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    The threat to cut health visitor and community nurse jobs in County Durham, while Covid-19 is still widespread, has been branded as ‘incomprehensible’ by Unite, Britain and Ireland’s largest union, today (Friday 24 July).

    Harrogate and District NHS Foundation Trust (HDFT), which is taking over the County Durham 0-25 family health service contract from 1 September, wants to axe about 37 whole time equivalents (WTEs), while the coronavirus is still widespread across the country.

    Although the HDFT also says it wants to employ 21 WTE new posts, there will be a net loss of 16 WTEs out of a workforce of about 230 WTEs.

    Unite lead officer for health in the north east Chris Daly said: “It is almost incomprehensible that when ‘public health’ is foremost in people’s minds because of coronavirus, Harrogate and District NHS Foundation Trust is swinging the jobs axe.

    “The vast majority of those being earmarked to lose their jobs are health visitors and school nurses – the very professionals at the public health frontline helping families with babies and young children, and children returning to school.

    “Disgracefully, the trust is consulting when staff, have been working flat-out throughout the Covid-19 crisis supporting very stressed families and young people. This flawed exercise is happening before the first wave of the pandemic is over and with the expectation that a second wave will hit this autumn and winter.

    “It is also very wrong that schools and GPs have not been told about the proposed cuts in school nurses. School staff returning in September will be phoning school nurses to come and help with children that they have not seen since March and who may be exhibiting worrying behaviours and dealing with distressing emotions.

    “We believe that already stretched GPs will be expected to pick up the shortfall in keeping babies, children and young people safe. However, there is a real risk that those most at risk may fall through the current safety net that HDFT seems intent on weakening.

    “This is not the time to reduce the health and school nurse provision for children and young people. However, it will be some time before the adverse impact of these cuts are brought into sharp relief.

    “The Durham country council should work with the trust to increase the funding for these essential frontline services. The long-term health of families is never enhanced by reducing the number of healthcare professionals.”

    Unite, which embraces the Community Practitioners’ and Health Visitors’ Association (CPHVA), will be making strong representations on behalf of its members before the consultation process ends on 31 July.

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    Summary

    The current National Health and Care System has shown the fact that a system can run on the basis of an ethic of altruism and public service, not profit.

    The hospitals have always held primacy in our system, and reorganisations have tried to rebalance the system in favour of community health and primary care.

    Public Health has been weakened by the 2012 Act and enjoyed more prominence during the period of Primary Care Trusts when it was integrated with Primary Care. This situation needs to be restored

    Health and Care need to be integrated regionally and the paper argues for Combined Authorities to be given overall control.

     

    No, the title was not a typo. There is more to healthcare than the NHS which we all know and love. Health Care includes Public Health, Social Care, Pharmacy and Dentistry, and they all need to work together. The present crisis has shown this. This is something which many experts in the field have acknowledged for years; doing something about it has proved elusive and difficult. This present crisis has shown not only the heroic dedication and commitment of the staff, but also the gaps and problems which need to be rectified, so perhaps this is the time to try and do it.

    In this paper I have tried to set out some sort of roadmap of the problems we need to tackle. That is why I have called the objective a National Health System, rather than the current NHS, but have preserved the iconic brand which is known all over the world. I once met mountaineers in a foreign land who praised the NHS.

    I am not an academic. I have taught about how the Health System works, but more practically I have been a councillor, worked for the NHS, served on a Clinical Commissioning Group and now Health Education England. I wrote a book about how the NHS should be organised with Sunderland University, and I will draw on bits of that in this paper, but my knowledge comes mainly from my practical experience. (“What Sort of NHS do We Want?”, Searching Finance, 2012)

    How we arrived at the present position

    There is much ignorance amongst the public as to how the NHS actually works. It is certainly very fragmented, but still able to respond as a national system, which has been shown by the present crisis. Many fondly think there was a “golden age” back in the 1950’s when the NHS was first established.  Aneurin Bevan boasted of a national system where the “sound of a bedpan dropped in Tredegar would reverberate around the Palace of Westminster”.

    We all know establishing the NHS was a political struggle and what emerged was a messy compromise. The immediate problem was sorting out hospitals which needed investment after the war. I can remember seeing pictures of my Grandmother, who was a hospital almoner, lining up the nurses to go out with the collection tins. Hospitals seem to have dominated ever since although they deal with a minority of the people who use the system. There are more patient contacts with GPs, carers, Public Health programmes ,  and Social Workers. Local Government had played an important role in health before 1948, and Directors of Public Health were important people. Much of what we would now call primary care was still run by local authorities up until the major reorganisation of 1974.  Strong central control was the way things worked in 1948, a legacy of the war – the NCB, British Railways, The National Grid and even the New Towns. The new NHS was no different.

    Initially Governments thought that a strong NHS would improve health and once the backlog of bad health had been dealt with, costs would reduce. This of course did not happen, so managing the NHS became a constant struggle between improving the service and keeping a lid on costs. In 1974 all health services came under Regional Health Authorities and this remained until the next major reorganisations at the end of Thatcher’s period in power. This was when the concept of the “market” was introduced into the NHS.

    At that time the model of the big top-down organisation was being challenged both in the public and private sphere. Although big organisations were still centrally controlled from the top, they wanted more flexibility locally to restructure and adapt to changing conditions at the bottom. Even the army now operates like this. The idea was that those who planned a service would commission it from who could provide it best. Commissioning meant what the service was going to be had to be evaluated and planned. The NHS had to think exactly want it wanted and the best, and most cost-effective way, of achieving it. This does not necessarily mean using the private sector. Other NHS and not for profit organisations are often involved. But it was never a free-for-all. The NHS was still in charge. Resulting from the Thatcher reforms there was a privatisation of many ancillary services such as cleaning, maintenance and catering. For clinical services there was still a preference to commission NHS and not for profit organisations. One consequence of these changes was that local authorities outsourced much of their social care provision, mainly for economic reasons.

    The Labour Governments after 1997 modified the model, introducing both Foundation Hospitals and Primary Care Trusts. In my opinion the PCTs were a very progressive reform, and one for which the Blair Governments, Frank Dobson and Alan Milburn received very little credit. They brought together Public and Community Health and allowed a high degree of local government involvement since they covered the same areas as local authorities and usually had councillors on their boards. Under the Blair Government resources were diverted to PCTS, and also prioritised deprived areas such as Easington in County Durham. There was a real push to reduce health inequalities. In my experience the PCTs also put a considerable amount of resource and effort into engaging with the public. In some ways this was a “golden age” for engagement, compared to the much less robust arrangements which replaced them.

