1 PLANNING THE HEALTH AND PERSONAL SOCIAL SERVICES TO REDUCE INEQUALITIES: AND A DISTRICT ACTION PROGRAMME

8.1 In the preceding analysis we have traced the decline of infectious disease and the relatively greater importance today among the causes of death and ill-health or injury, of conditions attributable to or exacerbated by smoking, environmental pollution, the hazards and poor conditions of work, and accidents. In explaining the decline in infectious disease also many authorities (see, for example, McKeown, 1976, chapters 3 and 4) have emphasised the importance of an absolute historical improvement in living standards (nutrition, housing, sanitation environment – stemming partly from an increase in family incomes) in proving a bulwark against infection, or at least the worst effects of infection, as well as improvements in medicine and the health services. In general terms, therefore, any strategy to reduce inequalities in health is bound to involve areas of social policy outside the health services as well as within them. In the next chapter we will outline some of the major steps which can be taken outside the purview of the health and personal social services and devote this chapter to the services falling under the general administration of the Department of Health. Inevitably this will include some services, like services for the under fives and the nutritional services, for which the Department of Health is jointly responsible with other departments.

A. THE DEFINITION OF OBJECTIVES AND PRINCIPLES

8.2 What kind of strategy for the health and health related services in reducing inequalities of health needs to be developed? We believe that a three-fold scheme of priorities – for children at the start of life, for those bearing the brunt of cumulative ill-health and deprivation, and for everyone in terms of preventive action – follows logically from our analysis in earlier chapters. Let us consider these in turn.

8.3 First, inequalities between the occupational classes in mortality rates are greatest in infancy and early adulthood. It would be wrong to suppose that improvements could be introduced for infants and young children without paying heed to the need for improvements in the living standards of their families and the physical constitution and access to health services of their parents, particularly their mothers. Nevertheless the wide gap in life-chances, especially among infants, together with the likelihood that the beneficial effects of any reduction of that gap will be carried over into adult life and may lead to savings in health expenditures demands that action must be taken at that stage. It seems to us, on the basis of for example, mortality data, that action needs to be taken within the health services to improve access and facilities in particular for pregnant mothers and others with infants, and that a bigger shift must take place to the community health services than hitherto planned. Thus the great majority of “excess” deaths in classes IV and V are attributable in the case of infant initially to congenital abnormalities and other complications of birth of the perinatal period, in later infancy respiratory diseases play a major part. In the case of children aged 1 – 14 the great majority of “excess” deaths in these classes are attributable to accidents and (again) respiratory disease and congenital anomalies (see OPCS, 1978, pp.168-171). As we will later go on to show, this means that special measures need to be taken in particular to improve and equalise the quality of community health services, particularly those devoting resources disproportionately to children and prevent risks of ill-health, injury or accident.

8.4 Second, we have shown that inequalities in health tend to arise from the cumulative deprivation of a life-time. The length as well as the fact of exposure to bad housing, poor working and environmental conditions, activities inimical to health (like smoking) and low income will be associated with the incidence and severity of chronic ill-health and disability as well as premature death. It cannot be sufficient to plan only for the next generation or to take steps to prevent certain health problems from arising in the future. Those who are the worst victims of past and current industrial and social practices deserve services to restore health and enable them to cope with disabilities, There is considerable evidence of the inequalities which exist. Thus, the reports of the General Household Survey for the 1970s (see Chapters 2 and 3 above) have consistently found a very marked difference between socioeconomic groups in the prevalence and severity of disablement. In the case of adults aged 15-64 the great majority of “excess” (over expected) deaths in classes IV and V are diseases of the circulatory system (especially ischaemic heart disease and myocardial infarction), diseases of the respiratory system (especially bronchitis and pneumonia) and accidents (especially motor vehicle accidents) (OPCS, 1978, pp42 and 64-66). Quite apart from preventive action within and outside the health services we consider that steps deserve to be taken to provide improved treatment for chronic conditions and services for rehabilitation, participation and domestic independence. If a broad meaning of “health” is adopted of the kind we have favoured the physical, psychological and service problems of disabled people would occupy a prominent position in a strategy to reduce inequalities of health. Moreover, as with our first objective, a marked shift of resources to community health and welfare services would be implied. We appreciate that the problem is widely dispersed in the population and that it may be possible to increase or transfer resources to measures to deal with it only gradually. Preference would have to be given to most severely disabled people first, and access for less severely disabled people improved at later stages. Inequalities between occupational classes seen to be largest among the youngest adult age groups though the problem of disablement is of course proportionately much smaller than at older ages.

8.5 Third, ill-health can be prevented and health positively encouraged by anticipatory planning, education and the right structure of services. Any examination of the causal factors accounting for inequalities, for example, in mortality rates, demonstrates both in relation to health policies and other policies the multiplicity of factors deserving attention. Such examination also opens up the possibility of causal determinants prior to those initially identified. Thus, it is now widely accepted that the contribution of medical interventions to the reduction of mortality and morbidity – even that associated with infectious disease – has been less than once though to be the case. Nutrition or diet, for example, can be a major determinant of resistance to disease. Adequacy of diet can itself be investigated in relation to social and economic factors. It becomes clear that whilst the determinants of adequate nutrition are complex, low income (combined with withdrawal of welfare foods, restricted access to markets from which the rural poor in particular may suffer, and excessive advertising of soft drinks, confectionery, and other foods of little nutritional value) can be a barrier.

8.6 What is clear in that equity in health depends on a high national standard of knowledge about self-care and the care of children and other dependants, and the pursuit of activities conducive to health, which themselves depend on such factors as high standards of home-keeping, good education and widely diffused physical and sporting activities. This suggests a coherent national programme of enormous scope and we can only hope to give illustrations of some of the most important parts of such a programme. They will include an expansion of health education, selective screening, and strong antismoking measures. What is important to convey is the relative inexpensiveness of measures which might reduce the numbers of certain kinds of patient or casualty. We are deeply conscious not only of the preposterously small part of NHS resources committed to “preventive health” but also the lack of understanding by, health authorities (education authorities) of good health practice and how they might contribute to strengthening and supplementing such practice.

8.7 Our objectives are therefore three-fold:

(i) To give children a better start in life.
(ii) For disabled people, to “reduce the risks of early death, to improve the qualitv of life whether in the community or in institutions, and as far as possible to reduce the need for the latter.
(iii) To encourage good health among a larger proportion of the population by preventive and educational action.

8.8 These objectives are of course interrelated. If they are pursued vigorously inequalities in health can be reduced. Later we set out in some detail how they might be interpreted. We recommend their adoption by the Secretary of State for Social Services.

8.9 How far are these objectives observed at the present time? If the analysis of inequalities in health has implications for policy then present methods of planning and resource allocation need to be reviewed to find whether any changes are required. In the next section, therefore we will review DHSS priorities and go on, in the following section to review methods of allocating resources to the health and personal social services. Our concerns are very much within the spirit of the two documents on priorities: Priorities for Health and Social Services in England and The Way Forward, and the Resource Allocation Working Party Report. We note that the Royal Commission on the National Health Service broadly endorsed both the priorities and the method of allocating resources (Report, 1979, pp 69 and 345). This prepares the ground for the two final sections of the chapter. In these sections we propose first a programme for all areas and second an additional programme to be attempted experimentally for ten areas with highest mortality.

8.10 This strategy requires one further brief introductory comment. What might be called an “area deprivation” strategy has not so far been formally adopted in health care policies although it has been followed up in the policies of other central departments – the Department of Education, the Home Office and the Department of the Environment – in the last 12 years. The concepts of “Educational Priority Area”, “Community Development Project”, “Housing Action Areas” and “Inner Cities” have become well known. The idea of “positive discrimination” has been pursued with enthusiasm though with some lose of clarity and coherence. Thus, different passages of Chapter 5 of the Plowden Report could be read as advocating discrimination in favour of the most educationally deprived areas, schools and pupils. These three are of course very different policies and an almost totally different list of beneficiaries. We are conscious of both the advantages and disadvantages of different forms of “positive discrimination”. The term itself can be misleading because it implies, or rather tends to be taken to mean, that individuals groups or populations are singled out for preferential or above-average” treatment to redress their deprivation. In practice, close examination suggests that new programmes are attempting only to bring services in a small number of places closer to the national standard by exceptional, supplementary action. There have been difficulties in selecting areas of deprivation because of lack of certain kinds of information. And the programmes have rarely been related either to the possibility of putting experimental schemes subsequently into wider practice or integrating them fully into the administration of services in their areas. On the other hands when money in tight there is some advantage from developing demonstration experimental and compensatory projects.

8.11 We believe that additional resources need to be committed to those at relatively high risk of ill-health or premature death through the community health, health-related and preventive health services. This must include action in all areas as well as in areas of high risk. The argument for selecting a small number of areas for special action is three-fold:

i. for purposes of demonstration. When resources are scarce the beneficial effects of adopting additional measures generally can be demonstrated for a few places; (ii) for purposes of experiment. When there are doubts about the best methods of developing certain features of services – for example early ante-natal attendance or collaboration in assessment and visiting of disabled or elderly people by the statutory and voluntary services – alternatives need to be tried and evaluated; (iii) for purposes of developing reasoned priorities. Comparatively little is known about the relationship between health service inputs and outputs and it is becoming more and more important to discover what additional developments (and rearrangements of service) are most economically related to high standards of health in a population and the reduction of inequalities in health. Research and information services have developed too haphazardly. While they have to continue to be developed in all regions of the country a complementary strategy of concentrating studies in a few areas deserves to be properly backed. Experienced and clever investigators can be induced to go to areas where the greatest problems are to be found. A programme of inter-related studies will be a lot cheaper to finance, and is more likely to produce the kind of results likely to assist the formulation of priorities.

8.12 For the above reasons we have divided the ensuing sections following our introductory section (A), on objectives and principles of analysis, into 4 parts: (B) a review of existing plans and priorities; (C) a review of the current methods of allocating resources; (D) the need for a district action programme in all areas, and the major components of such a programme; and (E) an additional and experimental programme in 10 areas of high mortality and social conditions.

