering new prevention contracts

    6     Consider a standing reference group for multi-agency practitioner level officers to co-ordinate intelligence flows, including soups kitchens, landlords and advice agencies alongside senior officers

    7     Access research evidence on theUSAchanges and mental wellbeing effects as “behaviour change” is exerted on populations

    8     Scope popular “living on a budget” skills options – repairing your home, cooking for a family – with a view to social media cascading

    9     Consider the new “local social fund” being linked to social prevention systems

    10  Discuss an extended local Mortgage Rescue Scheme facility, unless a national scheme is made available

    11  Identify key Big Society agencies/functions that must be protected

    12  Prepare some evidence-based and effective new schemes to mitigate against vulnerable groups failing to seek advice and support, for example the “advice in maternity pathway” pilot

    Jeremy Vanes

    Comments Off on The impact of national welfare reforms on Wolverhampton, alongside other disruptive factors, 2011-2017

    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.

    Tagged | 4 Comments

    This article has been republished as requested by Dr Tony O’Sullivan, co-chair KONP

    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.

    Tagged | 1 Comment

    As the UK moves to having four distinctive health care systems as a result of devolution, the role of local councillors in relation to health matters becomes less uniform. For example, unlike Wales, where health and local government bodies have been coterminous since 1974, England remains a patchwork quilt of overlapping health and local government bodies which is made worse by the ever increasing privatisation of both health and local authority services.

    This short article captures some common issues about which councillors across the UK might want to think. Topics covered include: scrutiny and public consultations, shaping integrated systems, and public health.

    Scrutiny and Public Consultations

    In all four administrations local government can play a key role in holding the NHS to account, both by standing arrangements for Scrutiny and by taking a leading role in testing any proposals for service change which the NHS might put forward. The machinery for doing this varies – especially in England where market –style arrangements are increasingly used to govern the relationship between “commissioning” and “providing” functions  and where the public health function is now placed firmly in the local authority domain.

    In England the Health Scrutiny Regulations 2013 are intended to give local areas flexibility and freedom to shape the scrutiny role of Health and Well being Boards as best fits local circumstances – including the option to establish topic – specific sub committees.

    Scrutiny

    Local authority scrutiny of selected health activities – based firmly on its democratic mandate for local leadership – should be built into the annual scrutiny programme. The regulations stress that local authorities are able to scrutinise three aspects: how health care services are planned, how they are provided, and how they are operated locally.  Local circumstances will shape some of the topics but councillors might want to might include at least one area of scrutiny work from each of the following categories.

    • The robustness of local arrangements between primary, social care and secondary care aimed at preventing  crisis referrals (and inappropriate admission) to acute hospitals
    • How well linked are health and local government planning functions for agreeing “need” and “demand” for the decade ahead in all parts of the Council’s  area (down to ward level)  – and the crafting of shared responses to such need.
    • How continuity of health care is ensured for looked after children leaving care.
    • How well local providers perform across a range of performance measures – including clinical performance and managerial / financial performance.

    Public consultations

    It seems inevitable that the NHS will continue to undertake public consultations on service change as austerity bites and increased attention is paid to existing service defects. Local councillors have a key role in all public consultations. They can:

    • Ensure key community interests are alerted as soon as news of impending consultations is known
    • Work hard, at an early stage, to try to shape the nature and language of the proposals so that the issues are written about in a way that ordinary people can see through what is proposed.
    • Ensure that the “Gunning  principles” on consultation are followed – for example, is it clear what the issue is about upon which views are sought; has sufficient information been provided; can it be seen that the decision makers are taking all comments seriously?
    • Use council resources (officer time to probe papers, meeting rooms for pubic sessions, generate publicity etc) to alert the public to the issues being  raised and to provide informed arenas to which health officials can come and have their proposals examined.

    Shaping integrated care systems

    Too often local councillors take little notice of what officers of health and local authorities are doing when it comes to trying to improve the co-ordination or integration of care offered by them both. Whether in the care of elderly, younger disabled, or mentally ill people, or in distinct services such as those relating to substance misuse and eating disorders, interest in, and leadership of, the better integration of services is sometimes lacking at elected member level.

    Yet there are key issues upon which elected members could make a difference. For example, is the Council an outward looking one that sets the pace for its key partners, or does it shy away from partnership work? Does it put the protection of its budgets first or is it willing to experiment with joint funding and pooled budget methods? What about joint appointments of senior staff, with the freedom to switch or blend local authority and health cash and craft teams of people from both bodies? How well do information systems support the planning of locally relevant services, or report on their delivery of care? How often does the full Council debate such matters in public meetings?

    Public Health

    The public health function brings powerful tools to an understanding of health issues – whether this sits within local government as in England, or within the NHS.

    Wherever it is located organisationally, elected councillors should take an interest in its work across a number of dimensions. Some of these are briefly described below.

    Health Status Reporting

    The production of useful and intelligible data on the health status of complete local authority areas, and smaller areas within them, should be a routine task of the public health function – and should be used regularly by Local Authorities. Housing, education and environmental health tasks of local government all play a part in ensuring good and improving levels of public health. Economic data should also feature as there is some evidence that health status and differentials in income in localities are linked.

    Mortality and morbidity data

    Local councils should have an understanding of what are the main killers are in its area, and what are the main causes of major illness that impact adversely on the quality of life. While the major causes of death are likely to be cancer and heart disease, the causes of significant lost years of life may extend to include suicide, accidents, violence and avoidable childhood diseases.

    Morbidity data will show how such conditions as depression, diabetes, substance misuse, chest disease, and physical disabilities  impact upon different social groups in different localities.

    Equity and access

    Linked to such data is the notion of equity and access – equity of outcomes and health indicators and access to health (and other) services. For example immunisation rates and attendance at screening services vary. Average life expectancy in many local authority areas will vary by 5 or more years between the healthiest and least healthy wards.

    The council as a public health body

    Despite the changes in 1974 when local government lost key health functions such as health visitors and medical officers of health, Local authorities have always had a key public health role beyond the narrow confines of Environmental Health. It is a key partner. Councillors should ensure they have machinery for assessing the nature and quality of their partnership arrangements.

    Tagged , | 1 Comment

    REPORT OF THE COMMITTEE OF ENQUIRY INTO THE COST OF THE NATIONAL HEALTH SERVICE

    Presented to Parliament by the Minister of Health and the Secretary of State for Scotland by Command of Her Majesty January 1956

    Cmd. 9663

    MEMBERSHIP OF THE COMMITTEE:

    C. W. GUILLEBAUD, Esq., C.B.E. (Chairman) Dr. J. W. COOK, F.R.S. Miss B. A. GODWIN, O.B.E. Sir JOHN MAUDE, K.C.B. Sir GEOFFREY VICKERS, V.C.

    The first section of the report, not reproduced here, is devoted to the Memorandum “The Cost of the National Health Service in England and Wales” by Brian Abel-Smith and Richard Titmuss, (Cambridge, 1956)

    SUMMARY

    1. We summarise below the main features which have emerged from this study of the trends in the cost of the National Health Service in England and Wales from 6th July, 1948 to 31st March, 1954; and some of the possible trends in the future. We do not propose to repeat in the summary all the definitions, assumptions, and qualifications on which the conclusions are based. These will be found by referring back to the body of the text of Part I of our Report and, where necessary, by reference to ” The Cost of the National Health Service in England and Wales” by B. Abel-Smith and R. M. Titmuss. We would emphasise, however, that all who wish to use these conclusions should read them in conjunction with the assumptions, etc., to which we have just referred.

    THE CURRENT COST OF THE NATIONAL HEALTH SERVICE IN ENGLAND AND WALES DURING THE PERIOD 1948 TO 1954

    General (1)   In England and Wales, the current net cost of the National Health Service in productive resources was £371 1/2  million in 1949-50.   In subsequent years it rose by roughly £15 million each year, reaching £430 1/2 million in 1953-54 (para. 17).

    (2)     The rise of £59 million in the current net cost of the Service over the four years was the combined result of a larger rise (£77 million) in gross costs, offset by a saving of £18 million arising from new or increased charges to beneficiaries (para. 18).

    (3)     Expressed as a proportion of total national resources (the “gross national product”) the current net cost of the Service fell from 3 3/4 per cent. in 1949-50 to 3 1/4 per cent, in 1953-54 (para. 20).

    (4)     During the period under review there was a considerable general rise in prices.   An attempt has been made to estimate the effect of price increases on the cost of the Service, recalculating expenditures at constant (1948-49) prices and wages.   The current net cost of the Service, expressed in “real” terms in this way, was only £11 million greater in 1953-54 than in 1949-50. Thus, the net diversion of resources to the National Health Service as a whole since 1949-50 has been of relatively insignificant proportions (para. 23).

    (5)     There was a rise of nearly 2 per cent, in population during the period under review.   Allowing for this and for changes in the age structure of the population, the cost per head at constant prices was almost exactly the same in 1953-54 as in 1949-50 (para. 24).

    (6)     Trends of expenditure have been very different in different parts of the Service.    Between 1949-50 and 1953-54 net current expenditure on the hospital services rose by £71 million, and that on local authority services by £11 million, while expenditure on Executive Council services fell by £24 million.   The movement of total Health Service expenditure thus represented the combined result of these divergent trends, a fact which needs to be taken into account in considering possible future trends (paras. 25-26).

    The cost of the Hospital Service

    (7)     A major part of the rise in hospital expenditure was attributable to rising prices (£41 ½ million of the £71 million increase from 1949-50 to 1953-54) but the rise in the real volume of goods and services purchased (£29 ½  million at 1948-49 prices) was also substantial (para. 29).

    (8)     Throughout the period under review, revenue from charges has contributed in only a very small degree towards the gross cost of the hospital service ; little more than 1 per cent, in fact (para. 27). (9)  Approximately 60 per cent, of the increase in resources purchased for the hospitals (£17 1/2 million of the £29 1/2 million) consisted of medical goods and services (para. 30). (10)  In the hospital service, the cost of medical staff increased by £4 million between 1949-50 and 1953-54.   This rise is attributable in the main to a substantial increase in the number of staff employed, both part-time and whole-time.    The increase in labour services as a whole accounts for three-quarters of the increase in resources used in the hospital service at constant prices.    The categories of staff which increased most were nurses and domestic staff (paras. 32-34).

    The Cost of the Executive Council Services

    (11)     Current net expenditure on Executive Council services fell by £24 million between 1949-50 and 1953-54.    Of this, £17 million represented a transfer of cost to beneficiaries by means of the charges introduced in 1951-52, but there was also a decline of £7 million in the gross cost of the services (para. 38).

    (12)     The different Executive Council services show different trends in expenditure.   While the pharmaceutical service and the general medical service each increased between 1949-50 and 1953-4 by £6 million, expenditure on the dental service fell by £24 million and that on the ophthalmic service by £13 million (para. 39).

    (13)     The rise of £6 million in the cost of the general medical service was entirely due to a rise in “price”, i.e., to the increased cost per patient-year resulting from the Danckwerts award to general practitioners (para. 41).

    (14)     The rise of £6 million in the net cost of the pharmaceutical service resulted from a rise of £12 million in gross expenditure, partly offset by £6 million in revenue from charges.    Owing to lack of information, it is impossible to give a complete explanation of the rise in gross expenditure.   It has been estimated, however, that the rise may have been attributable broadly to the following factors: 36 per cent, to an increase in the amount prescribed; 35 per cent, to the changed composition of proprietary and non-proprietary articles ; a decline of 11 per cent, to lower rates of payment to pharmacists ; and an increase of 40 per cent, to other factors (including the increased use of new and expensive drugs) (paras. 42-45).

    (15)     The decline of £24 million in the cost of the dental service over the four years was partly accounted for by £6 million revenue from the charges introduced in 1951 and 1952, but the major part (£18 million) resulted from a fall in gross expenditure. Of this figure, £13 million was the effect of the reductions in rates of payment to the dentists. The principal area of saving was in the cost of dentures which declined substantially.   There is evidence that the decline in work done by the service was not simply due to the introduction of charges; demand was already falling before charges were intro­duced, after the accumulated arrears of needs had been largely dealt with (paras. 46-50).

    (16)     The fall of £13 million in the net cost of the ophthalmic service was partly accounted for by £4 million revenue from charges, but mainly by a decline in gross expenditure of £9 million.  This decline was due almost entirely to a reduction in the amount of work done, chiefly in the supply of spectacles.    From the evidence examined it would seem that some decline would have taken place even if charges had not been introduced (paras. 51-56).

    (17)  A major part of the rise in expenditure by local health authorities (£7 million of the £11 million increase from 1949-50 to 1953-54) was the result of rising prices.    The rise of £4 million in the real volume of goods and services purchased occurred principally in the ambulance, domestic help and home nursing services (paras. 57-58).

    THE CAPITAL COST OF THE NATIONAL HEALTH SERVICE IN ENGLAND AND WALES—1948 TO 1954

    General

    (18)     The amount of capital expenditure by the National Health Service has been relatively small throughout the five years.   This expenditure has two components, expenditure on building up stocks which has fluctuated between £4 million and minus £2 million in different years, and a fairly steady rate of about £12 million a year of capital expenditure on fixed assets (paras. 59-60).

    (19)     As prices of building work and other capital assets have risen substantially over the period, the rate of capital expenditure in real terms has progressively declined.   As a proportion of national fixed capital formation, the fixed asset expenditure of the Health Service has been small and declining (from 0-8 per cent, to 0.5 per cent, in the five year period) (paras. 60-61).

    Hospital capital investment

    (20)  Fixed capital expenditure is almost wholly attributable to hospital work.   About 10 per cent, of expenditure has been for major extensions to hospitals and a further 21 per cent, of expenditure has been for ward accom­modation.  Expenditure on accommodation for staff has accounted for 19 per cent of the total.

    (21)  The rate of fixed capital expenditure on hospitals has averaged about one third of the pre-war rate in real terms.   Approximately 45 per cent of all hospitals were originally erected before 1891; and many are regarded by expert opinion as seriously in need of replacement or radical reconstruction (paras. 62-69).

    FUTURE TRENDS IN THE COST OF THE NATIONAL HEALTH SERVICE

    (22)     We cannot attempt to forecast how the cost of the National Health Service is likely to vary in, say, the next twenty years; we can only point the way to some of the factors which will have a bearing on the future cost— e.g., the rate at which the country may be able to make good the existing deficiencies in the Service; the rate at which the hospital capital investment programme can be expanded; fluctuations in the level of wages and prices; changes in medical techniques and in the incidence of disease and accidents : possible variations in the rates of charges paid by patients ; the effect of population changes and other social factors on the use made of the Service, etc. (paras. 76-78).

    (23)     From an analysis of the hospital population on the census night, 1951, the authors of ” The Cost of the National Health Service in England and Wales” have considered in particular the effect of demographic and other social factors on the demand for hospital care, and the effect of projected population changes on the future cost of the Service (paras. 79-89).   Their main conclusions are summarised below: —

    (a) Compared with the demands made by single men and women (and, to a lesser extent, the widowed) the proportion of married men and women in hospital even at age 65 and over is extremely small.