    The Black Report in 1979 pointed out that despite large investment in the NHS, health inequalities persisted.  Professor Townsend, one of the main authors, mentioned Easington in a later report and visited Peterlee to explain his ideas. The dominance of the Hospitals in the system had led to a neglect of both social care and the promotion of health in the community. To reduce inequalities meant placing far more emphasis on how people lived, the conditions in which they lived and looking after them in the community when they were frail or unwell. Successive reports re-emphasised what the Black Report had said.

    The Primary Care Trusts were an attempt to redress the power balance with the hospitals. More resources were given to community and public health, which were now integrated. GPs had a major role. The PCTs were coterminous (horrible NHS word) with local authorities, and the Director of Public Health was now appointed jointly between the local authority and the PCT.  Cooperation was much easier. Many PCTs had councillors on their boards. The PCTs now had more power to negotiate with the hospitals to get better deals, and work with them. At this stage commissioning was mainly for other public sector and voluntary organisations. The NHS was the “preferred provider”.  The PCTs made considerable progress in improving public health, such as the reduction of smoking and teenage pregnancies, and set up many community initiatives.

    In my opinion the PCTs were a very progressive reform, and one for which the Blair Governments, Frank Dobson and Alan Milburn received very little credit. They brought together Public and Community Health and allowed a high degree of local government involvement since they covered the same areas as local authorities and usually had councillors on their boards. Under the Blair Government resources were diverted to PCTs, and deprived areas were prioritised. There was a real push to reduce health inequalities. In my experience the PCTs also put a considerable amount of resource and effort into engaging with the public. In some ways this was a “golden age” for engagement, compared to the much less robust arrangements which replaced them.

    I think I should make a few remarks about commissioning.  Many on the left regard it as synonymous with privatisation. This simply is not so.  As explained above the NHS is not monolithic and contains many different sections and specialities. Some of commissioning is straightforward – estimating the number of routine, predictable operations required in a year, like hip replacements. Then it is about negotiating the best deal with a provider.  But some is more complex, such as public and community health which requires constructing alliances between different organisations. Using a private provider is not a necessary part of this at all.

    All this was changed by the infamous Social Care Act of 2012 which established the Clinical Commissioning Groups. It compelled contracts to be put out for public tender, so private providers could apply, and often threatened to sue if they thought they had not been fairly considered.

    Councillors were not allowed to be involved, and their only oversight was through Scrutiny Committees. Public Health was handed back to local authorities. A strong national agency, Public Health England was created to exercise many of the responsibilities which PCTs had previously done including disaster planning and campaigns to reduce smoking and other habits deemed to be harmful to health. I will say more about the consequences of that later.

    The CCGs were a result of lobbying by a minority of GPs who wanted to commission directly without the NHS bureaucracy and pressure from private providers who wanted a bigger slice of the action. The Government thought they could use them to reduce costs. The whole enterprise was ill thought out and very disruptive. It is a useful lesson in the sort of “creative destruction” advocated by the likes of Dominic Cummings. The idea being that somehow once the bureaucratic shackles of the NHS and local government had been thrown off, GPs would somehow emerge as the heroes of the NHS and challenge the dominance of the Trusts. I can remember attending seminars before the new act was implemented where it was even advocated that two GPs could form a commissioning group. How they would work out the necessary plans and calculations was not thought about. I can remember a seminar about the changes entitled “Breaking Though”.

    In reality it was only a minority of GPs who wanted to run the NHS.  Most of them simply wanted to get on with their jobs which were demanding enough. Much of the pressure came from private providers, aided and abetted by members of the government anxious to reduce costs and eliminate, as they saw it, unnecessary bureaucracy.  Andrew Lansley, in many other ways a fairly level-headed man, seemed carried away by it all, and David Cameron and Nick Clegg did not really understand it. The only contribution by the Liberals was to ensure lay representation on the new CCGs. The reorganisation was described by one critic as “visible from space” and disrupted the NHS for several years.  Patterns of cooperation between agencies, carefully established over time were either disrupted or had to be carried on “under the radar” in the new competitive model. A new bureaucracy had to be established from the PCT staff to perform commissioning.

    One hospital (Hinchinbrooke) was taken over by a private company which could not cope and had to hand it back to the NHS.  Many private providers attempted to run the new 111 services, but now most of them are organised by Ambulance Trusts.

    The idea behind the 2012 Act was that there would be a free market. The CCGs would commission the most efficient service, public or private.  Collaboration, whether between hospitals and other parts of the NHS was not, in theory, allowed. Private providers could take the NHS to court if they thought the NHS had an unfair advantage. In practice, however, the national NHS kept a firm grip on things. There is always the need in the NHS to pool risk.  If there is an outbreak or crisis in one area the whole system has to pitch in.

    The 2012 Act led to an extremely costly and disruptive reorganisation. Many health professionals soon realised that it did not work. In reality the bureaucracy expanded, and much energy had to be expended negotiating between different parts of the NHS. The majority view was that if the NHS was going to cope, two things were necessary. Firstly, more resources needed to be directed to promoting good health, and thus reducing those diseases which were caused, or exacerbated, by a bad lifestyle, such as diabetes. Secondly an ageing population meant more people would need care in the community, rather than treatment in hospital. If they did not receive this care, then they would end up in hospital, as so called “bed blockers”.  Hopefully if policies to address these objectives could be put into place it would reduce unnecessary hospital admissions.

    Local health professionals have tried to negotiate arrangements for CCGs, Hospitals and Local Authorities to work together.  These were originally called Strategic Transformation Partnerships, abut have now morphed into Integrated Care Systems.

    Simon Stevens, Chief Executive of the NHS, said in the Five Year Forward View

    “The government will not impose how the NHS and local government deliver this. The ways local areas integrate will be different, and some parts of the country are already demonstrating different approaches, which reflect models the government supports, including: Accountable Care Organisations such as the one being formed in Northumberland, to create a single partnership responsible for meeting all health and social care needs; devolution deals with places such as Greater Manchester which is joining up health and social care across a large urban area; and Lead Commissioners such as the NHS in North East Lincolnshire which is spending all health and social care funding under a single local plan.”(Implementing the five Year Forward View 2017)

    More detailed plans for ICSs have been set out last year

    The NHS Long-Term Plan set the ambition that every part of the country should be an integrated care system by 2021. It encourages all organisations in each health and care system to join forces, so they are better able to improve the health of their populations and offer well-coordinated efficient services to those who need them.(The NHS, Designing Integrated Care Systems in England 2019)

    It is important to notice the word “Systems”. These ideas rely on different organisations working together. They do not pool budgets, and have no one accountable management, just committees who liaise.

    The trouble is all this is against the 2012 Act. Manchester eventually commissioned other NHS organisations to deliver its community health services, but was threatened with court cases from private providers. All that would have wasted a considerable amount of public money.