B. PLANNING

8.13 In developing the right strategy existing methods of planning must be carefully reviewed. In this Section (B) we shall discuss the Government’s formulation of priorities, and in the next Section (C) the methods of allocating resources equitably and efficiently to relative need” (according to the terms of reference of the Resource Allocation Working Party). Priorities in the development of services, set out in the consultative document on Priorities (1976) and the Way Forward (1977) were reaffirmed in the planning guidelines for 1978-79 issued to health and personal social service authorities. For this period of the late and middle 1970s, therefore, the emphasis in theory has been upon care in the community. The document on Priorities sought above average (ie> 2% on current account) rates of increase in expenditure on services used mainly by the elderly (including home-nursing, hospital geriatrics, home helps etc); on services used mainly by children and families with children (including health visiting); and on services for the mentally handicapped. A less than average rate of growth was envisaged for acute and general hospital services, while (in the light of the then declining birthrate) expenditure on hospital maternity services would actually be reduced. Attention has also been drawn to the continuing importance attached to preventive health measures expanded family planning services, the special needs of ethnic minorities ( and the special problem of late entry to ante-natal care), the Inner City, development of facilities for women seeking termination of pregnancy, the rationalisation of acute hospital services, and the need to ‘consider ways in which local take up of ante-natal services might be improved’. With these general statements about priorities we are in whole-hearted agreement, though we regard improvement of the quality of maternity care as crucial: there can be no scope for savings here. Nonetheless, at least 2 disconcerting observations need to be made. First, objectives are neither clearly defined nor operationalised, A good example is that of ‘community care’. The Department itself seems to mean different things by this concept at different times. For example, in one overall review of planning the Department defined one of its primary objectives for the elderly to be to develop domiciliary provision and encourage measures designed to prevent or postpone the need for long-term care in hospital and residential homes’ (DHSS, Social Care Research 1978, p.13) but in the planning document The Way Forward community care was defined to cover a whole range of provision, including community hospitals, hostels, day hospitals, residential homes, day centres and domiciliary support. ‘The term “in community care” embraces primary health care and all the above services, whether provided by health authorities, local authorities, independent contractors, voluntary bodies, community self-help or family and friends’. (The Way Forward 1977, p9).

8.14 We appreciate that clarification of the objectives can sometimes provoke public controversy (because people then have something precise with which to agree or disagree), and that time can be taken up in needless acrimony. But the purpose of better educating the public can be served, the need for accountability in a democracy strengthened, and, very important, short-comings or ambiguities in the initial thinking made good.

8.15 Second, some of the changes recommended in the plan are simply not materializing, or are materializing so slowly as to be difficult to discern. Thus, the latest trends in spending on the personal social services give little or no sign of the planned decline in spending on residential care, with the corresponding expected increase in community care (Table 8.1). And a summary of local authority planning returns does not bear out the change in emphasis recommended by the DHSS. (Local Authority Personal Social Services Summary of Planning Returns 1976-77 to 1979-80. 1978). Developments can also be traced in the public expenditure White Papers. In 1972-73 and 1973-74 expenditure on the personal social services at constant prices grew by 15 per cent per annum (CMND 7049) whereas in 1974-75 and 1975-76 the rate slowed to 8.3 per cent and 6.5 per cent respectively, and became a negative rate in both 1976-77 and 1977-78, being minus 1.3 per cent and minus 1.6 per cent respectively (CMND 7439). So despite the high priority given to the growth of the personal social services in the 1976 consultative document and subsequently, the publications in fact marked a halt in the previous exceptional growth of those services. Moreover since expenditure in 1977-78 and 1978-79 estimated in the latest White Paper (GM 7439) falls short of what was planned in the previous 2 White Papers by about 2 per cent and one per cent respectively, there is reason to doubt the Government’s capacity to realize the prospective plans for growth of between 21/2 per cent and 3 per cent in the next 5 years. Planned changes in the emphasis of spending were modest, excessively modest as we will argue below, but the inability to fulfil them requires analysis and explanation.

Table 8.1 Distribution of expenditure within the personal social services

Percentage distribution of local authority expenditure
Year residential care community care day care other total
1974-5 49.6 22.7 11.3 16.5 100
1975-6 51.0 21.7 11.4 16.0 100
1976-7 50.8 21.0 11.8 16.4 100
1977-8 50.6 21.1 12.0 16.3 100

8.16 The latest guidelines, representing the priorities of the previous government, are shown by programme and by sector in Tables 8.2 and 8.3. [omitted] No doubt those will be reviewed during the current financial year by the present administration, following the general decisions about public expenditure and cash limits announced with the budget proposals in June 1979. expenditure on community health services is shown as projected to increase by 3.6 per cent per annum compared with 2.1 per cent for all health and personal social services, and 1.7 per cent for hospital services. Within the community health total, expenditure on health visiting (mainly directed at children) is seen as growing by 6 per cent per annum. We have already stressed the importance we attach to the ‘outreach’ capacity of health visitors. We are less happy about the projected zero growth rate for the school health service and only 0.7 per cent for welfare food. The justification for not increasing expenditure on school health is the declining numbers of school age children over the coming years. In our view there are many areas where even a decline in school population should not outweigh the need more regularly to monitor the health of all school children in determining the proper distribution of expenditure. If, as we recommend in Chapter 7, statistical reporting on the working of the school health service were made on the basis of the extent to which children, and particularly children at risk by virtue of social factors were examined, then the deficiencies of current levels of provision would be apparent. Such universal monitoring of child health is an essential accompaniment of the more selective interventions of health visitors. So far as welfare food is concerned we are aware of the low take-up and aware also that the figures have dwindled since the heavy advertising programmes in 1971 and 1972, when take up was greatly improved. Until April 1971, parents of children under 5 years of age could obtain a milk token book which entitled them to one pint of milk at a cheap rate. The extension of eligibility for free milk has not fulfilled expectations and we recommend that a non-means-tested scheme should now be introduced, beginning with couples with their first infant child, and infant children in large families. Publicity for, and distribution of, national dried milk and welfare vitamins should also be improved.

8.17 Table 8.3 (omitted) indicates that, overall, the community health service share of the total hospital and community health budget is intended to grow from 8.4 per cent in 1976-77 to 9.2 per cent in 1981-82 (Revenue account only). This expenditure includes 3 items – provision for the care of young children, provision for disabled and elderly people, and prevention – which we consider deserve to be accorded higher priority. Some other items deserving higher priority are to be found elsewhere in the tables particularly under the headings “Personal Social Services” and “Family Practitioner Services”. What is the right distribution of resources between services? It may be argued that there is very little hard evidence on the relationship between further investment in particular parts of the health and personal social services and an improvement in the health of the population. Yet the existing distribution as between different types of health care or service is not the result of the accumulation of knowledge of the best use of national resources in securing a healthy society, but more the result of the historical interplay of the health care professions, central and local administration and party and public opinion. Admittedly there are pointers from certain types of research. Thus, the DHSS sponsored a study of infant deaths in 3 areas to try to identify avoidable factors contributing to deaths. Two pediatric assessors believed there were avoidable factors in just over a quarter of the deaths – divided between parental factors (a third), general practitioner or hospital factors (a quarter) and social factors (a third). The hospital factors included hospital acquired infection, diagnostic failures or delay and faulty management The GP factors included delay in visiting, slow referral to hospital, underestimation of the severity of the condition and diagnostic delay or failure. (Report of Public Health Medical Subjects 1970 No 125). In other studies the poorer outcome of treatment for certain conditions in some hospitals than others has been measured. (For example, Ashley, Howlett and Morris 1971). These suggest what kind of steps cm be taken to correct the distribution of resources or concentrate them and improve accountability and administration. But they hardly allow precise quantitative assessment of the percentage of expenditure which should be devoted to each service. The same might be said, for example, of studies of in-patient costs in acute and long-stay hospitals and studies of the merits of residential versus domiciliary care. Thus, for elderly, physically handicapped, mentally handicapped, and mentally ill people quantitative evidence can be collected on capacity for self care, desire for independence, the degree of their social interaction, the frequency of medical and nursing treatment, general satisfaction with residence and the costs of accommodation. This kind of work may be said to be vital for the purpose of reaching better judgements about the desirable future balance between different types of service. Bat any claim to discriminate mathematically and finally the exact percentage of the population who should be in hospital or other residential accommodation rather than provided with supporting services in the home must remain spurious.

8.18 Nonetheless, there are 2 methods of making more reasoned estimates of how resources should be allocated between services. One is to acknowledge the force of certain evidence or arguments in favour of the more rapid growth of some services then others. Concessions can be made to studies of shortfalls in provision for meeting needs, studies showing the cost and other advantages of alternatives to institutional care and the pressure of public opinion in favour of improving services for dependent groups in the population, such as the elderly, as well an protecting and expanding general practice.

8.19 Thus, in 1976, the DHSS argued for a relatively higher rate of growth for primary than for hospital care (both acute and long-stay), and high rates of growth for day care for the elderly and other minorities, residential care of the mentally handicapped and mentally ill, home nursing and health visiting. Zero rates of growth were recommended for school health, clinics, welfare food and the midwifery service. However, no rationale was offered for the percentage rates chosen (DHSS 1976 pp 82.3).

8.20 The other is to make estimates of the shortfall of need in different sectors so that a statement of long-term objectives can be operationalised. A good example is provided by a succession of studies of the need of the elderly for home help (Townsend and Wedderburn 1965; Harris 1968; Hunt 1970), For some years the DHSS has consequently accepted a guideline of 12 home helps per 1000 elderly (Circular 35/72). By 1976 the number had in fact reached 6 per 1000.

8.21 These 2 methods need to be more explicitly developed and integrated. Whatever the difficulties involved in spelling out health care objectives in terms of resources, manpower and structures of service it is important for this to be done. Better short-term decisions about relative rates of growth of different parts of the health and personal social services (which are of course shaped in part by external economic and political factors) can then be taken. Moreover, some of the problems (often of a political nature) of translating long term objectives into programmatic measures of an immediate as well as more distant kind can more realistically be confronted. If both methods had been adopted in the consultative document on Priorities (976) it is unlikely that the irony of adopting a rate of growth for the home help service which would take 35 years to reach its object would have been missed.

8.22 Another example can be taken from the White Paper on Better Services for the Mentally Handicapped (1971). An attempt was made in Table 5 of that document to list the objectives of policy (flowing from research into the capacities of patients) in a quantitative form. It was proposed to reduce the number of adult inpatients of hospitals in a programme covering 15 to 20 years from 51,000 to 27,000 and to increase the number in residential care in the community (including short stay) from 5,300 to 29,400. Clearly there were marked implications for the allocation of resources between services of a proportionate kind as well as absolute kind, which were not clarified and, despite some obvious difficulties, deserve still to be clarified. At the rates of progress during the 5 years 1971-1976 Tyne has estimated that the former will take another 29 years and the latter 17 years to achieve (Tyne, October 1978).