    (b) Among married men and women, the rise in the proportion in hospital with advancing age is not at all dramatic; it does not reach very high levels even after age 75. only 1.5% of married males aged 75 years and over were in National Health Service hospitals, while the corresponding figure for married females was not more than 2.4 per cent.

    (c)  For all types of hospital and in relation to their numbers in the total adult population, the single, widowed and divorced make about double the demand on hospital accommodation compared with married people.

    (d) About two-thirds of all the hospital beds in the country occupied by those aged over 65 are taken by the single, widowed and divorced.

    (e)  The bulk of the population of mental and “chronic” hospitals are single people. Of the single and widowed men and women aged over 65 needing hospital care, most are to be found in these two types of hospital. The married state and its continuance thus appear to be a powerful safeguard against admission to hospitals in general and to mental and “chronic” hospitals in particular.

    (f) An analysis of the Government Actuary’s estimates of the population of Great Britain in 1979 shows that among those who make much the heaviest claims on hospital accommodation, the number of single women of pensionable ages will actually decline, while the number of single men of such ages will increase by only a negligible figure.

    (g) An attempt is made to estimate the order of magnitude of additional future costs to the Service arising solely as a result of projected population change taken as an independent, isolated factor. Changes in age structure by themselves are calculated, on a number of drastically simplified assumptions, to increase the present current cost of the National Health Service by 3 1/2 per cent, between 1951-52 and 1971-72. A further increase of 4 1/2 per cent, is attributable to the projected rise in the total population of England and Wales (using the official projection figures). In total, therefore, popula­tion changes by themselves are not likely to exert a very appreciable effect on the future cost of the National Health Service.

    PART II

    THE GENERAL STRUCTURE OF THE NATIONAL HEALTH SERVICE

    93.  Our remaining terms of reference are ” to suggest means, whether by modifications in organisation or otherwise, of ensuring the most effective control and efficient use of such Exchequer funds as may be made available; to advise how, in view of the burdens on the Exchequer, a rising charge upon it can be avoided while providing for the maintenance of an adequate Service; and to make recommendations.”

    An “Adequate Service”

    94.  Before we can deal with the many questions implied in these terms of reference, we must consider at the outset what is meant by the provision of an “adequate service “. If the test of “adequacy” were that the Service should be able to meet every demand which is justifiable on medical grounds, then the Service  is clearly inadequate now, and very considerable additional expenditure (both capital and current) would be required to make it so. We need only mention the deficiencies which would have to be made good in the provision of mental hospitals, mental deficiency institutions, services for the chronic sick, hospital out-patient departments, domiciliary health services, the dental services, etc. To make the Service fully “adequate” in these terms, a greatly increased share of the nation’s human and material resources would have to be diverted to it from other uses.

    1. Nor is it clear that such a service, even if it were to become “adequate” by this criterion, would remain so without continually increasing expenditure.    The growth of medical knowledge adds continually to the number and expense of treatments and, by prolonging life, also increases the incidence of slow-killing diseases.  No one can predict whether the speeding of therapy and the improvement of health will ultimately offset this expense; there is at present no evidence that it will; indeed, current trends seem to be all the other way.  There is every reason to hope that the development of the National Health Service will increase the years of healthy life per head of the population, but there is no reason at present to suppose that demands on the Service as a whole will be reduced thereby so as to stabilise (still less to reduce) its total cost in terms of finance and the absorption of real resources.

    2. It should not be forgotten, however, that the National Health Service is a wealth producing as well as a health producing Service. In so far as it improves the health and efficiency of the working population, money spent   on the National Health Service may properly be regarded as “productive”—even in the narrowly economic sense of the term.

    3. But even if it were possible, which we very much doubt, to attach a specific meaning to the term ” an adequate service ” at a given moment of time, it does not follow that it would remain so for long with merely normal replacement.   There is no stability in the concept itself: what might have been held to be adequate twenty years ago would no longer be so regarded today, while today’s standards will in turn become out of date in the future. The advance of medical knowledge continually places new demands on the Service, and the standards expected by the public also continue to rise.

    4. We conclude that in the absence of an objective and attainable standard of adequacy the aim must be, as in the field of education, to provide the best service possible within the limits of the available resources. It is clear that the amount of national resources, expressed in terms of finance, manpower and materials, which are to be allocated to the National Health Service, must be determined by the Government as a matter of policy, regard being had to the competing claims of other social services and national com­mitments, and to the total amount of resources available. The development of the National Health Service is one among many public tasks in which objectives and standards must be realistically set and adjusted as time goes on both to means and to needs.

    It is still sometimes assumed that the Health Service can and should be self-limiting, in the sense that its own contribution to national health will limit the demands upon it to a volume which can be fully met. This, at least for the present, is an illusion. It is equally illusory to imagine that everything which is desirable for the improvement of the Health Service can be achieved at once.

    Our main task

    99.It appears to us that the fundamental questions inherent in our remaining terms of reference are: —

    (i) In what manner should the money allocated annually to the National Health Service be distributed between the competing needs of each branch of the Service and the various authorities within each branch?

    (ii) What form of organisation will most efficiently and most economi­cally provide and control these services?

    (iii) By what means can the Health Ministers, Parliament and the public be assured that the Service is providing the best value for money spent?

    (iv) Where, if anywhere, is there any opportunity for effecting substantial savings in expenditure, or for attracting new sources of income?

    Distribution of available resources

    100.  As we have already suggested, the total amount of the country’s resources to be allocated annually to the National Health Service is, and must remain, the responsibility of the Government, which must relate the needs of the National Health Service to other competing demands. As it would be impracticable to discuss the distribution of these resources among the various authorities in the National Health Service until it has been decided what form of organisation will use these resources most efficiently and economically, we pass straight on to a review of the administrative organisation itself.

    THE BASIC ORGANISATION OF THE NATIONAL HEALTH SERVICE

    101.  Before examining in detail the services provided under the three branches of the National Health Service, we consider first the basic administrative structure of the Service as a whole and the proposals made to us for radical alterations.

    England and Wales

    1. Very briefly, the present system of organisation in England and Wales is as follows: — At the head of the Service is the Minister of Health, advised by the Central Health Services Council and a number of Standing Advisory Committees. In accordance with the National Health Service Act, 1946, it is the Minister’s duty ” to promote the establishment in England and Wales of a comprehensive health service designed to secure improvement in the physical and mental health of the people of England and Wales and the prevention, diagnosis and treatment of illness, and for that purpose to provide or secure the effective provision of services” in accordance with the provisions of the Act. 103. The services provided under the Act (which are available to everyone in the country and are not dependent on any insurance qualification) may be divided into three main branches: —

    (i) The Hospital, Specialist and Ancillary Services provided through the agency of 14 Regional Hospital Boards, 36 Boards of Governors of teaching hospitals and 388 Hospital Management Committees. The Chairmen and members of Boards of Governors and Regional Boards are appointed by the Minister, and the Chairmen and members of Hospital Management Committees by their Regional Boards. The Chairmen and members of both Hospital Boards and Management Committees give their services in a voluntary capacity.

    (ii) The Family Practitioner Services (ie the general medical service, pharmaceutical service, general dental service, and the supplementary ophthalmic service) administered by 138 Executive Councils. The members of the Councils serve in a voluntary capacity, and are appointed by the Minister, the local authority, and certain local professional committees. The Chairman is elected by the members of the Council. There is one Executive Council for each local health authority area except in the case of 8 Executive Councils each of which covers the areas of two authorities.

    (iii) The Local Health Services (i.e., maternity and child welfare, domi­ciliary midwifery, health visiting, home nursing, domestic help, vaccination and immunisation, prevention of illness, care and after care, ambulance transport, local mental health services, and health centres) provided by 146 local health authorities—i.e., the councils of counties and county boroughs and the Council of the Isles of Scilly.

    These three branches of the Service are described more fully in later sections of the Report where we also outline briefly the public services as they existed before the Appointed Day. For the moment, we are concerned only with the general pattern.

    Finance

    1. The net cost of the local health services (see (iii) above) is met by the local health authorities themselves with the aid of a 50 per cent, grant from the Exchequer.   Most of these services are provided free, but charges may be made for some of them.

    The Exchequer finances in full the remaining services except for certain payments made by patients ; and for some receipts which are appropriated in aid of the Service, the largest being an annual payment from the National Insurance Fund (£36,218,000 in England and Wales in 1953-54), and the superannuation contributions paid by employers and persons engaged in the Service (£23,597,101 in 1953-54).

    Scotland

    1. At the head of the Service in Scotland is the Secretary of State, advised by the Scottish Health Services Council and a number of Standing Advisory Committees.

    2. The hospital specialist and ancillary services (including clinical teaching facilities)  are provided through  the  agency  of 5  Regional  Hospital Boards and 84 Boards of Management.   There are no separate Boards of Governors for the administration of the  teaching hospitals  in  Scotland. Medical Education Committees have, however, been constituted for each of the 5 Regions to advise the Regional Boards on the administration of the hospital and specialist services in their areas in so far as they relate to facilities for teaching and research.   The members of the Committees are appointed in part by the Universities, in part by the Regional Boards and in part by the Secretary of State.

    3. The family practitioner services are administered through 25 Executive Councils, and the local health services by 55 local health authorities (i.e., the 31 county councils, (including 2 joint councils) and the town councils of the 24 large burghs). Because of the relatively large number of local health authorities in Scotland, responsibility for the provision of the ambulance services and health centres rests with the Secretary of State and not with the local health authorities. The ambulance service is provided through the agency of the Scottish Ambulance Service in association with the hospital and specialist services.

    4. The finance of the Service in Scotland is organised essentially on the same basis as in England and Wales.

    POINTS RAISED IN EVIDENCE

    Proposals for Basic Reorganisation

    109. In reviewing the basic structure of the Service and proposals for its modification, we have been very conscious of the fact that the National Health Service has been operating for only seven years, and that, in the early years, many of the newly constituted authorities could not reasonably be expected to do more than cope with the flood of day-to-day problems which came before them.    The evidence we have had suggests that, only in the last two or three years, have many authorities begun to consider seriously their long-term problems, to make plans for meeting them, to improve co-operation between the various branches of the Service, to effect economies, and to make the best use of the existing administrative machinery. The real test of the present organisation therefore lies not so much in the experience of the last seven years as in the results likely to be achieved in the next seven years.   If fundamental changes were now to be made in the administrative structure, new authorities would find themselves faced with new problems and the whole process of adjustment and adaptation would have to be gone through all over again.

    110. Moreover, despite certain weaknesses to which we shall refer later, our evidence has made it clear that the Service’s record since the Appointed Day has been one of real and constructive achievement.   As we have shown in Part I of our Report, the rise in the cost of the Service between 1948 and 1954, when expressed in real terms (i.e., at constant prices), was quite small; while many of the services provided were substantially expanded during this period.

    111. We believe therefore that unless an overwhelming case could  be made out for any basic reorganisation of the Service, it would be in the best interests of the Service to leave the present administrative  structure undisturbed.   We might add that this view was shared by the great majority of authorities and organisations who submitted evidence to the Committee.

    1. With these considerations in mind, we have examined the following proposals for radical reorganisation of the Health Service: —
    1. That there should be one statutory authority responsible locally for the administration of all the branches of the National Health Service.
    2. That responsibility for the hospital service should be transferred either immediately or by stages to the local health authorities.
    3.  That the work of Executive Councils should be transferred to the local health authorities or Regional Hospital Boards.
    4. That the National Health Service functions exercised by the Central Departments should be transferred to a National Board or Corporation.

    Proposed unification of the Health Services

    113.  Many   people,   both  before and   after   the   Appointed   Day,   have criticised the tripartite structure of the National Health Service because of

    1. the difficulty of integrating the services provided by the three branches of the National Health Service, particularly in relation to the maternity and child welfare, tuberculosis, mental and aged sick services;
    2.  the danger of duplication  and overlapping between  the three branches of the Service ;
    3.  the difficulty of adjusting priorities within the Health Service, when three separate administrative organisations—two financed wholly by the Exchequer and the third partly by the Exchequer and partly by the local rates—are responsible for the provision of the services;
    4. the danger that the Service may develop into a National Hospital Service, with all the emphasis on curative medicine, instead of a National Health Service in which prevention will play as important a part as cure.
    1. In order to solve these major problems of the Service, some have recommended the appointment of statutory ad hoc health authorities, on the lines of the present Regional Hospital Boards, with their members appointed by the Health Ministers (We use the term “Health Ministers” throughout the Report to signify the Minister of Health and the Secretary of State for Scotland) and their expenditure financed wholly by the Exchequer.   We have been told that these all-purpose authorities would be in a position to ensure that the hospital, family practitioner, and home health services(We use the term ” home health services” to denote the domiciliary health services (including maternity and child welfare clinics) provided by local health authorities under the National Health Service Acts)  are properly integrated, and that the health services generally are organised and financed in the most efficient and economical way possible. They would, for example, be able to balance the needs of the institutional and domiciliary services without being influenced by such financial considerations as the probable burden on the local rates.

    2. Even apart from practical considerations such as the question of the composition of such all-purpose authorities, we consider this suggestion unacceptable because it would remove from the local health authorities their important domiciliary health services and would create a division between different types of public health work at least as unfortunate as the present divisions within the National Health Service.  It would, moreover, drive a wedge between the home  health  services  now  provided  by  local  health authorities under Part III of the National Health Service Act and the welfare services provided by local authorities under Part III of the National Assistance Act—a division which would, in our view, be calamitous.   The aim in future should be to combine the local authority health and welfare functions as closely as possible, and we could not give our support to any recom­mendation which would seek to tear them apart.

    3. For these reasons, we conclude that the only form of major reorganisation which calls for serious discussion is one which would integrate the three branches of the National Health Service without depriving the local authorities of their existing domiciliary health functions—i.e., a reorganisation which would add responsibility for the hospital service and/or the Executive Council services to the present duties of the local health authorities.

    Proposed transfer of the Hospital Service to the Local Health Authorities

    1. The witnesses who have argued the case for the transfer of the hospital service to the local health authorities have contended that there is a fundamental  weakness in its present administrative  structure ;  namely, that the Regional Hospital Boards and the Hospital Management Committees (Boards of Management in Scotland) who are responsible for managing the hospital service are not responsible for finding the money to finance it, and have no direct responsibility to the electorate for their actions.   It is suggested, there­fore, that the hospital service should take its proper place with other local health, welfare, and social services under the unified administration of the local authorities whose members are democratically elected by the public, and who can be relied upon to provide an efficient and economical service.   This would be in line with the history of the development of the health services in this country, and also in keeping with our tradition of democratic government.

    2. These witnesses go on to point out that the present division between the hospital service and the services provided by local health authorities under Part III of the National Health Service Act has had other unfortunate repercussions, e.g.: —

    (a)  Too great an emphasis has been placed on the curative aspects of the Health Service and too little on prevention. The clinicians in the hospital service are said to be taking less and less interest in the social and preventive aspects of ill-health and to be increasingly concerned only with the treatment and cure of disease.