    The Conservative election manifesto recognised the system was not working in 2017 and proposed changes to the rules.  All this has since been forgotten about with the dominance of Brexit but will eventually have to be addressed.

    Some on the left see the ICS’ as some sort of conspiracy, implying that there is a secret plan to fragment the NHS and then sell off parts of it. Simon Stevens is often portrayed as being some sort of ogre who is using his American experience to somehow smuggle American health companies into this country.  Remember that health is largely organised on state lines in America, and the insurers who pay for much of it want single organisations whom they can work with. I think the reality is somewhat different. Many think Simon Stevens is a shrewd operator who managed to secure additional funding for the NHS.

    Ever since I have been involved with the NHS there have been efforts to join up health and social care at a community level, and to challenge the dominance of the hospital Trusts.  In the early 2000’s the former Sedgefield Borough Council worked with their Primary Care Trust and Durham County Council to effectively integrate services by putting social workers, district nurses and housing officers in the same room, and Easington PCT considered integrated care initiatives.  The Sedgefield initiative worked at a grassroots level because it did not involve redesigning systems.  As soon as you tried to set up a new structure people retreated into their bunkers.

    It is much easier to set up an integrated system in theory than in practice. One senior insider I spoke to recently said that negotiations to set up an integrated care system locally were not getting very far because of vested interests. Different organisations have different hierarchies and systems of accountability.  They are also keen to hang onto their budgets.  It looks like a solution will only be reached if the NHS imposes it, and they do not have much spare energy for that at the moment.

    I remember the days before local government was reorganised in Northumberland and Durham, and District and County Councils were merged into the present unitary ones. The Government asked councils to work out ways of working together. There were interminable liaison meetings between the different councils which got precisely nowhere, each one wanting to preserve its own interests. Eventually the Government imposed a solution.

    Insiders also tell me there is very little interest from councils in the new arrangements.  Although in practice working relationships between the local authority and the NHS in most areas are good, some councillors appear to prefer the scrutiny role than actually being responsible for the service.

    So overall I think the problem is not so much a conspiracy to carve up the NHS as some on the left seem to think, but rather getting our fragmented system to work together for the benefit of all of us.

     

    Where we are now

    Most people on the left believe in a publicly run health service, free at the point of use. They also value the dedication of the staff and think they should be better rewarded.

    Socialists also dislike privatisation.  There is a difference between having to use the private sector if nothing else is available and the obligation to put services out to tender regardless of whether they are functioning properly as happens now. Efforts to integrate services are also hampered if parts are privately owned, as private providers may not disclose their information and not cooperate. (I remember my efforts on the CCG to get Capita to produce its accounts to the Audit Committee for a service they provided.)

    Privatisation often results in poor staff conditions and pay.  I think nearly all Labour Party members would wish a future Labour Government to repeal the 2012 act and restore the NHS as the preferred provider.

    That is the easy part.  Now we get to the difficult issues of how we organise an integrated service in the future and ensure it is accountable. Let me stress now that I do not want another major reorganisation. Our NHS staff do not deserve that. Rather we must think about how what we have now can be made to work better.

    I have not said much about Social Care, either personal, which is delivered at home, or residential in care homes. It is widely accepted that the situation is at crisis point. The paper by Professor Paul Corrigan is an excellent starting point. A recent briefing by the Nuffield Trust emphasised the dimensions of it. (Nuffield Trust, Election Briefing Nov 2019.)  Here are a few statistics:

    We believe the scale of the workforce challenge has so far been underestimated: our new calculations show that just providing a basic package of care of one hour per day to older people with high needs would require approximately 50,000 additional home care workers now. To provide up to two hours would need around 90,000 extra workers. ( Then there is the question of where they would come from if Brexit is implemented)

     

    A decade of austerity has seen government funding for local authorities halve in real terms between 2010–11 and 2017–18,* which has led to councils tightening the eligibility criteria for care. It is known that there were 20,000 fewer older people receiving long-term social care services in 2017/18 than in 2015/16, but this is likely to understate the problem – estimates of unmet need go as high as 1.5 million.

    Constraints on public sector finances in recent years have meant that fees paid by councils to the organisations that provide home and residential care have been cut repeatedly. The predominant approach used for buying services from providers incentivises organisations to provide a bare minimum of services and nothing more. Some 75% of councils report that these organisations have either closed or handed back contracts in the last 6 months, creating enormous disruption and discontinuity for those receiving care.

    The problems of Care Homes have been highlighted by the current pandemic. There are roughly 11,300 care homes in the UK who look after 410,000 residents. Most of their income comes from fees paid by residents or their families, with a minority provided by local authorities.  In practice the private fees subsidise the public ones which are often insufficient to cover the costs of the residents. Sally Copley of the Alzheimers Society says “The whole system hasn’t been working properly for some time”.  Many staff are on zero hours contracts and staff shortages are endemic as Professor Corrigan pointed out. Staff are paid far less than they are worth and do not receive adequate training nor professional recognition.

    We all have formative experiences which make us socialists. One of mine was in a care home where a member of my family was a resident. I knew two married members of staff well. Both were dedicated to their work and the residents.  They were always cheerful.  I can remember them saying with great enthusiasm how they had saved up enough to take their young family to Great Yarmouth for a week in the summer.  Their work deserved far more reward than that. I though “something has to be done about this”.

    A proper care system would assess people on the basis of clinical need, not ability to pay.  At the moment there is continuing health care, provided by the NHS, which is free,  for those thought to have health issues, but domiciliary and residential care largely has to be paid for by the clients or their families except for the minority who benefit from a stringent means test. Dementia is not classified as a medical condition.  Many people feel this system is unfair. A senior commissioner I spoke to said she would rather commission “care” which would be provided by professionals trained by the NHS, rather than try and distinguish between continuing health care and social care.

    At the last election the Labour Party promised free personal care for those over 65, as in Scotland.  As the Nuffield Report points out this does not include assistance with cleaning and general supervision.

    One of the best assessments of the cost of integrating health and social care was done by Kate Barker and associates for the Kings Fund in 2014.  They looked carefully at what social care involves, and how it could be paid for. There are different levels of social care, and they conclude that the same principles should apply as to the NHS.  Afflictions can strike anyone, rich or poor, so care funding should come from the public purse. The costs of care and treatment should be publicly funded, although this might not include the actual “hotel charges” for residential care. The authors suggest various ways to raise the extra funding, such as means testing free TV licences, and requiring those (usually better off) who continue to work after the retirement age to pay national insurance.  There would of course be a need for those on higher incomes to pay more tax, possibly after the age of 40, and the Government should consider a wealth tax which in reality for most would be a tax on your home. There are various avoidance schemes and tax loopholes for the wealthy which could be closed.