8.23 While we are aware of the problems of conceptualising and measuring “need” (see for example the discussion in Lind and Wiseman 1978, pp 414-416) we consider there is no better alternative conceptual basis for developing a coherent rationale, for the allocation of health care resources, and recommend accordingly,

8.24 Our brief outline of recent plans published by the DHSS has called attention both to the relatively weak and inconsistent advocacy of a transfer of resources to community care and the evidence that Government intentions have not even been carried into effect in the mid and late 1970s. We recommend a shift of resources within the National Health Service and the personal social services on a larger and more determined scale than so far accomplished towards community care and particularly towards the increased availability of care for young children, and see this as an important part of a strategy to break the links between social class or poverty and health. As Table 8.4 suggests, there are parts of the health service in which current levels of expenditure need not be exceeded, or might even be reduced, because the number of patients or residents can be reduced and (as in the case of pharmaceutical services) major savings made in costs which otherwise seem all too likely to escalate.

Table 8.4 Planned and Recommended Revenue Expenditure on Selected Services (£m) (Nov 1976 prices)

1976-77 actual 1981-82 DHSS projection 1981-2 Alternative I 1981-2 Alternative II

Services to be given higher priority than at present

1. Health and Welfare of mothers and pre-school and school children
Midwives 24 24 26 28
Family Planning 12 15 20 21
Health Visiting 47 63 66 70
Day Nurseries 33 37 60 63
School Health 51 51 60 65
Welfare Food 18 19 40 43
Boarding Out 20 26 28 30
Sub total 205 235 300 320
2. Family Practitioner (other than pharmaceutical) 440 494 514 547
3. Care of disabled in their own homes
Home nursing 81 108 116 124
Chiropody 11 13 13 14
Home help 105 131 160 170
Meals 12 15 20 21
Day care 57 76 90 96
Aids, adaptations 13 14 30 32
Services for disabled 42 40 50 53
subtotal 321 397 479 510
4. Other specific preventive measures 14 17 50 53
Total selected “higher priority” services 980 1143 1343 1430
recommended increases (Total 1,2,3 & 4) +200 +287

Services to be given smaller priority than at present

5. Acute Inpatient and Outpatient, Mental Handicap IP and OP, Mental Illness IP and OP, Residential care for elderly
6. Pharmaceutical services
Total selected “lesser priority” services (5+6) 2992 3295 3095 3295
recommended decrease “lesser priority” services (5+6) -200 0
6. Experimental 10 area programme (30) 30

8.25 The first column of Table 8.4 shows actual expenditures under a number of programme headings for 1976-77. The second column, a projection of expenditures to 1981-82, is indicative of the modest shift of resources sought by the previous administration. Between 1976-77 and 1977-78 expenditure on our heading 1 (mothers and children) rose from £221.3 million to £230.8 million (at 1978 prices); or expressed as a percentage of all NHS and PSS expenditure, from 3.64% to 3.71%- Expenditure on our heading 3 (disabled) rose from £352.6 million to £359.4 million, but as a percentage of total NHS and PSS expenditure this actually represented a slight fall: from 5.80% to 5.78%. (expenditure figures taken from Royal Commission on the NHS Report Table El p426). In the third column (labelled “Alternative I”) we illustrate how the more determined shift of resources we consider necessary might be brought about essentially within planned levels of expenditure. This illustration shows savings of £200 million in 1981-82, set against additional expenditure of £200 million plus £30 million for the experimental 10-area action programme described below. This reallocation of resources does not imply reduction in current levels of expenditure, but only in the (admittedly small) anticipated rate of growth. In our view the largest scope for reductions in rate of growth of cost, if not in absolute cost, is in pharmaceutical services, and in general we endorse the recommendations made by the Royal Commission on the National Health Service designed to achieve this end (Report, Chapters 7 and 8).

8.26 Some of us consider that the rate of growth to 1981-82 envisaged in the planning documents quoted (ie. an expenditure of £3295 million on what we term ‘low priority services’) will do no more than permit an overall maintenance of current levels of provision. It would then follow that any reduction, even in these services, would have serious consequences. Column 4 in Table 8.4 labelled “Alternative II”) illustrates how the shift of resources we have recommended should be brought about on the more optimistic assumption that no service should be financed at a level below that previously forecast for 1981-82, and that additional resources could be made available. On this basis our proposals would require an additional £287 million, plus £30 million for the experimental action programme.

8.27 These recommendations should however, be thought of as money saving in two senses. First, by reducing inequality and laying a better basis for the maintenance of health, the incidence of ill-health (and hence the need for health care treatment) will be diminished. Second, by precautionary and supportive action the need for more expensive types of treatment will be reduced. Thus, whilst it may be true that many of those in hospital require additional resources yet if fewer patients need be admitted or if the duration of stay can be safely reduced, there can still be scope for savings.

8.28 We recognise that the links in planning between domiciliary and residential services need to be developed as much as the links between health and personal social services. In the next few years we recognise that conditions will differ between Areas and Districts and that the scope for redeployment of resources will depend very much on, for example, the revenue consequences of capital schemes now coming ‘on stream’, but we see no reason why an upwards revision of the approximate magnitude we have suggested should not now be a general target.

8.29 Diversion of resources to those NHS Regions, Areas and Districts in greatest need, and (through the planning process) to fulfil the 3 objectives listed above are 2 essential aspects of the strategy to tackle health inequalities. Two kinds of district action programme deserve to be developed; one which flows from the fresh principles of allocation of resources to all districts and supplementary programs in areas of greatest need. These will be discussed in turn. We do not believe that new programmes for special areas make sense independently of changes in general policy and administration.

8.30 Within the NHS there is a strong case for a new programme of activity, even though it would necessarily include a number of elements of existing activity. Personnel at all levels would wish to play their part in a new Health Development Programme and would expect to do so. Morale would suffer if an opportunity were not created and certainly there in a large amount of evidence that morale is a critical problem at the end of the 1970s. ‘It is not the organisation that is the Services’ chief ailment. The prime trouble in low morale in many workers – and some would no doubt assert that reorganization increased their despondency. What [the Service] needs, above all else, are clearer efforts, visible to all to increase the satisfaction and togetherness of its employees’. (Editorial The Lancet, 6 January 1979). Obviously adequate reward has much to do with morale but involvement in a project to raise standards and save lives would we believes capture the imagination and release the enthusiasm of many groups of health personnel.

8.31 It will not be our purpose to spell out a programme in every last detail. Since the Royal Commission on the NHS has recently reported on a wide of matters that would be invidious. Our task is rather to emphasise the principal causes in inequality in health and specify the kind of measures that can be adopted to reduce such inequality, leaving to the Secretary of State, after studying the Royal Commission’s Report, the responsibility of accepting and extending our suggestions in relation to those of the Royal Commission as he sees fit, but also to district teams the responsibility of deciding how national guidelines can be applied to local conditions.

8.32 In general we believe our recommendations complement those of the Royal Commission, particularly in relation to the need to improve primary care and introduce better preventive services and services for different groups of handicapped people.

(C) RESOURCE ALLOCATION

8.33 Within the planned growth of resources for the health and personal social services the Secretary of State has sought to reduce inequalities in the allocation of resources to different areas. The strategy was outlined in the 1976 Report of the Resource Allocation Working Party. Our recommendations complement those of that working party, in further operationalizing the philosophy expressed in their report. Some comments on the RAWP approach, which has been misunderstood by many commentators and which is fundamental to the reduction of inequalities in health, are a necessary preliminary.

8.34 The appearance of the Working Party’s Report (Sharing Resources for Health in England, 1976) was very welcome It ha been appointed in May 1975 “to review the arrangements for distributing NHS capital and revenue to RHAs, AHAs and Districts respectively: with a view to establishing a method of securing, as soon as practicable, a pattern of distribution responsive objectively equitably and efficiently to relative need and to make recommendations”.

8.35 The Working Party interpreted the underlying objective as being to secure, through resource allocation, that there would eventually be equal opportunity of access to health care for people at equal risk (1976, P.7). We would wish to endorse this objective. Secondly, as the terms of reference directed, the RAWP team emphasised the importance of ensuring that the availability of the finite resources at the NHS’s disposal, “should be determined in relation to criteria of need” (1976, p.8). Their procedure was essentially to use age-sex structure of the population together with standardized mortality ratios (in the case of certain services) to ‘weight’ regional populations for each of the various groupings of services. These groupings were: non-psychiatric in-patients; all day and out-patients; community health; ambulances; mental illness in-patients; mental handicap in-patients; and family practitioner committee (FPC) administration. Target revenues for each region were built up by assigning to each of these groups of services its current share of total national expenditure: costs of FPC services being excluded. SMRs, it was argued, were the best available indicator of morbidity (and hence by implication) of need for services. It was recommended that similar methods to be used in allocation at the sub-regional level. The effects of seeking to reallocate resources by means of weighting populations on the basis of their age and sex structure differ substantially from those of utilising a formula based also upon SMRs -thereby taking account of populations with disproportionately large numbers of people in the unskilled and partly skilled manual classes at greater risk of ill-health and mortality (See Fig A7.2).

8.36 In the case of capital expenditure needs, populations were weighted not by age, but by family practitioner consultation rates. Further information on the RAWP methodology is given in Appendix 7. It must be emphasised that the most important innovation introduced by the Working Party, and the one having most effect on allocations made, is the introduction of a morbidity factor based upon SMRS. Strong criticism have been made of this (for example, Barr and Logan, 1977, pp.996-997 and we would accept that where possible age-specific mortality ratios should be used either in substitution or conjunction. But though further refinements will have to be made, we do not think that the principle should be abandoned. Our view is that the SMR is the best available indicator of health care need, when used in conjunction with information about size and structure of the population. Those who have objected that morbidity indicators do not always correspond with SMRs (for example, Snaith, 1978) do not appear to give sufficient weight to the incompleteness of the former. Thus while there are separate indicators of acute and chronic illness they are neither comprehensive nor easily combined. Moreover further studies have tended to demonstrate a significant relationship between such indices of short, medium and long-term morbidity as are available and mortality, for areas and not only regions. (W Midlands Regional Authority, 1977)

8.37 Where the Working Party have less to say is first in accepting the current distribution of resources as between in-patient and community services, and second in accepting present national rates of utilization of different types of service. What happens is not a good measure of what should happen, however convenient that may be. However, an ideal allocation of resources cannot easily be defined and to us it seems possible only to give some preliminary indications of the steps that can be taken quantitatively (as in Table 8-4 above) to incorporate shifts between services and changes in the patterns of utilisation of services, along with the shifts implied by the RAWP analysis, that may be required. While acknowledging that those figures are preliminary and can be much improved, we seek to make two points: first, that policy priorities in the change in emphasis of services can be related much more exactly to needs for health care than has been appreciated; and that only by insisting on such a process of reasoning is it possible to produce, over a period of years, the necessary resources to make a sufficient contribution to the reduction of inequalities in health.