    (b)  It is obviously in the interests of economy and efficiency that, wherever possible, patients should be treated in their own homes by their general practitioners (with the support of the local health authority services) in preference to their being admitted to hospital where the maintenance costs are so high. As the hospital service and the local health authority services are provided through two separate organisa­tions, however, and as the first is financed wholly and the latter only 50 per cent, by the Exchequer, there is no financial stimulus to ensure that developments are carried out where they are most needed, i.e., in the domiciliary services of the local health authorities. Some authorities may be reluctant to develop their home health services and thereby to increase the local rate burden when the avowed intention is to ease the load on the hospital service which is 100 per cent. Exchequer financed. The present administrative structure and its method of finance may therefore be distorting the proper priorities in the development of the National Health Service as a whole.

    (c)  It is difficult to  provide  an  integrated  service for  patients when responsibility for its provision is divided. In the case of the maternity services, for example, the hospital authorities are responsible for institutional confinements and consultant services; the local health authorities for domiciliary and clinic services; and the Executive Councils for the family practitioner service. In the case of the tuberculosis services, the hospital authorities are con­cerned with the curative aspects and the local health authorities with prevention. In the services for the aged sick the responsibility is shared between hospital authorities, local health authorities, wel­fare authorities, and Executive Councils. In the services for the mentally ill and mentally deficient there is division of responsibility again between the institutional and domiliciary services.

    1. All these services it is argued, could be organised more efficiently and to the benefit of the patient, if one authority were responsible for their provision. Moreover, it would then be possible to build up the preventive services to a level which would attract sufficient professional officers of the highest calibre; and to give hospital doctors a better understanding of the socio-medical aspects of ill-health.

    2. Again, if the hospitals were transferred to the local authorities, the services of the local authority Treasurer, Engineer, Architect, Legal Adviser etc. would be available to the hospital service as to any other local authority service, with a consequent saving in salaries and staff now duplicated at Hospital Management Committee level.

    3. The witnesses who made this proposal appreciated that the finance of a local authority hospital service would present a serious problem.  The product of a penny rate in England and Wales is £1,417,798 while the annual cost of the hospital service is in the region of £300 million.   Clearly, therefore, the local authorities would not be able to bear this additional financial burden without substantial Exchequer support.  One suggestion put forward in oral evidence to the Committee was that the Exchequer might pay to the local authority a unit grant in respect of each hospital bed maintained by the authority, covering a substantial proportion of the total running costs—say 80 per cent.   The additional expenditure incurred by the local authority over and above the Exchequer contribution would rank for the present 50 per cent.  Exchequer grant.  The poorer authorities would be further helped through the operation of the Exchequer Equalisation Fund.

    4. For the planning of a local authority hospital service, it was suggested to us that Joint Authorities should be appointed regionally to decide how and where the hospital services should be developed in the Regions.    Once a decision had been reached by the Joint Authority (e.g., to construct a new hospital) the local authority of the area in question would be responsible for providing the building ; and the costs, both capital and current, would be shared by all the authorities whose ratepayers made use of the beds. Capital works would of course be financed by loan.

    The contrary view

    1. The great majority of our witnesses, however, while admitting the existence of many of the difficulties mentioned above, have firmly maintained that the time is not ripe for any radical alteration in the structure of the hospital service; that the present problems are mainly “teething troubles ” in the development of a new service; and that they can be solved without transforming the whole structure of the service.  These witnesses have also pointed out that: —
    1. Local   authority   areas   in   general   are   wholly   irrelevant   to   the administrative needs of the hospital service.
    2. The local authority record of hospital management bears out the contention that local authority services are always uneven in standard. The present administrative structure has greatly im­proved and levelled up the general standard of hospital services throughout the country.
    3. Past experience suggests that a system of administration based on Joint Boards and constituent local authorities would be unlikely to work efficiently or smoothly, particularly in planning the develop­ment of a hospital service. In the past, Joint Boards themselves have been labelled “undemocratic”; lacking in financial responsibility; and too far removed from the influence of the rate-payers. They have also been criticised for separating the services entrusted to them from the rest of the main machinery of local government, (iv) In the interests of sound local government, local authorities should retain at least a 50 per cent, stake in the cost of any service pro­vided by them. In the case of the hospital service, this would involve an intolerable burden on the local rates which could not be contemplated at least without some radical reorganisation of local government finance.
    4. The difficulties arising out of the existing tripartite structure of the Service have been greatly exaggerated, and there is no reason to believe that they would be eliminated by handing over adminis­trative responsibility for two or more branches of the Service to the local health authorities.
    5. The professions would not welcome any proposal to transfer the hospital service to the local health authorities (cf. the following extract from Dr. Rowland Hill’s evidence before the Select Committee on Estimates(The Eleventh Report of House of Commons Select Committee on Estimates, H.M.S.O. 1951, page 28.):

    “The relationships between our profession in the past and local authorities in many parts of the country have not always been of the happiest, especially in the hospital world. Local authorities, of course, were very new owners of hospitals, and if it had not been for the war and the National Health Service our relations with local authorities, as the years went by, might have grown happier. It is true to say that the one thing the medical profession dreaded before 1948, and this applies to general prac­tice as well as to hospitals, was the dread that they would find themselves placed under the local authorities. That dread might have been ill-founded and in the passage of some generations might have been shown to be ill-founded, but on that date it is a fact that it was a deep fear.”

    124.  We have also noted that some local health authorities are themselves opposed to the proposed transfer, and that others would prefer to postpone any decision on this question until it is known to what extent local govern­ment is likely to be reformed in the foreseeable future, and how far their finances are likely to be reorganised.

    Our own view

    125.We do not feel that a convincing case has been made out for transferring the hospital service to the local health authorities.    It seems to us that the present tripartite structure of the National Health Service has much deeper roots than the Acts of 1946 and 1947.  It is in the main the outcome of the evolution of medical and social services in this country during the last hundred years; and we do not believe that radical changes in the struc­ture of the National Health Service would be the right way of seeking to solve the undeniable problems which arise from this division of functions. We think that these problems can and will be solved by less drastic measures if the Service is given a period of stability.   Habits of co-operation need time to grow and in so far as they are at present weak, we believe that the cause lies in the newness of the Service, rather than in any organisational weakness.

    1. Moreover, we do not believe that a closer integration of the services would necessarily be achieved simply by unifying the control under one administrative body.   Any administrative system has inherent in it the problem of securing a proper co-ordination of its various parts, and the transfer of statutory responsibility to a single authority will not in itself do much to solve the problem.

    2. As for the practicability of the proposal, we doubt very much whether the local authority machine would be able to carry the additional burden of the hospital service.    A great deal  still remains to, be done by the local authorities in the development of their home health and welfare services, and it seems to us that their energies might be expended more profitably in this direction than in attempting to take on the whole of hospital administration in addition.   Bearing in mind also that some local authorities them­ selves would be reluctant to accept responsibility for the hospital service; that the bulk of the medical profession would be opposed to the suggestion; and that the financial burden would be intolerable unless the Exchequer grant were so substantial that it would render local government responsibility merely illusory, we feel confident that, whatever the merits of the proposal, it is not a practical proposition at the present.

    3. With further reference to the financial burden, we have noted that the cost of the hospital service, if grant-aided to the extent of 50 per cent, by the Exchequer, would represent on average (on present assessments) an additional rate burden of about 8s. in the £ to the local health authorities in England and Wales.   The rate burden could of course be reduced by increasing substantially the rate of Exchequer grant, but we would see no purpose in transferring the service to the local authorities if by far the greater part of the cost were to be borne by the Exchequer.

    4. As we have noted above, it has been suggested by some of our witnesses that the question of responsibility for the hospital service should be reconsidered after local authority areas have been reformed and local authority finance reorganised.    We cannot believe however that any reform of local government in the foreseeable future is likely to go far enough to affect the issues we are now considering.    Some form of regional authority will always be required for the efficient planning of a national hospital service, and if the service were to be managed by the local authorities, Joint Boards (or some similar bodies) would be necessary to carry out this planning function.   The service would then be administered through the Health Departments, (By the “Health Departments” we mean the Ministry of Health and the Department of Health for Scotland.)  Joint Boards, local authorities,   and presumably hospital managing committees.   This administrative structure would not be calculated to improve the co-ordination of the service either at the national level or at the officer level “on the ground” ; and would simply create new problems in the relationship between Joint Boards and local authorities.

    Transfer of certain classes of Hospital to Local Health Authorities

    1. Perhaps we should mention at this point the suggestion made by some of our witnesses that all maternity, tuberculosis, chronic sick, and infectious diseases hospitals, and all mental deficiency institutions should be transferred at once to the local health authorities.  This suggestion was usually put forward as an interim measure pending the transfer of the whole hospital service to the local health authorities, but there were some who recommended its adoption, whatever the future administrative organisation might be, because it was felt that the unification of these services was neces­sary in the interests of efficiency and economy and also in the interests of the patient.

    2. Whilst appreciating the need for the closest possible link between the domiciliary and institutional aspects of the maternity, tuberculosis, chronic sick and the other services mentioned above, we do not favour the proposal to transfer the hospitals concerned to the local health authorities as it seems to us that the hospital service would hopelessly disrupted if responsibility for its provision were divided between Regional Hospital Boards and local health authorities.

    Proposed transfer of the work of Executive Councils to Local Health Authorities or to Regional Hospital Boards

    Transfer to Local Health Authorities

    132.    Our attention has been drawn to the Report of the Royal Commission on National Health Insurance (Cmd. 2596 ) published in 1926, which recommended that ” Insurance Committees should be abolished and that their work, very much in its present form, pending any remodelling and unification of the Health Services should  be handed  over  to  committees  of  the  appropriate  local authorities with possibly a co-opted element.” The Commission advanced two reasons for this recommendation : —

    (i) ” Unification of local effort on health services is a consideration that should, in our view, be paramount whatever the success of isolated pieces of machinery that now exist.

    (ii) The evidence we have heard convinced us that whatever may have been the position at the outset and whatever the aims of the framers of the Act, in real fact these committees have not now sufficiently extensive or sufficiently improved duties to justify their existence as independent administrative bodies. . . .   The duties are now of a routine character and could equally well be performed by the same officials working under the control of the local authority.”

    After reviewing the functions of Insurance Committees generally, the Royal Commission concluded that the most important duty of the Committees was to enquire into complaints arising from the  provision of medical benefit (including the supply of drugs) ; but the Commission saw no reason why such enquiries could not be made equally well by a Medical Services Sub- Committee appointed by the local authority.

    1. Some of our witnesses have maintained that this recommendation of the Royal Commission is as valid today as it was in 1926 in that the Executive Councils, which have succeeded the Insurance Committees, are still largely concerned with work of a routine nature which could equally well be carried out by the local health authorities; while the need still remains to integrate more closely the health work of the local authorities and the family practi­tioner services.

    2. These  witnesses  have  usually  agreed,  however,  that  some  special provision would have to be made to deal with the complaints brought against doctors, dentists, chemists and opticians, as it might be considered undesirable to have these professional matters debated by the local authorities themselves.    One of the suggestions put forward for meeting this difficulty was that these disciplinary cases should be decided by the appropriate Services Committee with a right of appeal direct to the Minister.

    3. The great majority of our witnesses, however, have maintained that the Executive Councils are now playing a much more important role in the National Health Service than the Insurance Committees ever did in the National Insurance scheme.    The Executive Councils have to deal with a  wider range of functions and with a greatly increased public demand for the family practitioner services. Their statutory duties may appear to be somewhat restricted, but the Councils are suitably placed to take a wide view of the medical services as a whole, and have served as a useful mouthpiece for general practitioners who have been able to feel that they retain a measure of self-government in the Service.

    136.  It is clear too that the great majority of the medical profession would be strongly opposed to any suggestion involving the transfer of administrative responsibility for the family practitioner services to the local health authorities.

    Transfer to the Regional Hospital Boards

    1. An alternative suggestion we have heard for integrating at least two of the branches of the National Health Service is that the work of Executive Councils should be transferred to the Regional Hospital Boards.   We have been told that one of the most unfortunate results of the National Health Service has been the widening of the gulf between the hospital and the general practitioner, and that the gulf might be bridged by making the Regional Boards responsible for the administration of the family practitioner services. The needs of general practice would then be fully considered regionally in the planning of the hospital and specialist services.

    2. Here  again,   however,  the great majority   of  our   witnesses  have opposed this suggestion mainly on the grounds that: —

    (a) The Regional Board areas are quite inappropriate for the efficient administration of the family practitioner services, which operate within relatively small geographical areas ;

    (b) The Boards themselves, being primarily planning and policy-making bodies, are not suitable for taking over the detailed work now carried out by Executive Councils ;

    (c) The general practitioners would not welcome Regional Board control any more than local authority control.

    Our own view

    1. We agree with the great volume of our evidence which has borne witness to the fact that the existing Executive Council machinery has worked well at reasonably low cost, is fully acceptable to the professions, and should be left broadly intact at this stage.  We agree that there is need for the closest possible co-operation between the family practitioner, local health authority and hospital services, in the interests of patients, the profession, and the Exchequer; but we do not believe that this co-operation would be achieved simply by making either of the organisational changes referred to above. The problem of co-operation has been tackled more effectively in some areas than in others and as we have already said, where integration is lacking the reasons  are  probably  to be found more in the personalities concerned than in any defects of organisation.    Moreover, so long as the general practitioners are paid under a contract for services, we cannot see any major savings being achieved by changes in organisation.

    2. We endorse, therefore, the view of the Cohen Committee on General Practice which says: —

    “The Committee favours the retention of the present method of administering the provision of general medical services through Execu­tive Councils and Local Medical Committees. Five years’ experience has revealed no fundamental defect and testifies that the present administrative structure represents a successful evolution from the system of administration which was used in the National Health Insurance Scheme before 1948.”(Central Health Services Council.—Report of the Committee on General Practice within the National Health Service. (H.M.S.O., 1954), para. 28.)   –

    141.  In later sections of the Report, we deal more fully with the organisation    of    Executive  Councils  (paras.  428-443);  the  vitally    important relationship of the general practitioner to the local health authority and hospital services (paras.  504-508, and 616-619);  the general question of co-operation between the three branches of the National Health Service and with the welfare services provided by local authorities under Part III of the National Assistance Act (see Parts V and VII of the Report); and the future role of preventive medicine in the National Health Service (paras. 615-622).

    The case for a National Board or Corporation

    1. The question was raised by one or two of our witnesses whether a Government Department was an appropriate body to administer a National Health   Service,   and whether  a  National   Board or specially  constituted Corporation would direct the Service (and particularly the hospital service) more efficiently and more economically.