    There would probably be agreement amongst socialists that health and social care should be integrated and paid for out of taxation, but it is no good thinking only the rich would have to pay.  Everyone would have to pay something.

    Finally, there is the issue of Public Health. Transferring it to local government has not been a success. The budget, supposedly ring fenced, has been diverted to other local government departments because of the squeeze on local authority finance, and last year some of the poorest authorities took a very big hit. Durham lost almost 40% of its public health funding. Yet even in its diminished state, The Centre for Health Economics at York has estimated that expenditure on Public Health is four times more effective in promoting health than that spent on the NHS. Simple common sense tells us that keeping people healthy is better than curing them once they are ill.

    Several distinguished epidemiologists, including Professor Allyson Pollock at Newcastle, have argued that the marginalisation of Public Health locally has severely reduced the country’s ability to deal with the coronavirus epidemic. Back in PCT days Public Health had the resources and plans to deal with disasters, often pooling risk with others.  Now that has been transferred to Public Health England, leaving local authority public health departments to deal mainly with schemes to keep people fit. Worthy enough, but nothing like the resources they used to have.   A regional public health response might have led to better testing and efforts to contain the virus. The Government’s response has been “one size fits all”. Restoration of the importance of Public Health and its reintegration with the NHS should be a major aim of policy.

     

    Policy Objectives

    Our policy objectives will be ambitious. We might need a five year, or even ten year forward view to coin a phrase.

    We seek an integrated National Health System, encompassing the National Health Service, Social Care, Public Health, with links to Pharmacy, which has a role in primary care, and Dentistry, which is not a totally public service although the NHS controls the training. But we do not want a major reorganisation again. Our dedicated health and care staff do not deserve that. What we want to do is give the present system more resources and steer it in the right direction. Repealing the 2012 Act would be a priority.

    We must ensure that particularly in social care staff are paid a decent wage and given proper access to training. The present system which relies on the minimum wage and zero-hour contracts must end.

    The first thing we know is that all this will cost more than it does now, although integration may produce some savings. A future Labour Government has to be honest about this. It is no good promising a few rich people will pay, as the public simply will not believe it. It is a good principle that everyone should contribute to something which is part of national solidarity, so all feel that it is theirs, but contributions have to be proportionate to the ability to pay.  A proper revaluation of properties, which is akin to a wealth tax, would raise money through the community charge to make a substantial contribution to social care.  An increase in National Insurance, earmarked for the NHS should be considered, provided that it became more progressive.

    Then we come to the whole issue of Governance.  Despite showing little enthusiasm, local government needs to be involved in the whole strategic planning of the NHS. But they must not see it as simply concerning their own territory, so to speak. The present structure of Foundation Trusts should stay, but Public Health and Commissioning Services should be reintegrated into Primary Care Trusts, in my opinion one of the most successful NHS organisations in its long history of restructuring. The PCTs would have oversight of Pharmacy and Dentistry. Many of the responsibilities transferred to Public Health England should be restored to the PCTs. Their boards should contain both professional and local government representation.

    There is a need for a regional dimension in all this.  When the Northumbria Trust reorganised its A&E provision to build a super emergency only hospital at Cramlington it did not consider the effect on major hospitals in Newcastle like the RVI. Patients in Hexham, for example would find it easier to go there than to Cramlington. This is just one example of where a regional perspective would have been useful.

    Local authorities’ power over social care providers need to be strengthened. At present there is a real mixture of providers, commercial companies, charities, cooperatives and individuals who provide personal care as a small business. There is a strong argument for integrating the private sector, which is virtually bankrupt anyway, into area trusts responsible to local authorities. Standards and remuneration need to be strengthened.

    Trying to merge different organisations would be very difficult and disruptive. The result could be some unwieldy bureaucracy which would be difficult to manage and slow to react to changing needs and priorities. Accountability should be pushed upwards. We need to have some sort of accountable umbrella which ensures that hospital trusts, PCTs (coterminous with local authorities) and Social Care, which is regulated by local authorities, all work together. There will always be oversight from NHS England, NHS Improvement, and the Care Quality Commission, but these bodies are mainly regulatory.  There needs to be a more local system of Governance and Oversight.

    Nationally the country is moving to a system of Combined Authorities which at present oversee economic development and transport.  Manchester has also had community health added to its powers. A combined authority does not take powers away from local authorities.It has power and oversight over services provided by other organisations. Its membership is delegated from existing councils, with a mayor if that is agreed. It would seem logical for a combined authority to exercise oversight over the Foundation Trusts, PCTs and Local Authority Care in its area and produce a plan to ensure they work together. The CCGs now cooperate to cover larger areas in any case. That way we preserve flexibility within the system without adding another layer of bureaucracy,and move towards the integrated National Health System we want.

    I want to end by stating that as socialists we owe a great deal to the NHS and Care Services. They are an example, much admired elsewhere, of how a publicly run system can be successful, and that duty and altruism more important motivators of human conduct as making a profit.  It is our duty to ensure it is funded and run properly.

    David Taylor-Gooby, author on the NHS and member of the Socialist Health Association

    May 2020
    1 Comment

    David Taylor-Gooby, Secretary of the North East Branch, has asked us to put this information on the website.

    Dr Williams is a respected as a hard working MP, with a reputation for honesty and integrity.  He is an SHA member, in fact the only NE MP in the SHA.  He still practices as a GP.  He is a formidable SHA campaigner, but only has a majority of 888.  David would like to enlist our support for Dr Williams where we can.

     

    Jean

    1 Comment

    Last week I handed in my badge.  No, I was not playing a disgraced sheriff in a western.  It was my NHS badge and my term of office was up.

    I carry some treasured memories away with me.  The first thing I have to say is that everyone I encountered was very dedicated and extremely professional about how they did their job.  Secondly I am convinced that the NHS needs fundamental reform and that will not be easy.

    It needs more resources.  Even Theresa May thinks that. But that is not all.

    We need to think about what we are actually trying to do, and the best way of achieving it.  As Professor McKeown pointed out the big advances in health were achieved through better public health – that is better food, hygiene, housing and sanitation. Hospitals, perhaps it is stating the obvious, deal with the sick and injured.  Long term conditions need care, and that has to be provided in a community setting.

    Since the NHS began medical science has developed fantastically and the number of specialist consultants has increased far more than the number of GPs. The main killers in 1948 were circulatory disorders, in particular rheumatic heart disease, respiratory disease and infection. Today the picture is different and the main killers are heart disease, in particular coronary artery disease, and cancer. The incidence of these diseases can be reduced if we can tackle lack of exercise, unhealthy eating and smoking

    Publicity focusses on the problems of the hospitals.  Over half of them are in financial difficulties,and need funding

    But long term we need to prevent people becoming ill if we can,and to  look after those who have conditions which cannot be cured. Neither of those last two can be done in hospital.