Resource Allocation in Practice

8.38 How were the recommendations of the Resource Allocation Working Party put into practice? In the early stages of applying a new form of allocation one would expect certain modifications to be made at national, regional, and area levels. Decisions also have to be made about the rate of advance towards targets. At national and regional level this was brought out in the Secretary of State for Social Services’ statements of 21 December 1976 and 5 February, 1979 and his detailed letters to Regional Health Authorities of the 21 February, 1977 and 28 February, 1978 (See Appendix 8). Thus, attention was called to “certain specialist facilities which serve more than one region”, “the need to replace expensive equipment in dental hospitals”, and various provisions for teaching (Statement of 5 February, 1979). Acting on Departmental Advice, RHAs have also made modifications to “bring major capital works into use”, “enable clinical teaching to be maintained” and made good imbalances in distribution between areas, districts and individual hospitals “not picked up by adjustments to targets based on patient flows”. (Appendix 8, letter of 28 February, 1978, p.2). Table 8.5 sets out the decisions about allocation of resources for 1979-800, based on the RAWP methodology, reached by the then Secretary of State.

Table 8.5 Proposed allocation of resources for 1979-80 in relation to assessment of needs

Regional Health Authority Starting Figure (ie 1978/79 main revenue allocation) £’000 Revenue “target” £’000 Distance from “target” as % of starting figure revenue increase % Main revenue allocation £’000 Distance from “target” after allocation as % of allocation Capital allocation excluding joint finance £’000
North Western 317,878 416,572 -12.02 3.00 383,028 -8.76 36,700
Northern 272,094 300,513 -10.45 2.77 279,624 -7.47 23,800
Trent 358,297 394,735 -10.17 2.73 368,067 -7.25 37.000
West Midlands 426,405 462,502 -8.47 2.51 437,095 -5.81 32,000
East Anglian 151,641 163,189 -7.62 2.40 155,281 -5.10 19,600
South Western 268,867 285,954 -6.36 2.26 274,937 -4.01 21,000
Wessex 217,847 230,906 -6.00 2.22 222,677 -3.70 20,700
Yorkshire 308,756 327,218 -5.98 2.22 315,606 -3.68 29,300
Mersey 231,069 237,808 -2.92 1.90 235,459 -1.00 22,400
Oxford 177,571 179,633 -1.16 1.75 180,671 +0.58 12,900
SW Thames 296,993 283,218 +4.64 1.34 300,963 +5.90 18,400
SE Thames 372,052 338,462 +9.03 1.12 376,212 +10.03 22,700
NE Thames 389,333 348,358 +10.52 1.06 393,453 +11.46 24,700
NW Thames 351,236 308,751 +12.10 1.00 354,746 +12.98 18,500
4,194,039 4,277,819 -2.00 2.00 4,277,819 339,700

Resource allocation at the Sub-Regional level

8.39/40 We are unable to give a comprehensive picture of how the RAWP methodology has been applied by the Regions: systematic data on this were not made available to us . We therefore attempt only to illustrate the new process of allocation at this level. The evidence of the last 3 years is that the 14 RHAs have by and large endeavoured to implement the RAWP methodology, though 4 have not yet applied the SMR principle and 5 of the others have not yet felt able to adopt the more sophisticated cause-specific SMRs recommended in calculating the needs of their areas and districts for non-psychiatric in-patient care. Even among RHAs adopting the full methodology the progress made towards the restrictedly defined targets has been cautious, as Table 8.6 illustrates. After allowance for administration and a few other items the Table gives the AHA ‘target’ resources. It should be noted that the target for Newcastle includes a figure amounting to nearly 10 per cent of that target, representing the Service Increment for Teaching (SIFT) which is calculated independently of formula (some critics eg. The Radical Statistics Health Group, 1977, PP.14-15 have argued that this element of the procedure not only protects the relatively high resources of teaching hospitals but “also reallocates funds back to the Thames regions”) It can be seen from the Table that the Northern Region had an additional £6.7 million (at constant prices), or 2.6 per cent, to distribute in 1979/80 compared with the previous year. (This represents about £l.5 million or 0.6 per cent more than the standard national increase.) Nearly half the available increase was earmarked for the Regional Consequences of Capital Schemes’ (see column 3) – much of it going to one of the best endowed AHAs. We understand that future provision of this kind is likely to go disproportionately to the AHAs which are least well endowed, but the figures illustrate the ‘off-setting’ outcome that adjustments of this kind can have when attempts are made to equalise resources. The Table also illustrates the differential allocation of the remaining £3-5 million, ranging from an additional 0.9 per cent to Durham AHA to 2.2 per cent to South Tyneside. Assuming that the figure of £3.5 million was the maximum available for distribution this meant, in the case of these two AHAs, that Durham AHA obtained about £170,000 less for 1979-80 than it might have done under “incremental” planning arrangements and South Tyneside AHA obtained about £80,000 more. There will be those who would judge such sums as small relative to total health expenditure We take the view that if sustained for a number of years in a cumulative way and translated into the right services these changes in expenditure can exert a significant impact, and if, in addition, greater flexibility can be introduced into the flow from hospital-based to community services, and improvements also made in the distribution of general practitioner and health-related services, a notable transformation could be brought about in a period of 10 years.

Table 8.6 Northern Regional Health Authority 1979/80 Revenue Cash Allocations November 1978 pay and prices: £000’s

(Targets are based on the regional formula. Betterment funds are distributed pro rata to distance from target)

AHA 1979/80 target 1979/80 starting figure Provision for RCCS Distance from target General Development Funds 1979/80 proposed allocation % Target
Cleveland 49088 43375 550 5163 735 44660 90.98
Cumbria 37337 34417 100 2820 401 34918 93.52
Durham 48715 45217 500 2944 419 46190 94.82
Northumberland 28582 25409 68 3105 442 25919 90.68
Gateshead 14219 12678 1541 219 12897 90.70
Newcastle (T) 59283 53586 1840 3857 549 55975 94.42
North Tyneside 9467 8561 906 129 8690 91.79
South Tyneside 10311 8950 1361 194 9144 88.68
Sunderland 27822 24978 194 2650 377 25549 91.83
Total for AHAs 284824 257225 3252 24347 3465 263942 92.67

8.41 Whilst recognising the force of some of the criticisms of the RAWP methodology that have been put forward – eg, age-specific mortality ration should replace SMRs – we have argued that the approach is nonetheless justified. However, it has not been consistently applied at area or district level. Nor has the possibility of supplementing the approach by means of additional indicators of need been sufficiently discussed. Partly this is a question of time to develop an appropriate methodology, especially to deal with the problems of measuring utilisation when there are big differences between the statutory boundaries of health districts and the catchment areas of services, especially hospital services, in those districts. The characteristics as well an numbers of patients attending services outside the districts in which they live have to be checked and used in planning. Partly it may be a question of bringing general practitioner and health-related services also into the reckoning. But there is the question too of securing public confidence in the procedure, This leads us to recommend inviting Health Authorities to consider increasing the volume of information collected and published regularly for each health district about (a ) health experience (indicators of activities as well as of morbidity and mortality); (b) rates of usage of health and health-related services (including GP consultations, out-patient attendance, home nursing and health visits and in-patient and residential care) and (c) social and environmental conditions. Some of the misunderstanding of the RAWP report was due to the fact that precise illustrations at district level of the actual and desirable operation of different services were not given. We are conscious that some Authorities already collect such information for administrative and planning purposes but do not always make it readily available. While we would not wish to justify massive additional expenditure for this purpose we believe that during the present period of severe expenditure restraint it will become increasingly important for authorities to relate health service inputs to outputs and that modest expenditure on developing relevant information may be necessary to ensure economical methods of management.

8.42 We consider it both desirable and feasible in the allocation of resources that some account be given of (i) the composition of the population of an area, in terms not only of age/sex and social or occupational class but also of other groups likely to have particular needs for care, and (ii) extent of overcrowding and other aspects of physical-environmental conditions having established link with ill-health. To some extent this issue can be clarified by comparing the effects for areas and districts of applying (a) the SMR principle (b) social indicators of need. Our intention here will be to show only how and why this might be done. There are difficulties involved, as discussed above in applying RAWP’s philosophy at a sub-regional level (for this, see Snaith (1978), Senn and Shaw (1978)), to some extent associated with fluctuations in small numbers of deaths,, While not all RHAs have yet adopted the methods recommended in applying resources to areas and districts we suggest that some would be less hesitant if they were encouraged to review and bring forward evidence of other indicators than mortality of health experience and compare health with other area indicators.

Area Indicators of Social Deprivation

8.43 Are there area indicators of social deprivation which might be used independently or in supplementation of SMRs in developing a formula for resource allocation? Relevant indicators cannot, in general, be derived from surveys (such as the GHS) since sample sizes are inadequate for a breakdown by Health District or Area. The principal sources must be the Census (which means, of course, that indicators now reflect conditions obtaining in 1971) and, in principle, routinely-collected administrative and vital statistics. The Census provides information on a range of deprivation-related factors available at local authority, and enumeration district level. Despite the age of currently available data, and despite the fact that indicators reflect housing need in greater detail than they do other forms of need or deprivation, the Census indicators remain the principal source of ecological data on social conditions. Valerie Imber has used them to classify the 108 English local authorities with responsibility for personal social services (metropolitan districts, non-metropolitan counties, London boroughs) in terms of ‘need’ for these services. Because of the close connection between this form of ‘need’ and that for health care (and particularly need for preventive health care), her analysis provides a convenient starting place. It should be remembered that these 108 authorities (at least outside London) are essentially contiguous with the Area Health Authorities.