    2. We are satisfied, however, that a Service which costs the Exchequer more than £400 million per year must be accountable, through a responsible Minister, to Parliament.   There is no proper analogy with the nationalised industries which are revenue earning.   We have taken note of the comments expressed on this matter in the White Paper of 1944 on ” A National Health Service “.( Cmd. 6502 (H.M.S.O., 1944), page 13.)

    “The exact relation of this proposed body [i.e., the specially constituted corporation] to its Minister has never been defined, and it is here that the crux lies. If, in matters both of principle and detail, decision normally rested in the last resort with the Minister, the body would in effect be a new department of Government … If, on the other hand, certain decisions were removed from the jurisdiction of the Minister (and consequently from direct Parliamentary control) there would be need to define with the utmost precision what these decisions were. Clearly they could not include major questions of finance. Nor could any local government authorities responsible for local planning or ad­ministration reasonably be asked to submit to being over-ruled by a body not answerable to Parliament.”

    144.  As we see it, the great merit of a National Board, so far as the hospital service is concerned, would be to make possible the interchange of staff between the central body and the authorities at other levels of hospital administration.   Some of the difficulties of the present system of administration arise from the fact that the Health Departments are manned by officers of a different service from that administering hospitals at the regional and group levels.

    We do not believe, however, that this advantage would justify the appoint­ment of a new Board or Corporation whose constitution alone would pose a host of difficult problems. Nor do we believe that the appointment of a National Board would in itself improve the integration of the health services.

    145.  As for the local health services provided under Part III of the Acts of 1946 and 1947, we have already made clear our view that these services should continue to be administered by the local health authorities. Moreover, we agree entirely with the view expressed in the Government White Paper, quoted above. That such authorities could not be made responsible to a National   Board   or   Corporation   for   the   administration   of   their   health services.

    146.  We conclude therefore that the Minister of Health and the Secretary of State for Scotland should continue to remain directly responsible to Parliament for the administration of the Health Service.

    GENERAL CONCLUSIONS ON THE STRUCTURE OF THE NATIONAL HEALTH SERVICE

    1. We believe that the structure of the National Health Service laid down in the Acts of 1946 and 1947 was framed broadly on sound lines, having regard to the historical pattern of the medical and social services of this country. It is very true that it suffers from many defects as a result of the division of functions between different authorities, and that there is a lack of co-ordination between the different parts of the Service. But the framers of the Acts of 1946 and 1947 had not the advantage of a clean slate; they had to take account of the basic realities of the situation as it had evolved.    It is also true that even now, after only seven years of operation, the Service works much better in practice than it looks on paper. That it should be possible to say this is a remarkable tribute to the sense of responsibility and devoted efforts of the vast majority of all those engaged in the Service, and also to their determination to make the system work.

    2. We are strongly of opinion that it would be altogether premature at the present time to propose any fundamental change in the structure of the National Health Service. It is still a very young service and it is only beginning to grapple with the deeper and wider problems which confront it. We repeat what we said earlier—that what is most needed at the present time is the prospect of a period of stability over the next few years, in order that all the various authorities and representative bodies can think and plan ahead with the knowledge that they will be building on firm foundations.

    3. The present National Health Service is both too recent in origin and also bears too much the imprint of the historical circumstances from which it sprang, for any one to be able to do more than make a guess at the lines along which it may be expected to evolve. Those who have spent the greater part of their working lives under quite different conditions—for example consultants serving voluntary hospitals in an honorary capacity;  Medical Officers of Health;  members of local  authorities in charge of municipal
      hospitals—these and many others have not always found it easy to adapt themselves to the new order of things.  Some of the strains and stresses of the National Health Service are attributable to the difficulty experienced by many, who had grown up under the old system, when called upon to operate a service administered on different lines.  Longer experience of the working of the Service and the gradual emergence of a new generation may make comparatively simple many things which now appear difficult or impracticable.

    4. What is essential is the recognition that the hospitals, the general practitioners and the local authorities have each an indispensable task to fulfil in their respective spheres.    They are however each severally only a part of a single National Health Service ; and the efficiency of the Service depends not merely on the quality and quantity of the work that each of these branches performs within its own sphere, but on the degree to which they co-operate with one another to accomplish the ends for which the Service
      as a whole exists.

    151.We conclude therefore that no sufficiently strong case has been made out for transferring either the hospital service or the Executive Council services to the local health authorities, nor for transferring the executive Council services to the Regional Hospital Boards.

    In our view, a more important cleavage than the division of the National Health Service into three parts is that between the hospital service and the services provided by the local authorities under Part III of the National Assistance Act, and” we come back to this point in Part V of our Report when dealing with the services relating to the care of the aged.

    1. Having reached this general conclusion, we now go on to examine in detail the hospital, family practitioner and local health authority services in turn. For each of these services, we shall describe: —
    1. the public services which existed before the inception of the National Health Service;
    2. the services provided under the National Health Service Acts;
    3. the main suggestions made to us in evidence for improving the efficiency and economy of the Service ; and
    4. our considered views on those suggestions.

    While this may seem at first glance to be a rather lengthy form of presen­tation, we feel that it will serve a useful purpose to have this material summarised and placed on record in our Report.

    PART III

    HOSPITAL AND SPECIALIST SERVICES

    Brief History Pre-1948 England and Wales

    153.  Before the introduction of the National Health Service in 1948, there were two distinct systems of public hospital provision in this country—the voluntary hospital and the municipal hospital—each with its own separate origins and  traditions. In fact, on  the  Appointed Day, 1,143  voluntary hospitals with some 90,000 beds were taken over by the National Health Service in England and Wales, and 1,545 municipal hospitals with about 390,000 beds.    Of this latter number some 190,000 beds were occupied by patients in mental and mental deficiency hospitals, and there were nearly 66,000 beds still administered under the Poor Law.    In Scotland 191 volun­tary hospitals with about 27,000 beds were taken over and 226 municipal hospitals with some 37,000 beds.

    Voluntary Hospitals

    154.  The voluntary hospitals varied enormously in size and function, ranging from the well equipped large general hospital (with distinguished specialists and consultants available) to the small cottage hospital served in the main by local general practitioners.    A few of the voluntary hospitals could trace their origin back to mediaeval ecclesiastical foundations, but the great majority had come into existence since the middle of the 18th century.

    Each hospital had its own governing body which usually delegated its management functions to a Chairman, House Governor (or other officers) acting in conjunction with an Executive or House Committee. The medical care of the patient was entrusted to the visiting physicians and surgeons, etc., who jointly comprised the medical staff and acted in an advisory capacity to the governing body. Each governing body had planned its own service for the public as it thought best, subject to the conditions laid down by its constitution. Income was of course derived from voluntary subscriptions, donations or endowments, and payments by patients.

    Municipal Hospitals

    1. The municipal hospital service had developed from a wide variety of sources.    There were the hospitals and institutions administered under the Poor Law, and the general hospitals maintained by local health authorities since 1930 under their public health powers.   These together represented a very wide service, at every stage of development from the chronic sick wards of the Poor Law Institution to the fully equipped hospital with highly skilled staff.   There were, too, the infectious diseases and isolation hospitals, tuberculosis sanatoria, mental hospitals and mental deficiency institutions, many of which were provided through Joint Boards or Joint Committees of the responsible authorities.

    At the beginning of 1948, the authorities responsible for providing the municipal hospitals were generally the councils of counties and county boroughs—with the exception of the infectious diseases hospitals which were normally administered by the councils of county boroughs, boroughs, urban districts and rural districts in accordance with schemes drawn up by the county councils. The services were financed from the local rates with some indirect Exchequer assistance through the operation of the block grant to local authorities under the Local Government Act, 1929.

    The local authority hospitals were administered through the department of the Medical Officer of Health whose representative at each hospital was a medical superintendent directly responsible to him for the whole adminis­tration of the hospital (excluding such matters as finance, building and stores, in which the clerk, steward or engineer of the hospital might be responsible to the local authority’s treasurer, clerk, stores purchasing department, or engineer). During the 1930’s however there was a tendency to give a measure of direct responsibility to the clerk or steward (and to the matron) for then-respective duties, and to give these officers direct access to their opposite numbers at the Town or County Hall.

    Charges

    1. Local authorities were required to charge patients what they could reasonably afford towards the cost of treatment and accommodation provided (except in the infectious diseases hospitals where the authority had a discretion), and the voluntary hospitals usually followed the same practice. Many people made provision for this liability by joining one of the hospital contributory schemes, which undertook to meet the cost of hospital treatment, etc., in return for a weekly subscription. The total membership of these schemes was about seven million without reckoning dependents; and the voluntary hospitals shortly before the war were deriving from them about one half of their total receipts.

    Scotland

    1. In broad outline the development of the hospital services in Scotland was similar to that in England and Wales, but in 1948 the voluntary hospitals in Scotland were providing much the bigger part of the institutional service for the treatment of acute medical and surgical conditions. Only at a fairly late period did the local authorities enter the general hospital field, and at the Appointed Day there were less than a dozen local authority general hospitals, practically all of them in the four cities.  The tradition of the Scottish voluntary hospitals was to afford free treatment. There had been little development of the pay bed system and it was not customary in Scotland to ask the patient in ordinary wards to make a payment towards the cost of his treatment.

    Emergency Hospital Scheme

    158.  This very brief note on the historical background would not be complete without a reference to the war-time Emergency Hospital Scheme which had a considerable  effect on the  development  of the country’s  hospital services.   This Emergency Service was responsible for adding in England, Wales, and Scotland about 65,000 hospital beds, by the erection of new and the extension of existing buildings; also for upgrading many of the surgical and other facilities at hospitals ; developing specialised treatment centres; and providing recovery and convalescent homes.   Here was the beginning of an organisation which sought to plan the hospital service as an integrated whole and to transform the patchwork of individual hospitals into a coherent regional scheme.

    A National Hospital Service.

    1. The experience of the Emergency Hospital Service, the results of a survey of the hospitals of the country carried out with the help of the Nuffield Trust, and the influence of the Beveridge Report of 1942, all combined to demonstrate the need and inspire the preparation of plans for the reorganisation of the nation’s hospital service.  These plans were brought to fruition in the Acts of 1946 and 1947 which transferred most of the hospitals in the country and their staffs, to the Minister of Health and the Secretary of State for Scotland.   Less than 300 hospitals, mostly quite small, were dis­claimed and remained under private management.

    Hospital Services provided under the National Health Service in England and Wales

    1. The National Health Service Act of 1946 charges the Minister with the duty of providing, throughout England and Wales, hospital and specialist services “to such extent as he considers necessary to meet all reasonable requirements “.

    Under the service, in-patient and put-patient treatment of all kinds is provided, together with consultant advice in the patient’s home where necessary. The hospital accommodation provided by the service includes general and special hospitals; maternity accommodation; sanatoria; infectious diseases units ; chronic sick hospitals; mental hospitals and mental deficiency institutions; out-patient clinics ; and convalescent homes.

    1. All hospital property, whether land and buildings or equipment, is vested in and belongs to the Minister.   There are in all some 3,200 hospitals (with about 477,000 available beds) and clinics, etc., in the service and a staff of over 320,000 employed whole-time and 70,000 part-time.    Further services are provided by contractual arrangement with a number of institutions which remain privately owned.

    2. In addition to the provision of drugs when prescribed, various kinds of appliances (e.g., surgical boots, artificial limbs and wheeled chairs) are provided for patients through the hospital service where necessary.

    3. Normally patients are referred for hospital treatment by their family doctors, and they may use the hospital service whether they are being treated by their family doctors privately or under the National Health Ser­vice.    If they are too ill to visit hospital (either by public transport or by ambulance) the family doctor can arrange for a consultant to visit the patient at home.

    Where patients use public transport to and from hospital, the travelling expenses may be refunded in cases of hardship, after an assessment of the patient’s means by the National Assistance Board.

    164.  The great majority of patients are accommodated in general wards, but in many hospitals there are a number of “amenity beds” in single rooms or small wards where patients who desire privacy which is not considered necessary on medical grounds may be accommodated for a charge of 6s. or 12s. per day depending on the size of the room.   In all other respects, such patients are treated in the same way as patients in general wards, and no charge is made for treatment or normal maintenance.

    At some hospitals, a number of “pay beds” are also set aside for the use of patients who prefer to make private arrangements to be treated by a con­sultant of their own choice. The patient using one of these beds is required to pay the full cost of maintaining it in addition to the fees of the consultant providing the treatment. In most instances there is a maximum limit to the fees that a consultant may charge to patients occupying pay beds.

    Of the 477,000 beds provided in the service in England and Wales, only about 6,000 are set aside for use as amenity beds and approximately the same number for use as private pay beds. (See also paragraphs 416-424 below).

    Charges

    165.  Apart from the amenity bed and pay bed accommodation already men­tioned, the hospital and specialist services are generally available free of charge to patients under the National Health Service.  Charges may, however, be made   for: —

    1. The supply of appliances of an unduly  expensive  type  or their replacement or repair ; or the replacement or repair of any appliance previously supplied which is damaged owing to carelessness.
    2. The supply or replacement of dentures and glasses to out-patients where the examination or sight testing took place on or after 21st May, 1951.
    3. The supply of drugs and medicines to out-patients on or after the 1st June, 1952; and the supply, repair or replacement of certain appliances to out-patients ordered or prescribed on or after 1st June, 1952.
    4. Private out-patient treatment.
    5. Recoveries under the Road Traffic Acts from car users and insurance companies of payments which they are required to make where hos­pital treatment is required following a road accident.
    6. Certain miscellaneous items.   (See Appendix 4).

    The charges referred to in (b) and (c) above were introduced by the Acts of 1951 and 1952 and were part of the measures designed to keep the net cost of the Health Service within £400 million per year; in the main they were a corollary to the introduction of similar charges for the general practitioner services. Further information about the hospital charges (showing the people who are exempt, and the income yielded by the charges in England and Wales in 1953-54) is given in Appendix 4.

    How the Hospital and Specialist Services are provided in England and Wales Non-Teaching Hospitals

    166.  In the case of the non-teaching hospitals, the services in England and Wales are provided through the agency of 14 Regional Hospital Boards and 388 Hospital Management Committees.

    Regional Hospital Boards

    1. Each Regional Hospital Board is responsible for a Hospital Region whose boundaries were designed to ensure that the Board’s services could be linked with a University and its associated medical school or schools. There is one teaching hospital in each of the ten Hospital Regions in the provinces, and 26 teaching hospitals (12 undergraduate and 14 post-graduate) in the areas of the four Metropolitan Hospital Regions. The Regional Boards have no control, financial or other, over the teaching hospitals in their areas, though they have the right to nominate a certain number of members to the Boards of Governors of teaching hospitals. The populations served by the Regional Boards range from 4 1/2 million to 1 1/2 million (approx.). (In Appendix 6 we show the areas of the Hospital Regions in England and Wales and, in Appendix 6A, the estimated population, the number of Hospital Management Committees, the number of hospitals and clinics, and the number of beds in each Region.)