    People live now longer, which is a good thing, but it means that we have many more things wrong with us as we get older. The majority of NHS patients are elderly. Many have conditions, rather than illnesses, such as mobility problems, which cannot be cured but have to be cared for. The obvious need is for more to be spent on social care and public health, which encourages healthy living. In fact the budgets for both are being reduced. The total NHS budget is over £120 billion. Public health gets £2.5 and Adult Social Care £17 billion. Both got less this year than last year.

    The people who see most patients are the Family Health Services, that is GPs, Pharmacists, Opticians and Dentists. They get 22% of the budget whereas hospitals receive 43%.

    The obvious answer is we have to get our act together so fewer people end up in hospitals which are at breaking point. If more could be done outside hospital our system would run better and would be more patient friendly as more people could be treated locally and stay at home.  Durham Council and the NHS are showing how to effectively cooperate.

    Unfortunately the infamous 2012 Health and Social Care Act works totally contrary to this idea.  The then Coalition Government thought the answer lay in more efficiency. They believed, with scant evidence, that many public sector employees in the NHS were living a protected life and needed to be exposed to a competition. Hospitals were to compete like supermarkets and the private sector could bid for  NHS work. This goes totally against the idea of a cooperative model where GPs,Hospitals and Local Authorities, who run public health and social care, all talk to each other to provide the best for each patient.  Private providers are reluctant to fit into such a model, and there is little evidence that privatising services improves them. The present Government admitted it did not work in their last manifesto,but are in such a mess they are unable to do anything about it.  Meanwhile the NHS was to work round the rules as best it can.

    A future Labour Government needs to do two things quickly.  Repeal the 2012 Act and restore the NHS as “preferred provider” when contracts are awarded.The private sector should only be used if the NHS cannot do something. Moving to a cooperative model means building trust between different organisations. This will be difficult enough without people fearing it is a recipe for privatisation by the back door.

    The NHS is a fine example of where cooperation and mutual help works. Let us keep it that way.

    This was first published in the Newcastle Journal

    2 Comments

    It is a pleasure to be speaking with you about something that I know all of us in the room are passionate about changing in this country – health inequality.

    It comes as no surprise that the Office for National Statistics found earlier this month that the least deprived men at birth in 2014 to 2016 could expect to live almost a decade longer than the most deprived. This decade has seen a slowdown in improvements in life expectancy, an appalling consequence of this Government’s failure to improve the chances of the worst-off, as years of underfunding in health and social care take their toll.

    Similarly, the north south divide remains as relevant as ever. For both males and females, the healthy life expectancy at birth is the highest in the South East, at 65.9 years for men and 66.6 for women. I am sure you can guess which region is the lowest!

    Here in the North East healthy life expectancy for men is 59.7 years and for women it is 59.8 years – significantly lower than the England average. That means that inequality gap in healthy life expectancy at birth for the South East and North East is 6.2 years for men and 6.8 years for women.

    There are lots of factors that play into these figures, and life expectancy here is increasing faster than anywhere else in the country, but it is simply not good enough that those from deprived areas are having their life expectancy shortened. That is why we all need to make a pledge to change this.

    Today I’m going to speak about three public health epidemics that affect, not just the North East but the whole country: smoking, obesity and malnutrition. If we are able to tackle these epidemics, then we will be a step closer to achieving the goal of the UK having some of the healthiest people in the world.

    Smoking

    Smoking continues to be the leading cause of preventable deaths – in 2015, 16% of all deaths in people aged 35 or over in England were estimated as being attributable to smoking. It is estimated that 474,000 hospital admissions a year in England are directly attributable to smoking, which represents 4% of all hospital admissions. Smoking causes around 80% of deaths from lung cancer, around 80% of deaths from bronchitis and emphysema, and about 14% of deaths from heart disease. Therefore, smoking and its related health problems leave a heavy burden on our already financially strapped NHS, costing more than £2.5 billion each year.  Addressing smoking in our society could therefore help reduce that high financial cost and money could be directed towards improving our NHS and ensuring that we have a healthy society.

    Smoking prevalence is decreasing across the country, and I’m pleased to say that smoking rates in the North East is declining faster than the national average. This is due to great support from programmes such as Fresh North East, which since 2005 has been tackling high smoking rates here. They have clearly been doing an excellent job, as since 2005, the North East has seen a fall of nearly a third with around 165,000 fewer smokers. However, the North East still has the highest lung cancer rates in the country and smoking rates still remain high, especially among those who are unemployed or members of lower socioeconomic groups and it is deeply concerning that those groups, for whom poverty is rife, are not being sufficiently helped to quit smoking.

    I welcome the Government’s Tobacco Control Plan – even though it was delayed by 18 months – but the Government must move away from warm words and empty promises and commit to the right funding for smoking cessation services so that smoking rates can decline across the country.

    Obesity and malnutrition

    I have also been calling on the Government to go further in their commitment to reduce obesity levels.  The UK has one of the worst obesity rates in Western Europe, with almost two in every three people being either overweight or obese. I am one of those two, but I am back on a strict diet now to try and become the one, I hope that there will soon be a lot less of me! It is hard though, if it was so easy no one would be overweight.

    However, I was a skinny kid and a slim teenager and proud to say a size 10 when I got married and I still ended up overweight as time went by. So therefore I worry greatly when I see all the stats for this country’s children when a pattern now emerges at a very early age. In 2016/17 almost a quarter of reception children, aged between 3 and 4, were overweight or obese. In the same year, for pupils in year 6, it was over a third. An obese child is also over five times more likely to grow up into an obese adult, so the Government should be doing all that it can to ensure that child obesity rates are reduced as a matter of urgency.

    The Government’s Child Obesity Strategy to tackle this was welcome, but left much to be desired. I am sure some of you will know that it was published in the middle of summer recess, during the Olympics and on A- Level results day. At first, I thought the strategy must have been missing some pages. But it turned out, this world-first strategy really was just thirteen pages long. For whatever reason, many of the commitments David Cameron had promised and desired as his legacy had been taken out by Theresa May and her staff. We now know that May’s former joint chief of staff, Fiona Hill, is said to have boasted about “Saving Tony the Tiger”, the Frosties Mascot. Now that Fiona is out of the picture, we are expecting a second Childhood Obesity Strategy this summer, so I hope that there will be more than thirteen pages!