Table 8.7 Distribution Statistics of Social Indicators (1971 Census of Population): New Local Authorities

No Variable Mean Range
1 Number of children aged 0-4 years /1000 population 78 26-104
2 Number of persons aged 65 year+ /1000 population 131 74-235
3 Number of Irish Immigrants /1000 population 22 3-87
4 Number of New Commonwealth Immigrants /1000 population 29 2-145
5 Number of economically inactive persons aged 15 years+ /1000 population aged 15 years + 375 247-492
6 Number of households with more than 1 person /room /1000 households 66 32-164
8 Number of households living in rented property /1000 households 530 298-987
9 Number of households living in privately rented furnished property /1000 households 52 4-380
10 Number of households lacking at least one basic amenity /1000 households 184 25-489
11 Number of pensioners living alone /1000 pensioners 247 150-359
12 Number of households having one car or less /1000 households 916 810-981
13 Number of persons in employment without HN or degree /1000 population 917 803-980
14 Number of persons out of employment/ 1000 population 49 26-115
15 Number of unskilled workers /1000 population economically active 73 31-161
16 Number of persons employed in agriculture /1000 population economically active 19 0-133
17 Number of married women working more than 30 hours with children under 5 years of age /1000 working married women with children under 5 years of age 313 179-999
18 Number of lone parent families with children /1000 of all families with children 94 42-197
19 Number of married couple families with 4 or more children /1000 married couple families 42 24-116
20 Number of economically inactive males 15-19 /1000 population males 15-19 391 260-558
21 Number of economically inactive males 15-64 /1000 population males 15-64 82 51-157
22 Number of economically inactive males 15-59 /1000 population males 15-59 78 48-158
23 Number of households rented from council newtown or SSHA /1000 households 291 77-695

8.44 Imber begins with the variables listed in Table 8.7, but on the basis of the high correlations of some with others, and of a priori judgement as to which, though they reflect social conditions, are less obviously associated with need is able to reduce the number of variables from 23 to 10 (She then finds, by a cluster analysis procedure, that there are two distinct kinds of area showing high need for social services: inner city areas -typified by poor housing, high concentration of one-parent families and pensioners living alone – and areas dominated by newer housing estates with high concentrations of unskilled workers and large families.). Our purpose here is less that of classification than of selecting a limited number of variables which might be used in practice as differential indicators of need for health care (or for specific services) and it will be necessary to select still farther from these indicators. Those used by Imber, with their correlation coefficients, are shown in Table 8.8.

Table 8.8 Correlations between indicators of social need

6 9 10 11 14 15 17 18 19 20
Overcrowding Private rented furnished accom Lack of amenities Lone Pensioners Unemployment S.C.V Working mothers Lone parent families Large families Council Housing
9 .479 .586 .447 .067 -.164 .430 .752 -.068 -.376
10 .969 .736 .415 .477 .519 .794 .231 .051
11 .673 .469 .514 .208 .792 .289 .223
14 .637 .704 .150 .458 .665 .517
15 .615 .106 .309 .617 .725
17 .437 .381 .064 -.023
18 .735 .275 -.003
19 .618 .519

8.45 Table 8.8 suggests not only that, were a single factor to represent all aspects of ‘need’ sought, then ‘overcrowding’ has the highest correlations with all other indicators; it also shows how the variables cluster and might reasonably be reduced in number.

8.46 Since our focus here is principally upon the health services (though the problems to which these address themselves are not clearly separable from those of the personal social services), it is necessary to say something about the relations between these social need variables and mortality rates (ratios) – the RAWP indicator of need for health care.

8.47 There is in Britain a long tradition of study of the relationships between social conditions and mortality rates. Within this tradition, Gardner, Crawford and Morris (1961), used a variety of census indicators, plus a number of climatic and air pollution indicators, in the attempt to explain differences in adult mortality rates between the larger county boroughs of England and Wales. Multiple regression techniques allowed these authors to show, for example, that “social conditions” (an indicator combining degree of overcrowding, social class, average educational level etc was used), air pollution levels, and inclement climate were separately associated with mortality rate from bronchitis.

8.48 Using (like Imber) the 1971 census data,, together with 1971 mortality rates for children aged 0-4 and 5-14, Brennan and Lancashire sought to relate the death rates for children to social need variables, also at the county/metropolitan borough level (Brennan & Lancashire (1978). Using Kendall’s rank correlation coefficient, significant correlations were obtained between mortality rate (especially for the younger children) and extent of overcrowding, lack of basic amenities, extent of unemployment among male working population, and extent of council house occupancy.

8.49 A significant correlation was also obtained with proportion of unskilled workers and the authors then examined whether or not social class composition (understood in the restricted sense of the percentage of population in class V) housing variables (density, possession of amenities) and unemployment rate are independently related to mortality rates. Calculation of partial correlations (housing variables and unemployment rate held constant) show that the effects are independent of each other in the case of the under 5s.

8.50 Although this analysis does not bear upon causes of mortality at the individual level, it is important here in suggesting that areas having high unemployment rates, or bad housing, or a high proportion of unskilled workers (or worst, all three) are likely to have high rates of child mortality (especially in the first 5 years of life). A more sophisticated approach to the establishment of casualties would require hypotheses as to the probable delays with which deterioration (improvement) in socioeconomic conditions impacts upon mortality rates. There is no reason to such lags will necessarily be the same for say, housing conditions and unemployment. In Brenner’s work time series data are used to derive lags on the basis of best fitting of curves., Thus, he argues that post neo-natal mortality rates respond to changing unemployment with a delay of 3-5 years (Brenner, 1973/1979). In Britain an early study was carried out by Morris and Titmuss. They examined the relationship between rates of unemployment and mortality from rheumatic heart disease in the late 1920s to 1930s, and concluded that the strongest association between a changing rate and changing mortality was “when a mortality lag of 3 years is introduced”. (Norris and Titmuss, 1944, P.7). It also suggests, as the authors themselves conclude, that percentage of population in social class V alone will inadequately reflect the extent to which social factors pre-disposing to high infant mortality are present in an area. Brennan and Lancashire found in general a “strongly positive association” between high mortality and low socioeconomic position(P<0.001) for the age group under 5 years, with the older age group showing a less marked association (ibid). Of course more “inclusive” measures of class composition remain to be examined in relation to mortality. Table 8.9 shows which (post-reorganisation) metropolitan districts and non-metropolitan counties show up worst on each of 4 of the census indicators and 3 indicators of mortality (using this time recent mortality data). The frequent appearance of certain areas notably in the North West and the North East is apparent. Further work on relationships between indicators of social disadvantage and of mortality is needed.

Table 8.9 Highest ranking local authority areas on each of 8 census and mortality indicators (England)

1 2 3 4 5 6 7
Households with >1 person room per 1000 households No. unemployed per 1000 persons No. unskilled workers per 1000 economically active Married couple with >3 children per 1000 married couple families Perinatal mortality rate (average 1974-6) Infant mortality rate (average 1974-6) Adjusted mortality ratio 1976
Knowsley Knowsley Tower Hamlets* Knowsley Wolverhampton Rochdale Salford*
Islington* Liverpool* Southwark* Liverpool* Sandwell Oldham Tameside
Hackney* S.Tyneside Newham* Manchester* Liverpool* Salford* Gateshead*
Tower Hamlets* Sunderland Knowsley/ Liverpool* Birmingham* /Cleveland Gateshead* Wolverhampton Liverpool*/ Tower Hamlets/ S.Tyneside
Lambeth* Manchester* Cleveland Sefton Salford Manchester* Durham
Kensington /Chelsea Newcastle* Humberside Hackney* Rochdale Bradford Bolton/ Wirral/ N. Tyneside
Southwark* Cleveland Salford* Lambeth* Manchester* Calderdale
Brent Gateshead* Newcastle* Newham Walsall Kirklees
Camden Tower Hamlets*/ Hammersmith Islington* Salford*/ S.Tyneside/ Sunderland/ Wirral/ Lewisham* Knowsley Walsall

* indicates Inner City Partnership Scheme area

Social Need and Mortality Factors in Resource Allocation

8.51 The RAWP philosophy requires allocation of re sources in relation to need for health care; it is further argued that mortality rate (SMR) is the best indicator of need. We do not dissent from the view that SMR is indeed the single best readily available indicator. Some would no doubt argue that, since at the ecological level (child) mortality and social conditions co-vary (as Brennan and Lancashire showed) the case for this single indicator is strengthened. We have sympathy with this line of argument but prefer to keep an open mind. First, the case is at best preliminary. We would wish to see more sustained comparison of different measures of social or occupational class and social need. Second, a combination of SMR and other measures used in supplementation seems likely to produce more satisfactory, and administratively and politically defensible results. Our argument is that by also taking account of population and community characteristics (other than age/sex) indicative of need for care, as well as physical amenities and environmental conditions, a better overall measure of need for resources can be produced. This is not easy to prove since there is no direct measure of need which would permit regression of SMR (and any alternative measure of morbidity or health) and social conditions together.

8.52 Elsewhere in our report we have shown 1) that a high rate of early mortality in a population is indicative of a high proportion of surviving babies profoundly at risk of serious ill-health; and 2) that though the risks attaching (for example to low birth weight) can be compensated by an advantageous neo-natal environment, they are exacerbated by a disadvantaged environment. In other words though social factors may be reflected in the (infant) mortality rate they also increase the need for care among the survivors.

8.53 It remains true that the relative weighting of social factors and mortality rate in any need formula must be somewhat arbitrary. Yet since there is an element of necessary arbitrariness in the whole RAWP approach we do not see this as an argument against the attempt being made.

8.54 What we have in mind is perhaps best illustrated with reference to one of the (arbitrary) divisions of health services used to build up weighted populations – community health services. The basis for weighting population for community health proposed by RAWP is first, on the basis of age structure (since the average expenditure rates per capita on community care vary with age, approximately in the ratios 0-4 years 100; 5-14 years 48; 15 -64 years 4; 65+ 47) and second by SMR. It is therefore theoretically Possible for an area with a low mortality rate but a large number of children to gain at the expense of an area of high mortality rate but an aging population, compared with a distribution on an unweighted population basis. On the basis of our previous reasoning, and of the findings of Brennan and Lancashire, we may say that children living in overcrowded conditions, in areas of high unemployment or high concentrations of unskilled workers are at particular risk. We also know, though this is on a different basis, that children from one-parent families, or pensioners living alone, are likely to require more than average attention from health and personal social services. Since what is being established through population – weighting procedures is an ‘ideal’ (target) distribution of resources (with progress towards that target being a separate question) there is a particularly strong case for taking account of those special needs. In other words, in building up the weighted populations for community health purposes, the number of children in age range 0-4 should be weighted for overcrowding, for the proportion in large families, for occupational class and for unemployment. The number of elderly should be weighted for the proportion living alone.

8.55 We are very conscious of the fact that the limited number of indicators of area deprivation available from the census provide a much better guide to positive discrimination in housing policy than in health policy. Indicators which better reflect the implications of social conditions for health service needs are required, and must be devised. In Chapter 7 we have recommended that regular surveillance should be used to devise area indicators of child development: ‘direct’ measures of this kind provide a longer-term objective in generation of data for resource allocation procedures. But in the meantime, we should like to see many more NHS Regions and Areas, on the basis of Departmental advice, beginning to make use of available indicators of social need to supplement mortality rates in determining target allocations.