    The Minister is responsible for appointing the Chairman of each Regional Board and such other members as he thinks fit after consulting the asso­ciated University, organisations representative of the medical profession, the local health authorities in the Board’s area, and such other organisations as appear to the Minister to be concerned. (See Part I of the Third Schedule to the 1946 Act). The numbers of members serving on Regional Hospital Boards range from 21 to 31.

    Functions of the Regional Hospital Boards

    168.  Under the general guidance of the Ministry, and in collaboration with the Boards of Governors of teaching hospitals, the Regional Boards are responsible for planning and co-ordinating the development of the hospital and specialist services in their Regions and for generally supervising) the administration of  the   services   (particularly   in   relation   to   expenditure). Because of their planning responsibilities, the Regional Boards are also entrusted with the duty of drawing up and carrying out (with the Minister’s approval) programmes of capital works for all the non-teaching hospitals in their Regions.  They also have responsibility for: —•

    1.  appointing the Chairmen  and members of Hospital Management Committees ;
    2. appointing and paying the senior medical and dental staff at non-teaching hospitals; and, since the end of 1952, approving any increases in Hospital Management Committees’ staffing establish­ments within certain broad categories ;
    3.  allocating the Region’s maintenance moneys to Hospital Management Committees and approving Hospital Management Committees’ estimates of expenditure;
    4. making contractual arrangements with institutions outside the service for the provision of additional beds ; and
    5. running the blood transfusion and mass-radiography services.

    Functions of the Hospital Management Committees

    169.  Under the general guidance of the Regional Hospital Boards, the day-to-day running of the hospitals is entrusted to Hospital Management Committees appointed by the Regional Hospital Boards. At present there are 388 Management Committees, each responsible for the administration of a group of hospitals or a single hospital (usually a large one such as a mental hospital or mental deficiency institution) in accordance with regional schemes approved by the Minister. The Management Committees appoint and pay all the staff employed at their hospitals (except the senior medical and dental staff who, as already indicated, are appointed by the Regional Boards), but in recent years have required the Regional Boards’ approval to increases in establishments within certain broad categories.

    The Chairman of a Hospital Management Committee is appointed by the Regional Hospital Board who also appoint such other members as the Board think fit after consulting with the local health authorities and Executive Councils in the Board’s area, the senior medical and dental staff employed by the hospitals in the Hospital Management Committee Group, and such other organisations as appear to the Board to be concerned (see Part II of the Third Schedule to the 1946 Act). The number of members serving on Management Committees ranges from 9 to 28. It is the practise of most Hospital Management Committees to appoint House Committees for each hospital (or a number of hospitals) within the hospital group.

    Functions of the Boards of Governors

    170.  In the case of the teaching hospitals (i.e., those hospitals which, in addition to providing hospital services for patients, also provide clinical facilities for the undergraduate or post-graduate training of medical and dental students) the hospital and specialist services are provided through the agency of 36 Boards of Governors who are directly responsible to the Minister for the management and control of the teaching hospitals in the country.

    In general, therefore, the Boards of Governors combine the functions of a Regional Board and a Management Committee. They carry out their own capital works and expend their maintenance moneys in accordance with estimates approved by the Ministry, and are responsible for appointing their own staff. In recent years, the Boards have required the Ministry’s prior approval to the appointment of additional staff within certain categories.

    The Minister appoints the Chairman of each Board and such number of other members as he thinks fit. A certain proportion of the members are nominated by the University with which the hospital is associated, by the Regional Hospital Board, and by the medical and dental teaching staff of the hospital; the remainder being appointed by the Minister after con­sultation with such local health authorities and other organisations as appear to the Minister to be concerned (see Part III of the Third Schedule to the 1946 Act). The number of members serving on a Board of Governors, at present varies from 16 to 30.

    Voluntary service of members

    171.  All the members of Boards of Governors, Regional Hospital Boards and Hospital Management Committees give their services in a voluntary capacity and receive payment only for loss of earnings and additional expenses incurred in attending meetings etc., and for their travelling and subsistence expenses.

    The Ministry’s role

    172.  We have been told that, since the introduction of the Service, it has been the Ministry’s aim to allow Boards and Committees a wide measure of autonomy in the administration of hospitals, subject always to the Minister’s overall responsibility to Parliament. The Minister issues memoranda of guidance to Hospital Boards and Management Committees; and officers of the Ministry regularly meet the Chairmen and senior officers of Regional Boards and the senior officers of Boards of Governors for discussions on matters of general interest.

    Other Hospital functions

    173.  Certain functions relating to the hospital service remain outside the financial responsibility of the hospital authorities.    The more important of these are:—•

    (i) Acquisition of land and buildings. The power to acquire land and buildings is reserved to the Minister, though proposals usually originate with the hospital authorities concerned.

    (ii) War Pensioner Hospitals and various related services. The Ministry are responsible for the direct administration of the hospitals which were formerly administered by the Ministry of Pensions; also for the provision of artificial limbs etc., supply and upkeep of invalid tricycles (formerly provided by the Ministry of Pensions on an agency basis for National Health Service patients).

    (iii) Public health laboratory service. This service, which is distinct from the pathological laboratories in hospitals, is provided by the Medical Research Council on an agency basis. It is intended to assist in the diagnosis, control and prevention of infectious disease. Its work includes the bacteriological examination of specimens in laboratories established throughout the country and is carried out in close co-operation with Medical Officers of Health.

    (iv) Area nurse training committees. Under the Nurses Act, 1949, responsibility for nurse training arrangements is now vested in com­mittees answerable to the General Nursing Council. There is one Committee for each regional hospital area with financial responsi­bility for tutorial expenses.

    (v) State Institutions. Broadmoor Institution and the Rampton and Moss Side Hospitals for Mental Defectives with dangerous or violent propensities are administered directly for the Minister by the Board of Control.

    How the Hospital and Specialist Services are provided in Scotland

    174.  There are five Regional Hospital Boards in Scotland serving popula­tions varying from 2,800,000 in the Western Region to 190,000 in the Northern Region; in four of the Regions there is a university medical school, the fifth Region being based for geographical reasons on Inverness.  At the commencement of our hearings the membership of Regional Boards varied from 30 in the Western Region to 17 in the Northern Region, but by April, 1955, when a three-year programme of reduction in the size of the Boards had been carried out, membership varied from 24 in the Western Region to 15 in the Northern, North-Eastern and Eastern Regions.

    There are at present 84 Boards of Management, the number of hospitals under the control of individual Boards ranging from one to seventeen. The Boards administer some 400 separate hospitals and institutions, with about 64,000 available beds and a staff of approximately 45,000 employed whole-time and 9,000 part-time. The members of Boards of Management are appointed by the Regional Hospital Boards in the same way as the members of Hospital Management Committees in England and Wales; Chairmen of Boards of Management are however elected by the members themselves from their own number.

    There are in Scotland no separate Boards of Governors for the teaching hospitals, teaching hospitals being administered by Regional Hospital Boards through Boards of Management in the same way as other hospitals. To advise Regional Hospital Boards on the administration of the hospital and specialist services in their areas, so far as they relate to facilities for teaching and research, the Scottish Act of 1947 provides for the constitution of Medical Education Committees. There are no corresponding bodies in England and Wales. The members of the Committees (who elect their Chairman from among their own membership) are appointed partly by the associated Univer­sity, partly by the Regional Hospital Board and partly by the Secretary of State.

    1. Apart from the significant difference in the Scottish method of adminis­tration of the teaching hospitals the general organisation of the hospital and specialist services is substantially the same in Scotland as in England and Wales. The Regional Hospital Boards in Scotland have, however, a some­what different role from the Regional Hospital Boards in England. They act as agents of the Secretary of State in the provision of hospital and specialist services; they also act as principals in relation to Boards of Management, who are responsible to them generally for the management of the hospitals. Broadly the functions of the Regional Boards may be looked upon as serving two main purposes—the manipulation of resources (hospital facilities, specialists, highly specialised equipment and certain auxiliary ser­vices) that need to be deployed on a regional basis; and the control of expenditure generally.

    There is no separate Public Health Laboratory Service in Scotland, labora­tory services being provided by the Regional Hospital Boards as part of the hospital and specialist services. Blood transfusion services are provided by the Scottish National Blood Transfusion Association, a voluntary body working in association with the Regional Hospital Boards through a series of Regional Committees; practically the whole of the Association’s expendi­ture is met by advances from the Exchequer.

    HOSPITAL STAFFING

    Control of establishments in England and Wales

    1. Preceding paragraphs of the Report have described how responsibility for the appointment of hospital staff in England and Wales is shared between Hospital Boards, Boards of Governors and Hospital Management  Com­mittees.    The staff themselves are not employed directly by the Ministry and are not therefore civil servants. Their rates of pay and terms and conditions of service are settled by negotiation between the Management and Staff Sides of the appropriate Whitley Councils, and hospital authorities may not depart from these agreed rates without the authority of the Minister.    Table. 14 in Part I of our Report shows the growth in the number of staff employed in the hospital service in England and Wales since the Appointed Day.

    2. The expenditure of hospital authorities on salaries and wages accounts for more than 60 per cent, of the total cost of the hospital service.    In the latter part of 1950 therefore the Ministry decided, as one of a number of measures designed to secure economies in the service, to carry out a review of hospital staffs with the object of fixing establishments in four main cate­gories—namely medical and dental, nursing, administrative and clerical, and domestic and catering staff. The review was conducted by small teams of experts who visited hospital authorities and submitted recommendations to the Minister to enable him to determine the appropriate establishments for each authority.

    A very thorough review of administrative and clerical staff has now been completed, and the establishments which have been approved as a result of its recommendations show a reduction of approximately 3 per cent, in the previous establishments, i.e., in relation to the services as they existed when the review was carried out. In addition, a substantial number of staff have been regraded by agreement with the authorities concerned, following the recommendations of the review teams. This does not suggest that there was any large inflation of clerical and administrative staffs at that time. Any increases in the approved establishments now require the prior authority of the Regional Hospital Board in the case of Hospital Management Committees, and by the Ministry in the case of Regional Hospital Boards and Boards of Governors.

    In the case of staffs other than administrative and clerical, it soon became apparent that a detailed review of each hospital staffing arrangement would take a very long time indeed if it were to be carried out only by teams sent out from the central department. It was decided therefore that the task of reviewing the staffs of Hospital Management Committees should be entrusted to Regional Boards) and that direct reviews by central investigating teams should be restricted to the staffs of Regional Boards and Boards of Governors themselves.

    178.  Before making any increase in the establishments of staff (other than administrative  and clerical)  as they  existed  at  5th  December,   1952,  all hospital  authorities  are now required to seek the prior authority of the Ministry (in the case of Regional Boards and Boards of Governors) and of the Regional Boards (in the case of Hospital Management Committees). For the purpose of these controls, the staffs concerned are grouped into four
    broad categories: —

    1. medical and dental staff of the grades of consultant, senior hospital medical officer, senior hospital dental officer, senior registrar and registrar (i.e., the senior medical and dental staff for whose appoint­ment Regional Hospital Boards and Boards of Governors are responsible);
    2. other medical and dental staff (i.e., for whose appointment Hospital Management Committees and Boards of Governors are responsible);
    3. nursing and midwifery staff ;
    4. all other staff (i.e., other professional and technical staff, domestic staff, maintenance staff, etc.).
    1. In December, 1952, hospital authorities were also asked to review their establishments to effect any possible reductions within these categories generally; and to counter-balance any necessary increases in staff by effect­ing reductions elsewhere. In particular, in the case of staff employed in category (d) above, the Ministry suggested that hospital authorities should aim at a reduction of 5 per cent, in the numbers employed by October, 1953, where this could be effected without detriment to the service provided for patients.

    2. One of the results of the staffing controls is that Regional Hospital Boards and Boards of Governors cannot now make any additional consultant appointments without first obtaining the approval of the Ministry.

    Tagged | 11 Comments

    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.  This need for co-operation and integration should affect training for the service as well as the actual service itself.

    Though the public has benefited to a great extent from the service it has often involved considerable inconvenience to patients because of its organisational failures, and the public is often more aware of the benefits obtained by administrators,doctors and other health workers that the benefits obtained by the sick patient.  The bad conditions still often found in doctors surgeries, hospital out-patient departments,  the difficulties met with by patients in need of dental or other emergency treatment and the long waiting lists stand out among other difficulties.

    One of the basic facts to be taken into account when making plans for the future is that every patient must be seen as a whole person in his environment, and that includes his home as well as his work.   Undergraduate as well as postgraduate teaching in the past has been confined to patients in hospital, separate from their environment.  Preventive medicine, the study of minor ailments and industrial diseases have been almost completely ignored.  The isolation of the teaching hospitals from any local community has aggravated this problem.

    At present about 5% of the national income is being spent by the Ministry of Health.  We must convince the people that a larger amount must be spent and we should concentrate our attention on the periphery, that is, the service to the person and the family at home and at work.   Power must be less concentrated at the centre. The people at the periphery must feel that it is their service.  There must be coordination at district, regional and ministerial levels.

    The key to this development lies in enlightened general practitioner activity which must be integrated with all other health and social welfare organisation.   This can only be done by creating a new organisation; a local health authority.  What should this local health authority be based on?  A population of 250,000 is probably the absolute maximum; perhaps the optimum, would be a 100,000 to 150,000 inhabitants.  Many local authorities are thus too large for such an authority.   Similarly local executive councils are not suitable, but it appears that many management committee areas are convenient and in some of these there is already excellent liaison between the hospital service and the general practitioners.

    Eventually only a reform of local government can bring about an ideal solution to this problem. A local health authority of this size would also be an ideal one to administer the health centres which for such an area would, have to comprise one or two comprehensive ones and six to ten smaller ones.  We must educate the profession and the public to understand the need for these health centres without which an integration of the Health Service such as we envisage would be quite impossible.   On the preventive and occupational aspect this size of local health authority would also be convenient.   While we are working for this development to take place much can be done to prepare for it. Local committees can be formed to co-ordinate the work of the different authorities.

    We must examine the scope and structure of such a local health service more closely and consider the personnel it would employ. In doing so we would have to consider the training of this personnel for its special task.

    At present we have, often uncoordinated:-

    1. The General Practitioner and other services under the Executive Council.
    2. The Local M.O.H. and his staff.
    3. The Welfare Authority including the Children’s Officer.
    4. The Hospital Service
    5. The Tuberculosis Service.
    6. The Mental Health Service.
    7. The   Factory Health Service

    The main task of a local health authority would be to co-ordinate all these services.  It would help this task tremendously if many of the health workers in these different branches had part of their training in common, so that they better understood each other’s work.   This applies mainly to the social workers, such as almoners, psychiatric social workers, , welfare officers, children’s officers, health visitors, duly authorised officers, rehabilitation officers and perhaps   also the district school, clinic and factory nurses who could share one year of their course of training as a course in social case work.

    A unified administration could co-ordinate their work and see to the more reasonable distribution of these workers. At present for instance some hospitals are well staffed with almoners who often see every patient admitted or seen in the out-patient department, while in other hospitals there are no almoners. Trained social workers can then concentrate on what is their real function, that is to help, people, who have social and personal difficulties for which they need skilled assistance.   Untrained social workers can both waste time and do damage.  Under this same unified administration should also be the sanitary officers, factory inspectors and home helps.