    Of course, there is no silver bullet to tackling childhood obesity. As I said, if staying slim and losing weight was easy then we wouldn’t have the problem we have now.  However, there are two policy suggestions that I have been championing recently: restricting junk food advertising until the 9pm watershed on all channels not just on children’s channels and restricting the sale of energy drinks to young people.

    Advertising is so much more powerful than we all think. There is a reason they spend many millions on it!  According to a University of Liverpool report, 59% of food and drink adverts shown during family viewing time were for foods high in fat, salt and sugar and would have been banned from Children’s TV.  The same report also found that, in the worst case, children were bombarded with nine junk food adverts in just a 30- minute period, and that adverts for fruit and vegetables made up just over 1% of food and drink adverts shown during family viewing time. It is therefore no wonder that there are so many children in this country who are overweight or obese. That is why I’ve been calling for restrictions on junk food advertising on TV, but I know that other modes of advertising need to be investigated more widely too like advergames and food brands which are high in fat, salt and sugar sponsoring sporting events that are popular with children.

    This leads me to my next point of energy drinks, because to pin point just one brand, Red Bull who sponsor several extreme sports competitions which are not necessarily marketed to children, but are watched by children. When my son was a teenager, I would go so far as to say that he was addicted to energy drinks. And it was a huge problem for me, especially as he could legally buy them as he told me every day in his defence, in his eyes I was being ridiculous! He and his friends would buy and drink bottles and cans of them every day and it would completely change his personality. I’m pleased to say that ten years on he is older and much more sensible now, thanks to me warning him of the health dangers of energy drinks.

    Although that was a decade ago, the trend still remains that children, as young as ten, are buying energy drinks for as little as 25p. The UK has the second highest consumption of energy drinks per head in the world.  You might expect America to have the highest consumption, but it is actually Austria, home to Red Bull headquarters. A 500ml can of energy drink contains 12 teaspoons of sugar and the same amount of caffeine as a double espresso.  You wouldn’t give a child have 12 teaspoons of sugar or a double espresso, so why are we allowing them to drink it in an energy drink?

    If we want our children to be the healthiest in the world, we cannot sit idly on this any longer. Thankfully, many supermarkets and some retailers have now taken the step to restrict the sale of energy drinks to children. Supermarkets such as: Waitrose, Aldi, Asda, Sainsburys, Morrisons, Tesco, Lidl have restricted the sale. Boots lead the way in being the first non-food retailer to restrict the sale of energy drinks to children a few weeks ago, and just this week they were joined by Shell Petrol Stations and WH Smith. I am still calling on all supermarkets and retailers to take steps to do this.

    The Government have got to do better if our children are going to be encouraged to live a healthy lifestyle and eat a healthy diet.

    However, there are millions of people up and down the country who do not have access to healthy and affordable fresh food or the skills to cook up tasty meals or even the cooking equipment or the energy such as gas or electric especially when poor and on key meters, which leads us to another issue which certainly does not get the attention it deserves: malnutrition. Malnutrition affects over three million people in the UK, 1.3 million of which are over the age of 65.  Like obesity, malnutrition is a Public Health epidemic, but because it is literally less visible, it does not receive the attention or outcry that you would expect. On this Government’s watch, we have seen a 54% increase in children admitted to hospital with malnutrition and in the last decade, we have seen the number of deaths from malnutrition rise by 30%.  It should be at the forefront of this Government’s conscience that in one of the 6th richest economies in the world in 2018, malnutrition is increasing instead of being eradicated.  I’m proud to say that Labour will make it a priority to invest in our health services and ensure people don’t die from malnutrition in 21st century Britain.

    Both obesity and malnutrition are costly to our NHS, estimated at £5.1 billion a year for obesity and £13 billion a year for malnutrition. That is why prevention is so important and why I am a key campaigner for Universal Free School Meals, because it gives all children access to a hot and healthy meal, encourages a healthy relationship with food and is beneficial to their mental and physical development. Healthy food needs to be both affordable and accessible, and individuals need the skills to prepare and cook a fresh and healthy meal.

    NHS funding

    Finally, we all know that the NHS lacks the funding and the time it needs to do all of the things I have just mentioned. Since local authorities became responsible for public health budgets in 2015, it is estimated by the Kings Fund that, on a like-for-like basis, public health spending will actually fall by 5.2%. This follows a £200 million in-year cut to public health spending in 2015/16 and further real-term cuts to come, averaging 3.9% each year between 2016/17 and 2020/21. On the ground this means cuts to spending on sexual health services by £30 million compared to last year, tackling drug misuse in adults cut by more than £22 million and smoking cessation services cut by almost £16 million. Spending to tackle obesity has also fallen by 18.5% between 2015/16 and 2016/17, again with further cuts still in the pipeline in the years to come.

    The North East Commission for Health and Social Care Integration area spends £5.2bn on health and care each year. Over 60% of this is spent on tackling the consequences of ill health through hospital and specialist care, compared to the 3% devoted to public health. That is over twenty times more spent on consequences rather than prevention. So if the UK is going to be one of the healthiest countries in the world, then the Government really does need to recognise the importance of prevention and public health.  If we invest in our NHS and public health services, then we invest in the health of everyone in this country and that is why public health is so important.

    I look forward to working with you all now and in the future to ensure that one day we can proudly say that people in the UK are some of the healthiest in the world.

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    There is wide agreement that it would be beneficial to integrate social services and local NHS community services.  This could provide “wrap around care” and look after elderly and vulnerable people in a community setting. Such a system could reduce hospital admissions, but the reason for doing it is to improve the welfare of patients. Such scheme are already working well in Durham and other parts of the country.

    Where there is not agreement is when such a system could be constrained within a strict financial envelope . A possible consequence could then be the outsourcing of management and the reconfiguration of hospital services.

    The SHA does not believe in outsourcing or relying on the private sector unless absolutely necessary. Privatisation of particular parts of an integrated system could undermine the very integration which is desired. Compulsory tendering as prescribed in the 2012 act wastes a considerable amount of NHS time, and can leave the NHS open to legal challenge by a private provider with large pockets which will involve considerable unnecessary expense. Nor is the motive for integration to constrain costs but to improve the welfare of patients.

    At present the average patient receives half their total expenditure in the final year of their life.  There needs to be a rebalancing. The elderly and frail should be properly cared for  but some clinical intervention is unnecessary.  More should be spent on the young. This would help reduce health inequalities.

    The present system puts too much power in the hands of the acute trusts. There should be  a transfer to community and public health (as recommended by the Selbie Report for the North East)

    The national NHS needs to ensure proper standards but organisation of a local integrated system should be jointly in the hands of local authorities and NHS organisations. Possibly a not for profit trust or social enterprise. The management of such a system should give equal weight to the NHS and local authorities, with a neutral chair, perhaps along the lines of an elected commissioner.