8.56 But we realise that some RHAs have yet to adopt mortality rates as the principal method of allocation, and recommend that the Secretary of State should now ensure that they do.

8.57 We do not believe that a more equitable distribution of resources alone, without parallel attention to how these resources are to be used, will greatly serve to reduce inequalities in health. In the debate on the RAWP recommendations too much attention has been concentrated on criteria of the need for health care and too little on the effects upon health of allocating resources to one type of service rather than another. As argued in Section B of this chapter we believe both that “need” for health care must govern the definition of priorities and that at the present time definition of such need shows the case for making a more pronounced shift of resources towards community and preventive health care. This leads us to suggest a possible modification to the implementation of the RAWP philosophy. At present “health related” and family practitioner services are excluded from the RAWP formula. We believe this to be wrong in principle because they form an integral part of the Government’s objectives for better distributed and more efficient health services, and should thus be financed on the basis of need. We consider that the criteria used in allocating resources for community health should eventually be extended both to health related and family practitioner services. We recognize, however, that this objective poses certain problems. A number of Regions currently gaining under the RAWP formula also have the highest expenditures on family practitioner services (though this is not necessarily indicative of the quality of these services). Progress towards modification of the RAWP formula to include these and “health related” services must be in parallel with the determined attempt at improving the quality and coverage of general practice which we recommend below. (It should be noted that the Royal Commission on the NHS recommended the dissolution of Family Practitioner Committees and a study undertaken of the desirability and feasibility of a common budget for the family practitioner and hospital and community services. (Report P.351.))

8.58 At present, the proposal is that weighted populations for each of the groups of services distinguished should be combined on the basis of the share of total revenue which each of these services currently represents (see Appendix 7) – ie 8.8 per cent for community health, 55.9 per cent for non-psychiatric inpatients, etc. We believe that this process should reflect not current distribution of expenditure but that which is aimed at in the planning of services. That is, if community health is a priority (and is intended to absorb, say, 10 per cent of total resources, excluding those for family practitioner services, within 5 years time) then it is this figure which should figure in the combining of weighted populations. We therefore recommend that the resources to be allocated should be based on the future planned share for different services, including a higher share for community health.

8.59 Finally, we realise that a systematic planning process was introduced in the DHSS as lately as 1974 and a system of social services planning as lately as 1976. It would be surprising if in the few years since that time a method of allocating resources in tune with priorities had spread smoothly throughout the services. But it is necessary to stress the necessity of relating accounts of health service performance – whether expressed in terms of expenditure on sub-categories of each service at national, regional, area and district or local level, manpower as items Of service – to the operational definition of priorities for past and future years. We would reiterate the Royal Commission’s endorsement of the Expenditure Committee’s categorical view that:-

“the expenditure planning and priority setting of DHSS should be synchronised so as to enable Parliament to examine the relationship between the two.” (Ninth Report from the Expenditure Committee Session 1976-77, 1977, p1vi; and see also Report of the Royal Commission on the NHS, 1979, P.56).

D. A DISTRICT ACTION PROGRAMME

8.60 Our further health service-related recommendations designed to implement the 3 objectives set out at the beginning of this Chapter, fall into 2 groups. We first outline the elements of what we have termed a District Action Programme. By this we mean a general programme for the health and personal social services to be adopted nationwide, and involving necessary modifications to the structure of care. Second, (Section E below) we recommend an experimental action programme, involving provision of certain services on an experimental basis in 10 areas of particularly high mortality and adverse social conditions, and for which special funds are sought.

i. Health and Welfare of Mothers and Pre-School and Schoolchildren

8.61 Under-utilization of the community and preventive health services by poorer groups is well documented. Whilst we cannot assess the extent to which this is a consequence of inequitable provision of services (so that, for example, working class women might have longer journey times and waiting times in visiting child health clinics), we do know that under-utilization is also associated with organisational and cultural aspects of services. One authority puts the problem as follows –

‘Under-utilization of ante-natal and child-health services result from inadequacies in the services themselves and particularly from their insensitivity to the uncertainty and conflict of responsibility mothers feel regarding the question of their baby’s health. Two particular areas of inadequacy are highlighted by recent research: firstly, inadequacies as regards the organisation of ante-natal clinics (timing of clinics and length of waiting, location of clinics, facilities for children and other relatives, etc) and secondly, inadequacies as regards the actual content of the check-up (lack of individual attention and advice tailored to the individuals needs, lack of privacy, etc)’. (Graham, 1978)

8.62 We recommend that Areas and Districts should review the accessibility and facilities of all the ante-natal and child-health clinics in their areas, and develop plans to increase utilization by mothers. On the basis of our own field experience this must include such reforms as experimenting with evening and weekend opening, the dispersion of ante-natal sessions from hospitals covering large catchment areas to new centres in small areas, and the humanisation of ante-natal procedures and settings especially in clinics in hospitals. One clinic which we visited was described to us (not unfairly as it seemed) as a “cattle market”. We are aware that some of these matters will be illustrated in a forthcoming report on initiatives adopted in various parts of the country in “reaching the consumer in the ante-natal and pre-school child health services” which is being prepared by the Child Poverty Action Group in association with the Department of Child Health Research Unit in the University of Bristol.

8.63 The DHSS should publicise factors which explain high utilization in some areas, (eg Liverpool) and low utilization in others (eg Salford). Wherever possible clinics should be established in conjunction with group practice and health centres, in partial fulfilment of the recommendations by the Court Committee. As some commentators have pointed out, relatively few General Practitioners are keen to devote more of their time to practising preventive medicine and a change in outlook will take a long time to bring about (Alberman, Morris, and Pharoah, 1977, p. 394). But the change might be encouraged if more health visiting staff are seconded full-time or part-time to group practice. There is room for experimentation and it is possible for some health visitors to combine territorial and team responsibilities. There is an even more powerful case to be made out for the secondment of social work staff but in this case knowledge of welfare rights would be a very necessary part of their skills. Ease of access, good facilities, respect for the individual and availability of care and advice throughout infancy and childhood might be the watch-words of any planned development of services. The inducements available in France and Finland (see Chapter 5) have been called to our notice, but we are aware that they were introduced in very different conditions and are not convinced that reluctance on the part of the individual mother-to-be is the key factor in under-utilization in Britain. A case independent of that to induce mothers to attend clinics early can be made for an increased rate of maternity grant and allowance. In Finland the establishment of a national network of clinics in 1945 preceded the introduction of payments, and in France ante-natal payments were introduced many years before the dramatic improvement in the French perinatal mortality rate.

8.64 With the increasing number of births in hospitals there is the problem of securing the involvement of the family practitioner at an early stage in the life of the child. There are a number of steps which might be taken. One, already mentioned, is the association of more ancillary staff with primary health care teams. (We would then urge that the teams should generally be constructed on the basis of two and at most three General Practitioners so that some contribution might be made to the vitality and integration of the local community.) Another is immunisation. “Should not the responsibility for this now rest squarely with the General Practitioner and his nursing colleagues? He has the knowledge of family history, and of the health and development of the child, to help him take the responsibility of advising on the timing and safety of immunisation and vaccination – and the authority with the public to carry it through. Moreover, the General Practitioner will often be the first to know untoward reactions and he can follow children with such reactions.” (Alberman, Morris and Pharoah, 1977, p 394). In principle we advocate such a policy, though we recognise that for some time to come there will have to be back-up provisions in the community where the medical service is inadequate.

8.65 We are very concerned about the standard of general practice in some poor areas with high mortality. There are single-handed general practitioners who live at a considerable distance from the areas in which their patients reside, have little knowledge of or interest in local culture (which leads them to prescribe or otherwise treat patients inappropriately), who rely for a disproportionately large part of the year, the week or the day on the deputising services, and take little or no interest in the possibilities of new health centres, group practice or other forms of collaboration among and between health service and social service professional personnel.

8.66 Some are considerably older than 65 and others are new to practice in this country and include those who are virtually in transit to other career destinations. There are some who have resorted to work in these areas because they have been unsuccessful elsewhere and are exposed here to less criticism. We are aware that working in such areas are also some of the best and most dedicated members of the medical profession. As the Royal Commission on the NHS said of declining urban areas, “Many health professionals are coping courageously and effectively in these areas, but there is evidence in some places that services are inadequate. The GPs tend to be older and to have large lists. The accepted view today is that a GP will work most efficiently in a group practice or partnership with several other GPO and there may be some connection between the extent of single handed practice and low quality of care, although there are many excellent single handed GPs. More single handed practices are found in the inner city areas.” (Report, 1979, p 88). While the extent of the problem cannot, regrettably, be quantified and while there are wide variations between areas, we are satisfied that the dimensions of the problem in some areas are serious. The Royal Commission on the NHS also recognised this and made certain specific recommendations to remedy matters – namely of the need for close supervision of deputising services, a review of controls on the appointment of GPs, the offer of an assisted voluntary retirement scheme to GPs, a study of the feasibility of introducing a compulsory retirement age, the introduction of audit or peer review of standards of care and treatment and the development of health centres as a priority in inner city areas – with which we agree and which we endorse (Report,op cit, pp 91-91). But other steps might also be taken. We recommend that the professional associations as well as the Secretary of State and the Health Authorities should accept responsibility for making improvements in the quality and geographical coverage of general practice, especially in areas of high prevalence of ill-health and poor social conditions. Where the number or scope of work of general Practitioners is inadequate in such areas we recommend Health Authorities to deploy or, redeploy an above-average number of community nurses attached where possible to family practices. The review of coverage must include definitions of desirable standards of practice and keeping abreast of modern methods of practice as well as advancement in medical knowledge, and not only questions of remuneration and inducement. We further recommend that the distribution of general practitioners should be related not only to population but to medical need, as indicated by SMRs, supplemented by other indicators, and that the per capital basis of remuneration be modified accordingly.