    The person administering this social service would have to be specially trained, a medical man with a broad training in sociology is required who would work under the all purpose local health authority.

    In this new context the general practitioner’s work will gradually take on a new aspect. It will give him a chance of increasing specialisation for it is now no longer possible for one man to master all aspects of preventive and curative medicine. His contact with the preventive service and the hospitals would be improved and he could concentrate more on the effective scope of his work for which he will have to be specially trained, not only in hospital but also in health centres and in the field.

    To reorientate the training of general practitioners the undergraduate teaching schools should serve as district hospitals, taking a complete cross section of the sick of the local population, both acute and chronic.   It is wrong that the major teaching hospitals are situated in the centre of big cities and select their cases.  Health centres should also be associated with these hospitals so that students can have part of their training in them. If the teaching hospitals are also linked with the local health authority the student would get an insight into the working of the health service in the country.   There will have to be a reorganisation of the pre-clinical and clinical syllabus to provide a more balanced education.   Preventive medicine must become a part of the training and more time should be spent on the problem of the elderly sick.

    If doctors are to spend a good deal of their time on the preventive aspect then it is more essential than ever that they should be working on a salaried basis.  Preventive work takes up much time and cannot be related to a fixed number of patients. Practitioners lists will of course have to be cut down, even 3,500 is far too many. If the number is no more than 2,500 then the general practitioner will also have time to do school medical officers’ work as well as maternity and child welfare work from health centres.

    Even before we have health centres G.Ps. should start forming Group Practices as much as possible.  Specialisation within the group should be encouraged. Full equipment of surgeries should be ensured and pathological and radiological facilities provided for these groups.  Entry into practice will be facilitated by a salaried service and prolonged assistantships should be forbidden.The hospital can play its part in preparing the doctor for this work by making registrars posts a gateway to consultant and general practitioner work, especially if the registrar has the chance of working in a health centre attached to his teaching hospital.  The other way round many a general practitioner who has specialised may wish to enter hospital practice, starting as a. G.P. clinical assistant.  The path to consultant status should be broadened in this way and any great disparity in status between consultant and practitioner diminished.

    The hospital service will continue to need planning on a population basis larger than that of the local health authority already outlined, as there are many specialities which cannot be developed in a restricted locality.  However the hospital should serve the community in close cooperation with all other health and welfare provisions.  Until health, centres are provided and the desired modifications of local authority are made the district hospital with its management committee might serve as the focal point of health workers in the area.   So many problems demand immediate and increasing co-operation that meetings of those concerned are desirable. The hospitals need to discharge patients at the earliest moment.  This necessitates a close association of hospital doctor, practitioner, district nurse and social welfare administration.  This cannot be fruitful unless each understands the problems of the other and personal contact is essential. The team work of the hospital should extend to the district.  The dependence of the local community on its hospital should be reflected in the service of the people to it, for in future we should like to have much more recruitment of nursing and other staff from amongst those who we serve.  Conditions within the nursing profession have improved and they should remain good enough to attract intelligent local girls and any prejudice to local recruitment should be discouraged.  Every opportunity should be taken to interest the local population and practitioners in the hospital.

    Local interest and support for hospitals varies greatly in different localities and an increasing number of bodies of organised supporters known as “The Friends of X Hospital” or by a similar title have now developed. In general short-stay hospitals the members may be ex-patients, their relatives or any local citizen who has become interested in the hospital.  With Friends of Sanatoria, children’s long-stay e.g. orthopaedic hospitals, and particularly mental and mental deficiency hospitals the majority of members are relatives of the patients, as they have the maximum interest in and incentive to improve the particular hospital.

    Formation of these organisations is an indication of local interest and concern in the hospital and it is the development in the public of identification with its local hospital that can be our greatest safeguard when “economies” are directed to the lowering of hospital standards.

    Organisations of hospital friends can learn about the standard of care and the needs of their hospital; and their most useful function is to make known the need to focus attention on it and to stimulate those responsible to meet it.  Additional functions would be the visiting of patients who have no relatives; reading to blind or otherwise incapacitated patients and similar activities. They can also help in recruiting campaigns for nurses and other staff.

    The collection of funds for extra amenities should be a very minor function. The danger of such Organisations is that they may be used by people who are not representative and apparently represent no opinion but their own, and that they will be made an excuse for not providing amenities which the National Health Service should provide.

    On the other hand, if truly representative of the population the hospital serves they can make a valuable recruiting ground for members of Hospital Management Committees and Regional Boards.

    The deficiencies of hospital provision have been accentuated by the lack of any new hospital building since 1938.  If present methods of capital allocation persist this state of affairs will continue. We are patching up slum hospitals and are falling behind most nations in new building. Our conscience has become numbed about the needs of our ill people. The position is especially bad in the case of mental hospitals and mentally deficient institutions.  In tuberculosis also the situation is still serious in many parts of the country.  The waiting period for operations in the case of many women’s disorders and simple surgical procedures like tonsillectomies, operations for hernia or varicose veins is often months, if not years.  Co-ordination between some large and smaller hospitals has increased the service given but this must be extended. Too many vested interests frequently hold up planning and local prejudice perpetuates inefficiency. It is the function of regional boards so to plan existing resources that full use is made of all beds.

    We should study carefully the future of administration within this expanding service.  Undergraduate training has tended to produce a desire for professional freedom but it has neglected the need for co-ordinated activity.  Team work throughout is indispensable and some co-ordination of our efforts must be evolved.  Doctors should take their part in joint consultations with other health workers in all spheres of activity.

    Present methods of administration have taken the hospitals from the political field. Little pressure is exerted in Parliament on their behalf.  Regional Boards as selected are dominated by Chairmen who regard themselves as agents of the Minister. The status of the Minister of Health in relation to other Ministries is very low. When economy is in the air the health service is very vulnerable and it is essential that there should be a method of financing capital works other than from annual central allocation.  We certainly cannot wait for the completion of the national housing and rearmament programme before adding to our hospitals.

    The consultant staffing of our hospitals is still based on the uncoordinated activities of individual small all purpose hospitals which existed before the service.  Too many consultants-spend too much time travelling.  It is not unusual to find one management committee group served by five or six consultants in one specialty and they not having more than thirty beds in the various hospitals. The consequent inefficiency is obvious.  Often even serious emergencies are dealt with by comparatively junior registrars.While a considerable private practice persists and hospitals are staffed on a part-time basis it is often difficult for regional boards to discover the true consultant needs of a locality, for consultants often discourage increased competition.  An effective yardstick for consultant service should be evolved and this will entail further appointments, for few areas of the country can be said to have full provisions yet.  Whole-time appointments should extend throughout our hospitals.

    More highly specialised units should be established in regional hospitals for the increase of these in undergraduate schools has almost prevented the student from getting a correct perspective of medicine.

    The Junior Staffing of many of our hospitals is presenting great difficulty; this is in part due to the claims of the armed forces whose demands we hope will be temporary.   It is due in part to the fact that hospital experience brings no increased reward or status in general practice.  In fact the more post graduate hospital experience an applicant has had the less eligible is he often for an appointment by a local medical committee. This situation will continue until financial competition ceases to exercise such a strong influence and until the practitioners cease to assert an ability to cover the whole realm of preventive and curative medicine.  Another reason for the difficulty of junior staffing in hospitals is the division between teaching and non-teaching hospitals.  The young doctor who wants to specialise finds that he can only do so with any prospects of attaining consultant rank if he remains in his teaching hospital.

    The pre-registration house appointments will give some experience to all young practitioners but such experience should be extended to general practice as soon as conditions permit, for we cannot neglect training and experience in this field in which so many will spend the rest of their professional lives.

    Ambulance provision should be an integral part of hospital administration. The present divorce from its main user leads to wasteful lack of appreciation by all concerned.

    An Occupational Health Service integrated with a preventive and curative one can be seen to be so essential in mining and other heavy industries that it should soon be extended to the whole of industry.   The method of supplying these services from Health Centres will call for experiment and it may be that some centres can operate in factories where these are served by a local community.  Health centres too cannot be provided without a considerable capital outlay and this must be considered with the need for a capital expansion in the hospital service. We cannot hope to equip our nation for the effective increase of output if we allow our health service to remain in a state of poor development which was sufficient a century ago.

    If preventive medicine is to be encouraged practitioners and specialists will need many more convalescent and rest homes than are at present available.  Much organic disease and mental ill-health is resulting from strain both at home and at work.  This could be alleviated by preventive rest breaks.  These should be available for people of all ages. At present it is almost impossible to get adolescents or aged people away.  Teachers in school and university, health visitors, factory nurses and others should be encouraged to refer all who appear to be in need of such a change to their own practitioners for assessment.   Routine medical examination extending throughout life should be the aim when there are sufficient doctors and premises to supply it.  Health education also needs more imaginative handling than it receives at present.  A special study of it could be introduced into the medical curriculum. At the moment too much of it is left to ill considered articles in the press and too little has official and scientific backing.  The application of science to medicine and an increasing social awareness amongst its practitioners are resulting in revolutionary changes in treatment. Similarly great changes could be brought about in prevention. An efficient organisation of the health service can ensure our population reaping ever increasing benefits at the same time the health worker will have a more satisfying life freed from many daily frustrations.

    Tagged | Comments Off on The Future Of The Health Services

    On April 1st 2013 Local Authorities had returned to them after 39 years the responsibilities for Public Health.  This gives them an opportunity to take up the proposals of the Marmot Review.

    This, we believe in Local Government terms, to have been one of the few beneficial developments within the Health and Social Care Act 2011. This will enable Local Authorities to co-ordinate the wider responsibilities that they have to the community and will also benefit in tackling the serious health inequalities that exist in many communities. This is both in areas that you expect from the statistics in the North, Midlands and London but also in areas of the wealthy South East.

    In my own area of Aldershot, part of Rushmoor Borough Council which also covers affluent  Farnborough, there are three areas which are in the top 20% of deprivation  in the UK. This includes the ward I represent and have done for 37 years.

    Whilst the responsibility for public health has returned to local government the additional moneys have not fully – as you would expect from this Government. Local authorities have been squeezed alarmingly in settlement terms since 2009/10 where the level has been reduced overall by about now cumulatively 33 1/3 %, through the Communities and Local Government Dept. (CLG). However CLG  has given us more responsibility.

    The challenge is great, as it would be in any case, but in a time of austerity when poverty levels are increasing, benefits are being cut and food banks are now proliferating with ever increasing additions everywhere, including both towns in my Borough, the effect of that nations health also increases causing widespread effects on the community as a whole and in poorer challenged areas in particular. Investment in preventive diseases which save moneys lags.

    Into the mix we have the results some three years ago of the Marmot Review into Health Inequalities in the UK which followed on from the World Health Organisation Report by Sir Michael Marmot’s Team and pre-empts the work he’s currently doing for the EU.

    The Marmot Report of all the evidence, by the world’s leading expert in this field, showed the social gradient of deprivation was worsening for many but ironically the life expectation was rising. However the correlation between richer areas and poorer ones would suggest that the disparity was markedly also increasing as well.

    The report Fair Society, Healthy Lives recommended action to tackle social inequalities so as to reduce health inequalities, based on the  “social determinants” approach to preventing ill health. Health is closely linked to socio –economic status.

    The Marmot Team monitors the position in about 150 local authorities through its range of indicators which are:

    • Life expectancy at birth
    • Children reaching a good level of development at age five
    • Young people people not in employment, education or training (NEET)
    • Percentage of people in households receiving means tested benefits

    This is added to by the index of social inequalities for each local authority.

    Most will be familiar with the Health Observatory Reports which cover each local authority that for some local authorities are very challenging as to their results..

    The Marmot Team also calculate what health inequalities cost the taxpayer in England:

    • Productivity losses of £31-33 billion every year
    • Lost taxes and higher welfare payments in the range of £20-32 billion per year
    • Additional health care costs well in excess of £5.5 billion per year.

    Overall these figures, from 2012, could range between about £57 billion to £71 billion.

    Now we have austerity.  In a report completed recently for BHA for Equality and Social Care their conclusions were petty stark.

    For example on patient health there was the possibilities for deteriorating mental health due to work situation (stress), extra work loads, no work, struggling to make ends meet, benefits cuts, continual review cycles of appeals, depression and self medicating by drugs and alcohol.

    Some 25% and rising of all activity areas within Clinical Commissioning Groups (CCGs) are due to mental health support needs by resources. Many do not associate the mental health issues of serving soldiers with this area, domestic violence in general and wider support needs but they are essential areas for consideration.

    With regard to practice impacts there will be a changing workload, access by patient’s effects and staff morale.

    In secondary and support services patient transport has already been affected by cutbacks, delays in discharge letters can result in significant potential serious prescription errors and workers are now struggling to do any structured addiction work.

    There was also more pressure on rehabilitation services, occupational therapy and similar areas.

    In the key area of social work and housing in many areas discharges from hospitals were resulting in bed blocking, respite care was being marginalised, vulnerable adults and children were being further marginalised despite serious concerns over their safety within increasing reliance on the voluntary sector.

    So in all these pressured environments there has to be  a radical review of the balance between the Acute and Preventative Care Sectors. If between the CCGs and Local Authorities within their new remit there is a need to tackle some of the increasing key issues of say obesity, diabetes, sexual health issues, mental health and so on, then with money being tight there will have to be priorities.

    However its the immediate issues which need to be tackled – the health reaction to the effect of austerity superimposed on the existing levels of health inequalities or else there will be a marked decline in the nation’s health.

    In conclusion there needs to be an immediate robust response to the austerity issues which are now increasing prevalent.

    • There needs to be an indication of the economic outlook and the effects, as Marmot work indicates, on the wider determinants of education, jobs and skills,
    • There is the need for a robust discussion on the work which needs to be done on the key health issues of our time as indicated and, therefore, the balance between acute and preventative expenditure
    • The wider determinant’s that effect the health of the individuals and their communities such as planning and transport need to be factored into the decisions of all stakeholders’ particularly local authorities.
    • There must be an immediacy over the effects of Government Policy in its reaction to austerity and the effects on people in general, communities and those challenged especially through an impact analysis

     Sources

    (1)   UCL Institute of Health Inequality background briefing

    (2)   Tackling Health inequalities – Healthier Scotland the Journal SHA Scotland

    (3)   Marmot Report 2010

    (4)   RTPI Planning and Health Inequalities

    (5)   TCPA Planning and Health Inequalities

    (6)   BHA Report

    Mike Roberts

    Tagged | 1 Comment

    Councillors in England  have two formal routes to influence the NHS – the Scrutiny Committees and the Health and Wellbeing Board.  We need more discussion about good and bad practice in the running of these committees, which clearly varies widely.  There should be a Joint Strategic Needs Assessment and a Health& Well being Strategy which have been publicly discussed for each area.