    GPs should be integrated into a local system.The present  private contract system could be replaced by salaried GPs, Many now prefer this way of working.

    There are serious concerns about the state of some care homes.  The provision and management of care homes should be integrated into the system set out above. This would lead to much closer relations between GPs, hospitals and care homes.

    Research and innovation is very important.  Hospitals in the North of England are very good at innovation, but undersell themselves.  Universities should work closely with the NHS as is now promoted by the North Health Science Alliance. Funding tends to focus on the South.  Funding for research needs to be rebalanced regionally. The regions outside London also need to promote their research and innovation more loudly.

    Devolution proposals could lead to an integration of health and local government as in Manchester.  This development needs to be evaluated as it progresses.

    Conclusion

    We envisage a situation where local authority social care, NHS hospitals and community care systems, GPs and Care homes are integrated into one system, run as a not for profit trust or cooperative.  Such a system would need representation from the NHS, Local Authority and independent members on the Board, with possibly a neutral chair who could be elected.

    Regional networks are necessary for the effective management of hospitals. A specialist hospital in one part of a region would obviously serve the whole region.  Nevertheless the health and care trusts envisaged here should not be too big. In the North East for example Durham would be a good example, or the proposed North of Tyne authority.

     

     

     

    David Taylor-Gooby

    Feb 14th 2018

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    In Easington we held a seminar on January 16th 2016 jointly between Easington Constituency, The Socialist Health Association and Unite and invited the public to come. There was a great turnout, including people who were willing to admit they suffered, or had suffered, mental health issues. There were almost 50 people there.

    We had some good speakers too, who were willing to give up their time on a Saturday, Dr Paul Williams from Teesside and Dr Kamal Sidhu from Easington, joined by Anna Lynch, Director of Public Health for Durham. I am very grateful to all of them, as well as the people who made an effort to come.

    The following points emerged from the discussion

    1. The Marmot Report on Health Inequalities addresses the issue of how we are to achieve greater equality in health and advocates concentrating more resources on young children People who suffer from mental health problems often live in communities which do not function well, and are likely to suffer from lack of work and money. Giving children a better start in life will help.

    1. By contrast many thought we should spend less on end of life care. Many frail older people end their days in hospital rather than in their own homes with the support of friends and family, which is where they would usually much rather be. But caring for the frail elderly in the community sounds very rosy, and even the most dedicated families need support, and at the moment that support often simply isn’t there. It is provided from the social care budget which is funded by local authorities. One response from the government is to transfer money from the NHS, and although the Better Care Fund, which is what the joint working with local authorities is called, works well in this part of the world, it means less money for the NHS. There other response is to say local authorities can levy a higher business rate to pay for social care, but the business rate is likely to be lower in the north than in the more prosperous south. So to ensure that pressure is taken off the NHS, and families receive the end of life care they want, more has to be given to local government, particularly in the North.

    1. The group agreed with the speaker who had said that priority needs to be given to provision in the early years. The first few years of life are crucially important in providing a foundation for good mental health. The closure of Children’s Centres was certainly not helpful.
    1. Anna Lynch, Director of Public Health, stressed the bad effects of social isolation and loneliness on not just the old, but everyone, and how this contributed to mental health problems. 18 to 34 year olds surveyed were more likely to worry about feeling alone and to feel depressed due to loneliness than the over 55s according to work done in Durham. Voluntary and community organisations do a wonderful job in helping combat loneliness, but they do need support, particularly in a less well-off area like the North East.

    1. Dr Sidhu, a GP in Easington, described the initiatives currently taking place in the area, particularly with “Talking Therapies” as an alternative to prescriptions. But concerns were raised about IAPT. It’s too often delivered by phone, when people want 1 to 1 face-to-face attention. 25% of prescriptions are not used as intended in any case. GPs would like to spend longer with their patients to investigate mental health issues. There is a funding issue, as always. It has been calculated that the needs of 100 patients in Easington are equivalent to 123 in more prosperous parts of the country. What doctors call the “inverse care law”. The most money goes to those who need it least.

    1. Much can be done by the voluntary/community sector (VCS), but it needs proper support. This is not an excuse to save money, or some romantic “Big Society” idea, but a practical way of mobilising community resources and empowering people and communities. The cooperation between the NHS, other agencies such as housing, the local authority, and the VCS as demonstrated by the Area Action Partnerships in County Durham is a good example to follow. Awareness of mental health issues should be part of the school curriculum, and even things like “mental health first aid”, training people to spot symptoms and help, rather like “First Responders”.

    1. Regarding funding proper funding of Social Care would reduce pressure on the NHS and allow people to be supported in their own homes, and support for the VCS reduces pressure on both families and social care. Organised trips to take older people out reduces loneliness, and activities as varied as fishing and mountaineering allow young people to interact with others and reduce isolation. (There are examples where the NHS and local authorities have funded such things) The important point is to reach those in need. There is a difficult balance to ensure that the better off do not dominate such activities, but that they are not simply reserved for those deemed to be in need. What is needed is a comprehensive social mixture.

    1. Funding is always a difficult issue when discussing the NHS, and there is no doubt that more funding will need to be made available for the NHS, and that people will have to contribute more, albeit in a fair and progressive way. But the distribution of funding is also important and recent changes in the funding formula have clearly benefitted more prosperous areas, and mental health issues tend to be concentrated in areas of deprivation.

    1. Regarding the care of the elderly, there is a crisis in the funding of nursing homes. Better trained staff are required, and better links with the NHS. Carehomes could be built in hospital grounds and publicly funded.

    1. Better information is needed about what services are available. The group liked the idea of Stockton’s ‘Navigators’—people who help others to find their way round the system and get to the right services for them. Better information via social media seems to be needed; that’s especially relevant for younger people. GPs need to put in more effort into finding out what services are available in the community. But it was recognised that things do change–directories of services are soon out of date etc.
    1. Employers need to be better at supporting employees with mental health difficulties. It was suggested that there could be a mental health occupational health service that employers (especially smaller employers) could link into to support their employees.
    1. Community development is an essential aspect of good mental health. The group talked about the need for communities to be caring, knowledgeable and prepared to help people with mental health difficulties. Isolation is lessened when a community is really operating as a community. Bear in mind that loneliness is experienced by the young as well as the old.
    1. Service integration is needed. Still too many people are ‘bounced around’ the system and their issues are not properly addressed. Some left on medication for years. And still too much fragmentation. Why is social care means-tested while health services are free? This points to the need for integration of health and social care which the Labour Party was the first to champion.
    1. There’s strength in numbers. Everyone needs to realise that the best way to make complaints about inadequacies in the system is by collective action.
    1. Much care for people with mental health issues is delivered at home, and in the family context. Parents struggle with isolation and stigma. This can often make the condition worse and could lead to self-harm. Proper support is needed, and as pointed out above can be delivered through the VCS and a community development approach so that those who really need it are contacted.
    1. Responding to mental health issues is something where everyone can play a role. Government has to support and facilitate. That means funding, and ensuring it is distributed fairly.