8.67 One possibility deserving careful consideration is the attachment of additional, newly qualified GPs, to existing group practices and health centres for periods of, say, 2-5 years. Every effort should be made to provide housing temporarily or permanently within the areas. One problem of the poor areas is that health centres are not yet the main form of medical organisation. In Gateshead only a fifth and in Tower Hamlets fewer than a tenth of GPs are in health centres. Previous studies have demonstrated that a more effective policy deserves to be adopted. “The NHS has not brought about any dramatic shift in the location of GPs .…. Areas which are currently facing the most serious shortages seem to have a fairly long history of manpower difficulties, whilst those which are today relatively well supplied with family doctors have generally had no difficulty in past years in attracting and keeping an adequate number of practitioners (Butler, Bevan and Taylor, 1973). A separate type of study of data from the NHS, mortality statistics and GP statistics in 1972 and 1973 found a lack of significant positive correlations between age-standardised acute sickness, chronic sickness or mortality and the number of GPs per million population, suggesting that the supply of GPs is not matched to health care need (Forster, Frost, Francis and Heath). In addition to the weakened medical service which we consider exists in some poor areas there is a heightened need in those same areas for medical care – as indicated by SMRs, rates of limiting long standing illness and low participation rates of the preventive services. As a previously quoted survey of general practice concluded, “certain areas of the country are medically deprived in the sense that the existing services are unable to cope with the demands placed upon them, while others have a relative abundance of medical resources in relation to their needs” (Butler et al, 1973).

8.68 With the relative increase in number of one parent families and increased employment of young mothers with children, the problem of facilities for those without relatives living nearby is considerable. Present plans for the expansion of day nurseries are meagre, and the rate of expansion needs to be larger. Within the proposed Health Development Programme at national level we recommend the financing of new services for children under 5 from the savings that are being made as a result of the decline in the school population. This proposal is further elaborated below (Chapter 9).

8.69 Traditionally the school health service has afforded opportunities for preventive work, including health education. In areas of social need there are advantages in intensifying some of the present work. It would be possible to monitor the health of children in certain types of family more frequently, for example, and there are also possibilities of relating health surveillance to teaching about health and the health services. Both a Scottish Home and Health sub-group on the child health service and the Court Committee argued for the greater integration of the child health services ( Scottish Home and Health Department, 1973 and ‘Fit for the Future’, 1976) and this was accepted in principle by the Secretary of State (Circular RC(M5). The Scottish working party expected “that in the course of time much routine school health work will be carried out by primary care teams but the more specialised aspects such as the assessment of handicapped children will be the responsibility of paediatricians working closely with other professional colleagues”. (Towards an Integrated Child Health Service. 1973. p 101). Like the working party, we recognise that there will have to be different systems of provision of school health care for some time to come, but recommend that every opportunity should be taken to link revitalised school health care with general practice, and to intensify surveillance and follow-up both in areas of special need and for certain types of family. For this purpose we take the view that certain assessments can be undertaken by social workers (and health visitors) – especially where they are already working in association with group practice.

8.70 It is perhaps necessary to refer briefly to the special place of child guidance within the school health service. Child guidance clinics have traditionally provided psychiatric care for relatively small numbers of maladjusted children on an intensive basis. There is evidence of long waiting lists, misunderstood systems of queueing,, and of a negative image of the work of the clinic among parents (Fitzherbert, 1977 pp 85-96). At the same time there is evidence from surveys in the Isle of Wight and in London (Rutter et al 1970; Rutter et al 1975) of a very much higher prevalence of maladjustment among children than had been thought, or than could be helped by traditional psychiatric methods. There is a growing view, which we share, that emphasis must increasingly be upon preventive methods; upon increasing co-operation between psychiatrists, educational psychologists and teachers. For example, the “nurture group” pioneered by Marjorie Boxall provides a special therapeutic environment (to compensate for inadequate early experience) within the infants school, from which children are gradually returned to normal classes. Such experiments must be encouraged and evaluated.

8.71 For handicapped children Ministers have already accepted in principle the establishment of District Handicap Teams. The teams can help to provide careful diagnosis and continuing help and advice and support to handicapped children and their parents. We recommend that an assessment which determines severity of disablement should be adopted as a guide to health service priorities, and that this should be related to the limitation of activities rather than loss of faculty or type of handicap. This procedure would help to equate the provision of services for mentally handicapped as well as physically handicapped children. Though we attach priority to the implementation of this recommendation in the case of disabled children, we believe that it must ultimately apply to all disabled people. We recognise that since 1977 most local authorities have adopted classification of severity of disablement of people on their registers of the handicapped. We hope this can be extended to people with all types of handicap and to patients in the Health Services. We argue elsewhere for the rapid confirmation in legislation of the Pearson Commission’s recommendation for an allowance for severely disabled children, within a comprehensive disablement allowance for people of all ages. Receipt of such an allowance could operate as a form of registration, which would allow the need for services to be monitored.

ii. The Care of Disabled and Elderly People in their Own Homes

8.72 When disablement is understood in terms of functional limitation it becomes possible to rank severity and provide a better guide to the selection of priorities. Efforts have to be made to compare the entire range of provision of services, specifying numbers accommodated or served to a varying extent and at varying cost, with assessments of both objective and subjective needs. For example, conventions about the division of clients according to type, or conventional categorization of clients or patients as requiring hospitalisation, residential care, sheltered housing or domiciliary support, may need to be re-examined. Quality of care, as evidenced by detailed analysis of hospital costing returns, disposition of manpower, size of wards and number of amenities, access to occupation and degree of social integration, does not correlate well with degree of need. We take the view that 2 forms of inequality affecting disabled people have to be distinguished. One is inequality in opportunities for treatment, care and rehabilitation between those in different types of hospital. We recommend a review of the distribution of facilities and services between acute and long stay units and also of the distribution of elderly patients in geriatric, psychiatric and general hospitals. In relation to mental and physical state many people seem to find themselves in a particular type more by chance than specific medical reason. The second form of inequality is inequality in the opportunities for care, rehabilitation, occupation, privacy and social relations between, on the one hand, hospital patients, and residents of local authority, voluntary and private homes, and, on the other, disabled people living in their own homes. These inequalities have attracted rather less attention than inequalities in services between areas.

8.73 Although further steps are required to reduce inequalities in quality of care and individual rights within institutions and between institutions and private households, we take the view that the first step is to clarify the meaning of community care and give much greater emphasis to the tendencies favoured in Government planning documents. Thus it could be argued that provision for the reduction of the population of mental handicap hospitals could be accelerated, that the objectives outlined in the 1971 White Paper on Mental Handicap were too cautious and that those objectives are being fulfilled too slowly. The Report of the Committee of Enquiry into Mental Handicap, Nursing and Care comprehensively endorses this point of view. The Committee has reiterated the condemnation of conditions in too many hospitals (Oswin, 1978; Morris 1969). It identifies 3 broad sets of principles:

(i)Mentally handicapped people have a right to enjoy normal patterns of life within the community.
(ii) Mentally handicapped people have a right to be treated as individuals.
(iii) Mentally handicapped people will require additional help from the communities in which they live and from professional services it they are to develop to their maximum potential as individuals.

8.74 The Committee concluded

“The mentally handicapped person should have access to the full range of services and facilities available to the general public and specialist services should be provided only where the general services cannot cope with a special need. But where special provisions are required they should offer a wide range of options in the 3 spheres of day, domiciliary and residential services. Mentally handicapped people in residential care should not be isolated from their neighbourhood or, more importantly, from their families. The staff who care for mentally handicapped residents should be compassionate and caring, but also professionally trained; their role should be to help each mentally handicapped person to develop mentally, physically and emotionally. Residents should live in small family-type groups sharing experiences informally with the staff, making their own decisions and taking necessary risks.” (JAY Committee, March, 1979, Page 140.)

8.75 In realising such aims one obstacle in the development of services for mentally handicapped people, as for other groups of disabled people, is that responsibility for sheltered housing, as distinct from residential accommodation, is not the responsibility of the personal social services. As a consequence we believe that residential care is sometimes offered to disabled people when sheltered housing would be the more rational choice. We recommend that a Working Group (to include representatives of voluntary organizations concerned with relevant client groups) should be set up to review whether sheltered housing should be a responsibility of social service or housing departments and make recommendations.

8.76 Community care for elderly people has not been developed as rapidly as general aims of policy suggest. The 1976 Consultative Document on Priorities stated “The general aim of policy is to help the elderly maintain independent lives in their own homes for as long as possible. The main emphasis is thus on the development of the domiciliary services and on the promotion of a more active approach towards the treatment of the elderly in hospital. But old people who can no longer continue to live independently in the community even with the support of all available health and social services will need long term residential or hospital care” (DHSS, 1976, page 38). In practice, evidence of capacities among residents and their subjective preferences is not always given the attention it deserves. We recommend that clear criteria for admission to, and for continuing residence in, residential care should be agreed between the DHSS and the local authority associations, and steps taken to encourage rehabilitation and In particular to prevent homeless elderly people from being offered accommodation only in residential homes. Priority should be given to expansion of domiciliary care for those who are severely disabled in their own homes. It may be that in the light of criteria which emerge numbers in residential care could be frozen and even reduced, thereby freeing additional resources. At times the DHSS has seemed to favour such a policy (for example, DHSS, Social Care Research, 1978, page 13). Table 8.10 illustrates recent evidence about the capacities of residents. In the 1970s the population of residential homes has become older. Below are the latest statistics made available by the DHSS. The rise in the percentage aged 85 and over certainly suggests that the percentage likely to be severely or substantially incapacitated my also have increased (though that correlation needs to be demonstrated). However, there remains considerable evidence that a substantial fraction of residents, perhaps two-fifths or even more do not require continuous or even substantial occasional “care and attention” in a residential setting, as the table illustrates. (This may not mean that it would be right or practicable to attempt to find some alternative accommodation for these particular residents, rather that alternative accommodation must be found in future for those who would be admitted unnecessarily).

Percentage of elderly residents of different age (England)

65-74 75-84 85+ Total number
1966 21.2 47.1 31.7 100 87,100
1970 20.1 44.9 35.0 100 99,700
1973 19.7 43.0 37.2 100 105,500
1974 19.6 42.6 37.8 100 107,200
1975 19.0 43.2 38.0 100 109,700

TABLE 8.10 Evidence of capacity of elderly residents of Homes for self-care

Date of Study Scope of study Percent of residents with capacity for self-care (local authority residents only unless otherwise specified)
(1) 1958-59 National sample survey of Homes in England & Wales 72% neither bedfast nor requiring help dressing
59% mobile outside Home without assistance
52% (new residents only) with “little or no incapacity for self-care”
(ii) 1963 National sample survey Homes in Britain 37% little or no incapacity for self-care
21% little or no incapacity for self-care and household management
(iii) 1969 National survey, Homes in Scotland 67% complete capacity for self-care (ie able to wash, dress and use toilet)
48% “fit” ie having complete capacity for self-care plus no impairment or only mild impairment of mobility, mental state and continence
(iv) 1970 National census, Homes in England 45% minimally dependent (ie continent, mobile without assistance, able to eat and drink without assistance, and mentally alert)
(v) 1972 Survey of council Homes in eight London Boroughs 55% high or very high capacity for self-care
(vi) 1973 64 Homes in Cheshire 63% able to wash, dress, feed and go to toilet unaided
42% no mobility problems, no assistance of any kind required and no behavioural problems

Sources i) and (ii) Townsend, 1962 and 1973; (iii) Carstairs and Morrison, 1972; iv) DHSS, 1975; (v) Plank, 1977; (vi) Kimbell and Townsend, 1975.