    Public Health

    It’s very easy to get sucked into defending individual NHS institutions, but we think it’s more important in the long term to focus on health inequalities.  Local Councils can do a lot more to address inequality than NHS services can.  Even in prosperous Kensington and Chelsea life expectancy in the poor part of the borough is 12 years less than in the poshest ward.  From April 2013 local councils take over public health.  We hope to organise some events to share experience in this area, as its still a bit unclear how it will work.  Most councils claim that they are not getting enough funding to continue existing public health measures

    Sir Michael Marmot’s review of Health inequality made 6 specific recommendations:

    • Give every child the best start in life
    • Enable all children, young people and adults to maximise their capabilities and have control over their lives
    • Create fair employment and good work for all
    • Ensure healthy standard of living for all
    • Create and develop healthy and sustainable places and communities
    • Strengthen the role and impact of ill health prevention

    In the White Paper Healthy Lives, Healthy People the Government accepted five of these.  The idea of ensuring a healthy standard of living for all seemed to cause them a problem – and it may not be within the power of local authorities to deliver either – but it is clearly the most important.

    We think Councillors can helpfully address some of these issues, and in particular should demand information about inequalities at ward level, and at super output area level to expose differences in life expectancies, infant mortalities, obesity rates etc., and what strategy there is to address them. Stories about differences in small areas can be very dramatic and generate a lot of media interest.  We can also compare these things between districts.  Councillors should focus questions on (a) the effectiveness of local policies that have a beneficial impact on the determinants of health (so, education, housing and employment – particularly employment) as this potentially provides a platform to (i) oppose central Govt. austerity whilst also (ii) offering a challenge to Councils that would prefer to focus solely on the local NHS, and (b) the integration of social care and health services in the face of austerity – this might help shift focus from the social care to NHS cost-shift, to honesty about the consequences of reduced social care spending.

    Goal-directed community development – strengthening community groups and establishing cross-sector partnerships can be very effective in addressing inequalities.  Is that included in local strategies? Do staff of health agencies participate in those partnerships and can they engage directly with residents and community groups to solve mutual problems?  The condition of the local community sector (not just the community as individual residents) should be in the JSNA?

    We need to be much more aggressive in challenging poor eating, drinking lifestyles and the manufacturers and retailers who are making profits out of selling unhealthy products – tobacco, fast foods, coca-cola and fizzy drinks, confectionary, alcohol and crisp manufacturers. This should include all public services and commercial organisations who supply them such as the conference trade who could all be persuaded to adopt healthier policies.

    Social Care

    Local Authorities still have responsibility for social care, and this stretches into many areas of healthcare including substance misuse, childraising practices, mental health, as well as care in the community.  Starving social care of resources leads to more NHS expenditure.  We should be looking much more at joint funding, but also making it clear that cuts in social care are the direct responsibility of central government.  We could encourage joint local authority/nhs community ventures which actually involve local people.

    Care staff are paid too little, are often untrained, unsupervised and sometimes allowed to remain in the job despite offences to patients. Health & Wellbeing Boards need to take responsibility to ensure quality Health & Social Care and  to remedy shortfalls in staffing, inadequate quality and patient satisfaction.  Social Care is undervalued and therefore achieving less than it could.

    Health services for people in residential and nursing care are particularly problematic.  This is not just about good, prompt, proactive GP services, but inputs from physiotherapists, occupational therapists, falls prevention teams, dieticians, and particularly community psychiatric nurses to help manage dementia-related problems.  Some residents may also need specialist nursing services visiting (eg stoma care, tissue viability).  And all these professionals need to work in partnership with home staff to help the latter deliver good quality care. It’s an area that is still, very sadly, completely overlooked and where there’s a lot of blame and buck passing.

    NHS Services

    Monitoring quality of NHS services is difficult because healthcare is a complex business.  There is lots of information available, but making sense of it is difficult.  The performance of one part of the system is affected by other, especially by what goes on in primary care, which is very variable. Councillors need to listen to the experiences of their constituents. The patients view of the system may be very different from the official account.  Local Healthwatch should be helpful in finding out patients’ experience, especially those unable to speak for themselves.

    Some issues we think are worth investigating:

    Clinical Commissioning Groups should be consulting and involving patients and the public in their strategy.  Some are doing it well, some not – ask searching questions about who is consulted and how. It’s not been done well be most of the NHS in the past and councillors may be able to make dramatic improvements.  We should be pushing very hard for transparent decision making processes in a situation where large sums of public money are in the gift of a club of private businesses.

    Commissioning services are the part of the NHS most disrupted by Lansley’s reforms. There are now many players and the relationships between them are not always clear.  The local Clinical Commissioning Groups are accountable, other than for services commissioned by the NHS Commissioning Board, and that is where councillors should direct their attention.  They should deliver Quality control and action on complaints and significant events.  Don’t get too sucked into questions about patient choice.  Sicker patients are not much interested in choice of where they are treated.  They are more interested in how they are treated.

    Ask questions about commissioning, contracting and tendering.  It’s easy to see price but it’s hard to see quality, especially in services for the most disadvantaged people. Tendering in health care disadvantages both smaller local services and public services who don’t have a tendering department. There are already huge issues about transparency in the awarding of contracts to the private sector. Loads of public money goes on consultancy and legal advice with no prior public debate about the desirability of outsourcing or the shape of the tender brief. The advice and contractual discussions are then concealed on the pretext of commercial confidentiality until a preferred bidder emerges – by which time it’s realistically too late to stop the bandwagon. There should be open discussion before the process is embarked upon and full disclosure throughout.  There should be an agreed process where the question of whether a tendering process is appropriate is considered. There should be proper consideration of whether a publicly provided service is likely to be better, or not, and if an existing service is thought not good enough whether it could be improved.

    There is nothing to prevent full transparency being imposed on contractors by contract, even though some of the legislation does not bite on them.  We should be arguing that the price of a contract includes full disclosure of all its terms and monitoring information, once it is awarded.

    Cherrypicking contracts – it’s easier and cheaper to run services for healthier younger patients.  If there is a tendering exercise make sure services for the entire population are considered. Less qualified and experienced staff are cheaper to employ.  Temporary staff, even if well qualified, often give a poorer service because they are in an unfamiliar situation. A well run service with permanent experienced and well trained staff will usually be better value for money.

    The future of hospital provision is always a big political issue, and it’s difficult not to defend your local hospital, but the reality is that many smaller hospitals are trying to deliver services which are beyond their capability. Clinicians know this but don’t tell the local population. Clinical redesign will probably shut large numbers of A&E depts at night. The idea of the District General Hospital which provides all services is no longer defensible. Serious surgery needs to be concentrated on far fewer sites. Most hospitals in future won’t do surgery, especially urgent surgery at night.  Similar arguments apply in paediatrics. Hospital care for children is now rare and also needs to be on far few sites. There are too many acute medical admissions of confused old people for no specific reason, some of whom are clearly at the end of their life. Local GPs will all have stories about  how their plans to care for people at home at the end of their life are frustrated by pointless and expensive hospital admissions. There are decent arguments about travel times, but they don’t apply at night. Even central London isn’t usually congested after 9pm.  Of course different considerations may apply in remote areas.  We may have to think seriously about community hospitals.

    We should be arguing for major hospitals to be properly open 7 days a week with diagnostics, imaging etc, and if all that is open why not outpatients too?

    You may go out on the hospital picket line but don’t promise that the next Labour Government will reopen things that are shut. It won’t.  These changes are driven by clinicians and they will continue whatever government is in power.  But it is perfectly reasonable to ensure that there are adequate facilities within the community before any acute facilities are withdrawn.

    Tagged , , | Comments Off on What can local councillors do to protect patients from government policies on health and social care?

    Legal status of Public Health

    Section 1 of the Health and Social Care Act 2012 reads as follows

    Secretary of State’s duty to promote comprehensive health service

    (1)The Secretary of State must continue the promotion in England of a comprehensive health service designed to secure improvement—

    (a) in the physical and mental health of the people of England, and
    (b) in the prevention, diagnosis and treatment of physical and mental illness.

    (2)For that purpose, the Secretary of State must exercise the functions conferred by this Act so as to secure that services are provided in accordance with this Act.

    (3)The Secretary of State retains ministerial responsibility to Parliament for the provision of the health service in England.

    (4)The services provided as part of the health service in England must be free of charge except in so far as the making and recovery of charges is expressly provided for by or under any enactment, whenever passed.

     Section 11 of the Act (the Secretary of State’s duty as to protection of public health) and section 12 (Duties as to improvement of public health) appear under the subheading “Arrangements for the Provision of Services”

    The following sections of the Act appear under the subheading “Further Provisions Relating to Local Authorities’ Roles in the Health Service”

    29. Other health service functions of local authorities under the 2006 Act

    30. Appointment of directors of public health

    31. Exercise of public health functions of local authorities

    32. Complaints about exercise of public health functions by local authorities

    Section 29 of the Act reads:-

    In section 249 (joint working with the prison service) after subsection (4) insert—

    (4A) For the purposes of this section, each local authority (within the meaning of section 2B) is to be treated as an NHS body.

    Section 64(4) of the Act says

    The NHS” means the comprehensive health service continued under section 1(1) of the National Health Service Act 2006, except the part of it that is provided in pursuance of the public health functions (within the meaning of that Act) of the Secretary of State or local authorities.

    The format of the Health and Social Care Act 2012 is mainly to amend the National Health Service Act 2006. For example the appointment of directors of public health takes place under section 73A of the National Health Service Act 2006, which was inserted into that Act by section 30 of the Health and Social Care Act 2012.

    From this we can infer

    • Public health in Public Health England and in local authorities is part of the health service
    • It is not however part of the NHS
    • However some of the functions transferred to local authorities (Health & Well Being Boards, Healthwatch, custody health, and medical examiners) do appear to be part of the NHS.

    Constitutionally significant points are

    • Local authorities will manage part of the health service for the first time since 1974
    • For the first time ever part of “the health service” is not part of “the NHS”. This is an entirely new distinction.

    The Significance for Local Authorities of Managing Part of the Health Service 

     The following paper was presented to the Leadership Team of Stockport MBC on 17th April 2012

    Public health is part of the health service and will remain so. Not since 1974 have local authorities had health service functions and it is important that we understand the differences between this situation and our other functions.

    Constitutionally the responsibility for most local authority functions lies with the local authority. DCLG’s responsibility is that of a regulator and a mediator of relationships. DCLG is not accountable to Parliament for local government services. Its role in finance is as the custodian of its distribution.

    Responsibility for the health service lies with the Secretary of State directly. He is accountable to Parliament and must write an annual report to Parliament on the health service in England. The financial allocations are made out of NHS money for which the Secretary of State is responsible. His function is then devolved to NHS bodies and also now to local authorities.

    How much this constitutional difference will matter in practice is unclear but there will be some differences

    • DH will have wider powers of direction and intervention than DCLG
    • It will also be more accustomed to using them
    • It is unlikely that ring fencing will be removed from the public health grant without replacing it with some other method for the Secretary of State to account for its value e.g. outcome-based funding
    • Certain legal constraints will apply e.g. we will not be permitted to charge
    • Certain NHS systems will apply (although not all because the Government is now drawing a new, and to some extent mystifying, distinction between “the health service” and “the NHS”)
    • It will be possible to raise questions about public health in Parliament

    MANDATED v NON-MANDATED SERVICES

    The Secretary of State will identify certain public health services where it is sensible to ensure national consistency. These will be called “mandated services”. Mandated services are likely to be the subject of more national intervention to standardise provision and non-mandated services are likely to offer more scope for local variation.

    It is important to appreciate that mandated services are not the most important services; they are the services which it is most important to standardise.

    The distinction between mandated and non-mandated services is not a duty/powers dichotomy. Management of the part of the health service for which we are responsible is a duty. Mandated services are a different concept related more to the degree of freedom we will have to decide how to discharge the duty.

    The Significance of Being Part of the Health Service but not Part of the NHS

    There is no clarity as to why the Government has chosen to introduce the distinction between “the health service” and “the NHS” which is introduced by s64 (4).

    Ideas range from the strongly positive (“Andrew Lansley wants to emphasise public health but when people talk about the NHS they always focus on health care so this liberates us”) through the neutral (“There needed to be a term for the services commissioned by the NHS Commissioning Board and CCGs and so this distinction was an efficient way to create that”) to the long term paranoid (“It is all part of Oliver Letwin’s plans to make the NHS no more than a brand name. If you want to privatise something you have to separate out its public functions first.”) to the immediately paranoid (“They’ll not give us the NHS level of growth and they’ll just throw us to the wolves.”)

    Apart from the fact that there is no evidence yet to support the immediate paranoia, there is no clarity as to which of these is right. A number of comments by Anne Milton have adopted the positive explanation.

    The immediate practical question is which health service systems will be seen as NHS systems and will therefore exclude public health, and which will be seen as health service systems and will therefore include us. This is a question which civil servants are painfully working their work through. This  task might have been easier, and more likely to be done effectively, if anybody had the foggiest idea what  the distinction is intended to mean and what (if anything) it is actually for.

    Tagged | Comments Off on Legal status of Public Health Under the Health and Social Care Act 2012

    David Colin-Thome, Independent Healthcare Consultant and Visiting Professor, Manchester Business School, Manchester University, UK and School of Health, University of Durham

    Brian Fisher, GP and Patient and Public Involvement Lead, NHS Alliance

    Key message

    If Health and Wellbeing Boards are to make a real and lasting impact on the health and resilience of the populations they serve, they must revitalise the principles of community-oriented primary care, with its values of health protection, social justice and community development.

    Why this matters to us

    When I (Brian) started GP practice in 1976, I found a community-development programme a few steps from the health centre in south-east London. It was founded on principles of social justice and values of co-operation and challenging power. It changed my life (and I married the community worker…) and I have tried to put these values into operation across the NHS ever since.

    When I (David) began GP practice in 1971 I was greatly influenced by Dr Julian Tudor Hart and Dr Geoffrey Marsh who, as GPs, focused on the individual and the population of patients. Later, I was influenced by my friend Professor John Ashton as we explored the GP practice as a public health organisation, and further shaped by my work as  a local councillor.

    Key message

    If Health and Wellbeing Boards are to make a real and lasting impact on the health and resilience of the populations they serve, they must revitalise the principles of community-oriented primary care, with its values of health protection, social justice  and community development.

    Health and Wellbeing Boards are one of the innovations in the Health and Social Care Act of 2012. They could herald a long overdue new public health by harnessing community activity such as asset-based community development.  Health and Wellbeing Boards are intended to span the worlds of public health and primary care.

    The Role of Health and Well-being Boards

    Each top tier and unitary authority will have its own health and wellbeing board. Board members will collaborate to understand their local community’s needs, agree priorities and encourage commissioners to work in a more joined up way.