    North East Socialist Health Association Report, March 2016

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    Whatever you think about the new regime in the Labour Party, one of the good things about it is a willingness to discuss policies openly, and to invite other people to join in. In Easington we held a seminar jointly between the Constituency, The Socialist Health Association and Unite and invited the public to come. There was a great turnout, including people who were willing to admit they suffered, or had suffered, mental health issues.

    We had some good speakers too, who were willing to give up their time on a Saturday, Dr Paul Williams from Teesside and Dr Kamal Sidhu from Easington, joined by Anna Lynch, Director of Public Health for Durham. I am very grateful to all of them, as well as the people who made an effort to come.

    Dr Williams mentioned the Marmot Report on Health Inequalities (an excellent read if you are interested in the subject) which addresses the issue of how we are to achieve greater equality in health. Concentrating more resources on young children is the answer, according to Professor Marmot. People who suffer from mental health problems often live in communities which do not function well, and are likely to suffer from lack of work and money. Giving children a better start in life will help.

    By contrast many thought we should spend less on end of life care. Many frail older people end their days in hospital rather than in their own homes with the support of friends and family, which is where they would usually much rather be. But, and there is always a but, caring for the frail elderly in the community sounds very rosy, but even the most well-meaning families need support, and at the moment that support often simply isn’t there. It is provided from the social care budget which is funded by local authorities. Now we all know the budgets of local authorities are being squeezed, and local authorities are in the north have been hit worst because they received extra help from the previous government. The government’s response has been first to transfer money from the NHS budget, and although the Better Care Fund, which is what the joint working with local authorities is called, works well in this part of the world, it means less money for the NHS. There other response is to say local authorities can levy a higher business rate to pay for social care, but you don’t have to be a genius to realise that the business rate is likely to be lower in the north than in the more prosperous south. So to ensure that pressure is taken off the NHS, and families receive the end of life care they want, more has to be given to local government.

    Anna Lynch stressed the bad effects of social isolation and loneliness on not just the old, but everyone, and how this contributed to mental health problems. 18 to 34 year olds surveyed were more likely to worry about feeling alone and to feel depressed due to loneliness than the over 55s. according to work done in Durham. Voluntary and community organisations do a wonderful job in helping combat loneliness, but they do need support, particularly in a less well-off area like the North East.

    Dr Sidhu described the initiatives currently taking place in Easington, particularly with “Talking Therapies” as an alternative to prescriptions. 25% of prescriptions are not used as intended in any case. GPs would like to spend longer with their patients to investigate mental health issues. There is a funding issue, as always. It has been calculated that the needs of 100 patients in Easington are equivalent to 123 in more prosperous parts of the country. What doctors call the “inverse care law”. The most money goes to those who need it least.

    So there is a clear message. Dealing with mental health is a challenge for all of us, and we can all help, even in small ways such as befriending lonely people. But we cannot escape the fact that the Government needs to distribute resources for both health and social care more fairly and in accordance with need.

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    By Clare Bambra, Durham University and Alison Copeland, Durham University

    The north-south divide is a powerful trope within popular English culture and it’s also evident within the country’s health. A recent report by Public Health England showed that between 2009 and 2011, people in Manchester were more than twice as likely to die early (455 deaths per 100,000) compared to people living in Wokingham (200 deaths per 100,000).

    This sort of finding isn’t new; for the past four decades, the north of England has persistently had higher death rates than the south, and the gap has widened over time. People in the north are also consistently found to be less healthy than those in the south across all social classes and among men and women. For example, average male life expectancy in 2008-10 in the north-west was 77 years, compared to 80 in the south-east.

    A large amount of this geographical health divide can be explained by social and economic differences with the north being poorer than the south. Certainly, over the past 20 years the north has consistently had lower employment rates (for example this is 70% in the north-east compared to 80% in the south-east).

    This is of course associated with the lasting effects of de-industrialisation (with the closure of large scale industry such as mining, ship building and steel) and the lack of any replacement jobs or a strong regional economic policy.

    While the NHS clearly cannot address all the issues that cause the north-south divide, there have been attempts to increase NHS funding in areas that have the worst health – and many of these are in the north. The current NHS funding formula considers factors such as deprivation and ill-health indicators by area, so places with worse health and higher deprivation have higher NHS budgets.

    However, NHS England has a new funding formula out for consultation which fundamentally changes the way money is allocated to General Practitioners for the care of patients, and it appears that the north will lose out.

    In our BMJ letter, we mapped the new NHS funding data and this showed clearly that the more affluent and healthier south-east will benefit at the expense of the poorer and less healthy north. For example, in areas like south-eastern Hampshire, where average life expectancy is 81 years for men and 84 years for women, and healthy life expectancy is 67 years for men and 68 years for women, NHS funding will increase by £164 per person (+14%).

    This is at the expense of places such as Sunderland, where average life expectancy is 77 years for men and 81 years for women and healthy life expectancy is 57 years for men and 58 years for women, and where NHS funding will decrease by £146 per person (-11%). More deprived parts of London will also lose out with Camden receiving £273 less per head (-27%) under the proposed formula.

    While the objective of the new formula is to provide “equal opportunity of access for equal need”, these geographical shifts are because it has defined “need” largely in terms of age and gender, with a reduced focus on deprivation.

    It also uses individual-level, not area-level need, GP-registered populations rather than higher wider population estimates, and secondary care (use of hospitals and A&E) not primary or community care use. This means that areas with older populations have higher health care usage so they are getting money transferred to them from areas with fewer old people.

    However, areas with more old people are also areas that have healthier populations who live longer – hence there are more old people. These healthy old people are largely in the south-east so, within a fixed NHS budget, the new NHS formula can only shift money to them by taking it from others.

    The new formula appears to shift NHS funds from some unhealthy to healthy areas, from north to south, from urban to rural and from young to old.

    Many of the areas that will lose NHS funding if the new formula is implemented are the same areas that have also lost out from above average cuts to local authority budgets. The scale of the potential NHS funding shifts will add further stress onto these local health and social care systems and potentially widen the north-south health divide by reducing access to NHS services where they are needed most.

    The authors do not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article. They also have no relevant affiliations.

    The Conversation

    This article was originally published at The Conversation.
    Read the original article.

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