    • Health and wellbeing boards will have strategic influence over commissioning decisions across health, public health and social care, integrating services.
    • Boards will involve democratically elected representatives and patient representatives in commissioning decisions alongside commissioners across health and social care.
    • Boards will bring together clinical commissioning groups and councils to develop a shared understanding of the health and wellbeing needs of the community.
    • Through undertaking the Joint Strategic Needs Assessment (JSNA), the board will drive local commissioning of health care, social care and public health, bringing in other services such as housing and education provision.

    R.H.Tawney said: ‘The poor have remained beloved by the Gods being afforded excellent opportunities for dying young’.  This remains a truth today despite the huge improvements in the public’s health and in healthcare. These improvements have disproportionately benefitted the more advantaged.  Narrowing these inequalities should be a priority of Health and Wellbeing Boards. Can they deliver this when so many public health policies of the past have not? We argue that they can, and they must. To do so they must complement the present public health approach that is concerned with discrete interventions targeted at individuals, with on-going interventions that help whole communities and families to help themselves.

    General practice has always had a population responsibility (the registered list) as well as a responsibility to individual patients. These twin responsibilities lie at the heart of what it means to be ‘family and community-oriented’ – concerned not only with treating the diseases that a patient has, but also recognising the impact of their social context – family relationships, jobs, crime and so on. Indeed, this is one of the main reasons why  decentralised generalist healthcare systems are more effective than centralised specialist-led systems. In the words of Berwick:  “general practice and primary care is the soul of a proper, community orientated, health-preserving care system’[ii]. In the words of Starfield: “The well known but underappreciated secret of the value of primary care is its person and population, rather than disease, focus[iii]

    Clinical Commissioning Groups  now have their hands on the reins of the NHS. This presents an opportunity to meaningfully span the general practice role of personal care and public health in collaboration with their local authorities through Health and Wellbeing Boards. General medical practices are statutory members of CCGs and have to work together to achieve the aims of Clinical Commissioning Groups to reduce costs and retain quality. As has been described in recent papers in LJPC, it is becoming increasingly common for clusters of 10-20 practices who serve populations of about 50,000 to come together to develop collaborative practice – to share the load of overwhelming demands, for mutual support, and for improved care. Different places have called them different things – ‘Local Health Communities’, ‘Health Networks’, ‘Cells’ and ‘Hubs’.

    These new clusters of general practice could provide a shared space for collaboration between public health and primary care. In these spaces multiple agencies could work together to provide in our cities and towns what pioneers like Julian Tudor Hart in South Wales[iv] and achieved in small communities – improving whole community capacity and resilience as well as personal medical care. They could translate to the 21st century the vision of Sidney Kark’s ‘community oriented primary care[v] and Ashton’s ‘New Public Health’[vi],

    Health and Well-Being Boards  could make this happen, by ensuring that general practice and community services plan and act in concert with public health, local authorities, schools, voluntary groups and many other organisations, to synchronise their efforts for health improvement. Conventional individually-focused approaches to health promotion (e.g. smoking cessation, healthy eating and physical activity) could be complemented with social approaches that harness the energy in communities (termed ‘asset-based community development)[vii].  This approach helps people to help themselves – more effective than imposed solutions. As Kretzmann says: “healthy communities have never been built upon their deficiencies but have always depended upon mobilising the capacities and assets of people and place[viii]. It means recognising that health is more than the sum of their medical diseases, and includes a sense of coherence that Antonovski calls salutogenesis[ix] and MacIntyre calls Narrative Unity[x].

    In this paper we revisit the evidence that a social approach to health improvement is effective at improving health and that it is cost effective. From this we suggest what Health and Wellbeing Boards can do to shape a winning course.

    A community development approach improves health

    Community development builds confidence to act for health improvements. For example, community development work on the Beacon estate in Cornwall showed sustained improvements – when the community realised that they could make a difference by working together, their motivation to act increased and they caused sustained improvements in housing, education, health and crime[xi]. Similar results have been seen in Balsall Health[xii].

    The key link is that community development extends and strengthens social networks. These are the links between people that shape their sense of identity – making them feel that they belong and capable of making an impact. Social networks are formed in thousands of ways everyday brief encounters – in pubs and shops, clubs and schools for example.  Social networks are good. A meta-analysis of data across 308,849 individuals, followed for an average of 7.5 years shows a 50 % increased likelihood of survival for people with stronger social relationships.  This is consistent across age, sex, cause of death and is comparable with risks such as smoking, alcohol, Body Mass Index and physical activity[xiii].

    Social networks and social participation also protect against cognitive decline and are associated with reduced morbidity and mortality[xiv].  Low levels of social integration, and loneliness significantly increase mortality[xv].  Social networks are weaker in more deprived areas and poor social participation is associated with mental ill health[xvi].  Improving social networking and social relationships reduces the risk of depression[xvii].

    Those areas with stronger social networks experience less crime[xviii]   while enhancing employment and employability[xix].  Social cohesion and informal social control predict a community’s ability to come together and act in its own best interests and is derived, in part, from participation in local associations or organizations[xx].

    There are a variety of models of different kinds of community development to examine, many of which have improved healthcare services. For example the “Linkage plus” programme developed and deepened social networks for older people while redesigning health services with their participation. Significant improvements in health and independence resulted[xxi].

    Two examples of what has become to be termed ‘Asset Based Community Development’:

    The Health Empowerment Leverage Project, HELP

    HELP  focuses on the creation of a long-term problem-solving neighbourhood partnership between residents and front-line services from health and other agencies. The partnership is led by residents but generates parallel action and learning amongst agency staff enhancing the development of confidence, skills and co-operation and creating a cumulative momentum so that such developments are self-renewing so the whole atmosphere of the neighbourhood becomes more positive.

    HELP adopted a method known as ‘C2’,   which displayed exceptional success over 15 years across 6 deprived rural and urban estates.  A review of the longer term effects of a C2 project run on the Beacon Estate in Penwerris, Cornwall found improvements between 1995 and 2000 in education, health, employment and crime.18

    HELP has developed an approach that can assist Clinical Commissioning Groups and Health and Wellbeing Boards to assess the social capital of their communities and track changes that have taken place as a result of intervention.

    Connected Care in eleven sites since 2006.

    The Connected Care project,  part of the organisation Turning Point, set out to build on existing social capital and resilience to improve health and social care outcomes for local people in Owton ward in Hartlepool.

    Community Researchers were recruited from the local community and supported by Turning Point and local agencies. Two hundred and fifty one local residents participated in an audit via one to one interviews, focus groups and a community “have your say” event.

    The results of the audit informed the development of the Connected Care service that is delivered through a local community social enterprise, incorporated as a Community Interest Company. The service includes navigators, a debt and benefits advice service, support for older people to stay in their own homes for longer, supported housing for young people as well as a gardening and handyman service. It also includes a time bank to utilise the skills of local residents and co-ordinate volunteering between local people. Connected Care is now managing 32 flats in Glamis Walk that are owned by Accent Foundation who have now commissioned Connected Care to manage the whole estate.

    Connected Care is being rolled out across Hartlepool building on the service delivered in Owton ward and community research activity across the town over the last 18 months.

    The programme in Hartlepool has expanded from 100 people receiving support to over 500 people benefiting from the range of services – including benefits and welfare advice, luncheon clubs, social activities, gardening and handyman services, and meals on wheels. This service is expecting to triple again the number of people in the SAILS programme over the next year. On the back of this expansion the Council has awarded Connected Care the contract to provide luncheon clubs and reablement support for elderly people leaving hospital.

    Cost-benefit of Community Development Initiatives

    The evidence above shows that community empowerment improves health, and there are good reasons why general practice should contribute to leadership of such community empowerment; also the contemporary clustering of general practices into geographic areas provides a new practical shared space for it to happen. Surely Health and Wellbeing Boards and Clinical Commissioning Groups must therefore ensure that it happens.

    But there is one important other piece of evidence – is it cost-effective?

    Studies show that community empowerment is cost-effective, not merely in deprived areas but in all economic climates[1]. When people in an area take charge of their destiny, they can better contribute to the design of cost-effective and humane services that improve quality and contain costs better than when they are unable to contribute.  Making resources available to address the association between poor health and poor social networks and break the cycle of deprivation has been shown to decrease health care costs[2].

    Social Return on Investment19 is a social value approach to measuring an economic return on investment. It has been used to track the cost benefit of a community development worker in four local authorities, identifying, supporting and nurturing volunteers within their areas to take part in local groups and activities.

    An investment of £233,655 in community development activity was found to have created approximately £3.5 million in social return, a return of 15:1. The time invested by members of the community in running various groups and activities represented almost £6 of value for every £1 invested by a local authority.

    Lomas shows that harnessing social networks has an effect comparable to bio-medical interventions. He estimates for every 1000 people exposed to each “intervention” per year

    • Social cohesion and networks of associations would prevent 2.9 fatal heart attacks
    • Medical care and cholesterol-lowering drugs would prevent 4.0 fatal heart attacks in screened males

    HELP was asked by the Department of Health to explore the cost-benefit of community development . Examining the HELP interventions in three neighbourhoods across England,it was estimated that serious medical events would be reduced by 5% per year – an NHS saving of £558,714 over three years on depression, obesity, cardio vascular disease. This is as a result of local interventions such as exercise groups, dietary interventions and deepening of social networks.  This is a return of 1:3.8 on a £145,000 investment in community development over the three years.  Adding savings produced by reductions in crime and anti-social  behaviour would produce a further saving of £96,448 a year per neighbourhood using directly age standardised mortality rates per 100,000  £868,032 across the 20% most disadvantaged neighbourhoods of a local authority and £130m across England. This represents a return of 1:9.

    What should Health and Wellbeing Boards Do?

    It is understandable why there has been so little general practice leadership of community empowerment – medical training that emphasises the treatment of discrete diseases and the science of collaboration and empowerment is largely absent from formative and continuous medical education. Health and Wellbeing Boards must act to reverse this, firstly at the post-graduate level, working with Local Education Training Boards to develop skills to lead this in the new clusters of general practices.

    It is understandable why there has been so little collaboration between general practice and public health practitioners to lead community empowerment – general practices have operated in isolation to deal with patients on a one-to-one basis. Previously attempt to systematically build community resilience and social cohesion have only been realistic in small communities where the shared boundaries are given by nature. In larger areas the absence of shared boundaries fragments collaborative initiatives. Health and Wellbeing Boards must act to consolidate these new clusters of practices as a shared developmental space where local authorities, public health business and third sector organisations can contribute to a New Public Health.

    It is understandable why there is not more evidence of the huge untapped potential of community empowerment to improve health. Databases in the NHS are focussed on individuals with individual diseases.  Health and Wellbeing Boards must ensure that Clinical Support Units routinely gather data of the effect of these clusters on things like unscheduled admissions to hospital, place of care for those who are dying, and a breadth of other indices that will be affected by the large number of small acts of kindness that happen in empowered communities. They must provide reports of these data on a regular (monthly) basis so local people can witness the effects of their actions.

    Health and Wellbeing Boards should also support pilot projects within these clusters, and create mechanisms for results to be fed back to Clinical Commissioning Groups so others can learn and change. Health and Wellbeing Boards should encourage such long-term capacity-creating interventions as an antidote to the usual old-fashioned projects that have short-term focus. They should work with universities to support evaluation of these initiatives.

    The literature about Asset Based Community Development is particularly worth reviewing. This involves residents identifying local skills and experience, then discovering what they care enough about to change, then creating mechanisms to act together to achieve those goals. HELP and Connected Care use this approach.

    If Health and Wellbeing Boards perceive their roles narrowly they will chart a traditional course with two or three key priorities focused on (probably medically-perceived) priorities. And they will fail. But if they claim a wider role (and they should), they could position themselves as enablers of a new public health that provides the training, the conditions and the evidence that community empowerment produces better health at lower cost.

    References


    [1] Knack S. Social Capital, Growth and Poverty; A Survey of Cross-Country Evidence. Social Capital Initiative, Working Paper No. 7, Washington, D.C.: World Bank. 1999

    [2] Fair Society, Healthy Lives Strategic Review of Health Inequalities in England post 2010 p139 The Marmot Review February 2010 © The Marmot Review ISBN 978–0–9564870–0–1 Xiix

    [ii] Berwick DM. A transatlantic review of the NHS at 60. BMJ 2008;337:a838

    [iii] Starfield B, Shi L, Macinko J. (2009) Contribution of primary health care to health systems … quality of care in England. N Engl J Med. 361(4): 368–78

    [iv] Hart J. A New Kind of Doctor. (1989) Merlin Press

    [v] Communityoriented primary care: the legacy of Sidney Kark. American Journal of Public Health. 83(7):946-7, 1993 Jul. Gillanders WR)

    [vi] Ashton J, Seymour H. The New Public Health. Milton Keynes:  OUP, 1988

    [vii] Morgan M. & Ziglio.  Revitalising the public health evidence base: an asset model in Morgan & Ziglio (Eds) Health Assets in a Global Context: Theory, Methods, Action, Springer. 2010.

    [viii]  Kretzman and McKnight.  Building Communities from the inside out. 1993.

    [ix] Antonovsky, A. Unraveling The Mystery of Health – How People Manage Stress and Stay Well, San Francisco: Jossey-Bass Publishers, 1987.

    [x] MacIntyre A. After Virtue. London: Duckworth, 2000

    [xi] Developing sustainable social capital in Cornwall: a community partnership for health and well-being (The Falmouth Beacon Project) By Hazel Stuteley O.B.E. and

    Claire Cohen Cornwall Business School, 2004

    [xii] Atkinson D. Civil Renewal . Brewin Books 2004 ISBN1 85858 267 9

    [xiii] Holt-Lunstadt, Smith, Bradley Layton Social relationships and mortality risk: a meta-analytic review..Plos Medicine July 2010, Vol 7, Issue 7.

    [xiv] Jenkins R, Meltzer H, Jones P, Brugha, T and Bebbington, P. Mental Health and Ill Health Challenge. London:Foresight. 2008.

    [xv] Bennett K. 2002. Low level social engagement as a precursor of mortality among people in later life. Age and Ageing 31: 165-168.

    [xvi] Berkman LF and Kawachi I (2000) ‘A historical framework for social epidemiology’ in Berkman LF and Kawachi I (Eds.) Social epidemiology. Oxford: Oxford University

    [xvii] 9 Morgan E and Swann C. Social capital for health: Issues of definition, measurement and links to health. London: Health Development Agency. 2004

    [xviii] Ed. Fulbright-Anderson K and Auspos P. Fear of Crime and Neighbourhood Change. Community Change: Theories, Practice, and Evidence. 1986

    [xix] Clark P and Dawson S. Jobs and the Urban Poor. Washington, D.C.: Aspen Institute. 1995

    [xx] Ed. Fulbright-Anderson K and Auspos P. Fear of Crime and Neighbourhood Change. Community Change: Theories, Practice, and Evidence. 1986

    [xxi] Willis M and Dalziel R. LinkAge Plus: Capacity building – enabling and empowering older people as independent and active citizens. Department for Work and Pensions Research Report No 571 2009

    Tagged | Comments Off on Health and Wellbeing Boards for a new public health