8.77 The report of the comprehensive Scottish Survey by the Research and Intelligence Unit of the Scottish Home and Health Department, based on research at the end of the 1960s, concluded:-

“61% of residents had characteristics which suggest they might live in sheltered housing … with assistance from the domiciliary services If necessary.” (Carstairs and Morrison, page 73).

8.78 For the early 1970s there were broadly similar findings for parts of England, as Table 8.10 shows. Social service departments have continued in the mid and late 1970s to undertake studies of their elderly residents. The conclusions about the extent to which residents could or should live in alternative accommodation vary, sometimes because it in not easy to decide whose view of the capacities of residents is most “objective” or disinterested. The latest studies continue to produce findings in favour of an emphasis on community care. Thus, a Warwickshire study concluded that “given sufficient domiciliary services and alternative suitable accommodation including very sheltered housing and supervised lodgings, the rate of elderly people in our old people’s homes could be significantly reduced per 1,000 of the elderly population”. (Oldfield and Whitbread, 1978, page 8). Other research studies have also produced evidence that substantial proportions of the residents have capacities for self-care and even housecare. (See Alexander and Eldan, 1979; Bond and Carstairs, 1979).

8.79 We believe that the tendency of the residential population to grow and become older reflects in part the social difficulties of the elderly population – not just because more of the elderly are aged 75 and over – but because of lagging real incomes, displacement at younger ages from occupations and housing, and especially the tendency for women increasingly to outlive men and live alone. Services and community initiatives have not developed fast enough to meet nearly enough of the additional problems of the over 75s. But part of the explanation is to be found in the reduction of the percentage of elderly cared for within the hospital system. The elderly residential population has grown at the same time as the hospital population has diminished. For reasons of cost or professional definition of medical or nursing need, including ideas contributed by a new group of geriatricians, fewer elderly are to be found in hospital at any particular date. We are not sure that the most severely disabled section of the elderly residential population have as much access to medical and nursing expertise an they would have done had they been in hospital. Nor are we aware that rehabilitation is pursued an actively with the less severely incapacitated in residential homes as it is with the severely incapacitated in hospital. We believe that the future functions of residential accommodation deserve therefore to be thoroughly reviewed. They are by far the most costly element in the personal social services. In planning an efficient system of care for the elderly we my need to ensure that the minority of people in residential accommodation who are very frail and require close and continuous medical and nursing supervision and treatment for long term rather than short term conditions deserve to be in very small residential nursing hospitals, annexes and even day centres under local geriatricians. On the other hand, sheltered housing may be the best environment for that large fraction of people in residential accommodation whose disabilities are slight or at least not substantial, and perhaps in some instances also of residents whose disabilities are severe. We therefore recommend that the present functions and structure of hospital, residential and domiciliary care for the disabled elderly should be reviewed in relation to their needs to decide the best and most economical balance of future services. We believe that such a review is likely to demonstrate the accelerated relative priority that deserves to be accorded to the development of domiciliary services. Strictly, the responses to the consultative document A Happier Old Age (DHSS 1978) provide in some respects the material for just such a review. However, the issue deserves more sustained expert examination and research, especially into the subjective attitudes of elderly patients and consumers of residential and community services, than it appears to have attracted.

8.80 The care of disabled people, many of whom are elderly disabled people, requires more co-ordinated action by health and social service authorities than currently exists. The introduction of joint funding has encouraged more collaborative planning. We recommend that this initiative should be developed and that there should be further central government funding of a more specific kind to encourage joint care programmes. Within the general category of severely disabled people, sub-categories should be more clearly defined so that both types of authority can comprehend their individual but also joint responsibilities at different stages of chronic illness or disablement. We further recommend that sums within the joint finance allocation should be reserved for payment to authorities putting forward joint programmes to give continuing care to disabled people – for example, post-hospital follow-up schemes, pre-hospital support programmes for families, and support programmes for the severely incapacitated and terminally ill. Funding might be based on a percentage or per capita grant. Health and local authorities may be involved in broader types of in-service training and acknowledgement of the need to interchange staff between hospital and day centre, or hospital and home.

8.81 Like all policies, a more vigorous community care policy on behalf of disabled people in their own homes would encounter many difficulties. Risks are involved in encouraging some people to continue living alone when disabled. Attempts to increase the pattern of social contacts in supplementation of support services for some elderly people living alone have not always met with success, and traditions of individual privacy, quite apart from the constraints of poverty and bad housing, do not make any easier the patterns of supportive social interaction which would better suit disablement in old age. In the long run a choice has to be made between the encouragement of further dependency on the part of disabled people in the hands of different professionals, and the ready availability in the community of support, with greater diffusion of information and expertise, reciprocation of services within the community, self-help, and all the risks of depending on spontaneous and other expressions of good-will among neighbours and generally in the community.

8.82 For community care is itself a form of “prevention”. It helps people to deal with their own problems in their homes and preserves for them the dignity of the status of responsible actors.

8.83 In Table 8.4 particular attention has been called to the rapid expansion of the home help service. In practice many home helps undertake a wide range of responsibilities on behalf of disabled people and we recommend that this should be formally encouraged, with short courses of training, specialisation of some functions and with access to mini-bus transport, especially to day centres.

iii. Prevention – the role of Government

8.84 A consultative document on prevention and health was published in 1976 and was reprinted 3 times within the space of a year. This indicates widespread public interest. Paradoxically, the 1978-79 planning guidelines issued by the previous administration allowed for a growth of expenditure on prevention from only £14 million in 1976-77 to £17 million in 1981-82 (at 1976 prices) which would still be less than 0.3% of revenue expenditure on health and personal social services. Moreover, provisional 1977-78 figures show that expenditure on prevention actually fell between 1976-77 and 1977-78: from £15.6 million (at 1977-78 prices) to £15.1 million. (Report of the Royal Commission on the NHS, Table E1).This expenditure covers vaccination and immunization programmes, fluoridation, and other preventive measures – mainly preventive medicine and health education.

8.85 As Ministers stated in a foreword to the document on Prevention and Health “the Preventive approach should permeate and inform all aspects of the health services”. This will involve a change of outlook in the DHSS and more determined changes in organisation and the allocation of resources. For the attainment of national objectives the distribution of information and knowledge about health and management of illness needs to be less hierarchical and more widely shared. In Part this means taking a new view of health education. We have already called for the resurgence of the school health service and the introduction of special forms of teaching in the schools. But the issue in not simply the better instruction of individuals at key periods of their lives. As those concerned with health education are aware, there are at least 3 distinguishable sets of reasons for health education: “to produce changes in beliefs and behaviour in order to reduce mortality and morbidity; to influence norms and values governing the use of health services; to produce a general understanding of certain more diffuse ‘health’ issues in order to obtain a population who have a general understanding of health issues and to avoid certain forms of ‘undesirable’ or not directly definable ‘unhealthy’ behaviour”. (Tuckett, 1979, Page 4). A balance has to be struck between creating better and safer conditions of work, safer travel, well-regulated manufacture of food products and other goods, and the creation of social and occupational conditions minimising stress, as well as the conventional “do-it-yourself” approach to health education. We are conscious of studies showing that the 19th. Century reduction of mortality owed more to improvements in the standard of living, changes in public engineering and the quality and availability of food supplies than specific measures to treat infectious disease and administer forms of screening like smallpox immunisation (McKeown, Record and Turner, 1975, especially Pages 401-422).

8.86 While laying stress on the importance of designing and regulating appropriate occupational environmental and social structures, we recommend that a greatly enlarged programme of health education, with a particular focus on schools, should be sponsored by the Government. The DHSS and the DES, as well as other Departments would be involved, and at the local level health education in schools should be the joint responsibility of AHAs and LEAs. Such a programme of health education would include new initiatives to use the media for publicity; a drive to involve young parents in a programme of health education arranged in conjunction with local clinics, and corresponding programmes for those caring for disabled people at home.

8.87 It in not, however, sufficient to regard preventive medicine as purely a question of individual initiative and responsibility based upon more information (important though this is). We explained in Chapter 6 how the very possibilities for such initiative and responsibility are themselves a function of social circumstances. We accept, for example, the importance of publicity for, and advice on, the importance of adequate diet and of exercise, for health. Yet, it is not always possible for people to act in what they know to be their own best interest. Whilst the value of exercise must be made clear through the media, facilities for exercise are also required. We thus endorse the view of the Expenditure Committee (HC 169-i, 1977) when they recommended “The Department of the Environment and local authorities (should) be required to make more adequate provision for physical recreation in any future major developments or redevelopments both public and private, particularly in inner city areas”. We consider also that additional grants for the establishment of facilities for physical recreation should be made available. Vaccination and immunization are not used as much as they should be and in some cases (eg polio) the rate of immunization has declined. Doctors and others in the NHS must convince members of the public of the importance of these preventive measures. Tougher measures against both smoking and alcoholism are required. In general we would note that the Government’s response to the Expenditure Committee Report (Preventive Medicine), contained in the White Paper Prevention and Health (Cmnd 7047, 1977) failed to provide the positive measures we believe necessary.

8.88 We recommend that national health goals should be established and stated by Government after wide consultation and debate. Measures that might encourage the desirable changes in people’s diet, exercise and smoking and drinking behaviour should be agreed among relevant agencies.

8.89 In the case of smoking these measures are clear, and cannot rest upon exhortation alone. An anti-smoking policy must involve new forms of education and counselling but also preventive and stringent control measures. During recent years there is disturbing evidence of growing inequality in cigarette smoking between rich and poor sections of the population. Between 1958 and 1975 men in professional occupations reduced their smoking by more than half whereas unskilled workers increased their consumption by 9% (Atkinson and Townsend, 1977, page 493). We take the view that unequal access to information about the effects of smoking has contributed powerfully to this trend. We recommend the adoption of the following measures; which should be seen not only as priorities in themselves, but as illustrative of the determined action which needs to be taken by government in relation to all necessary elements of a strategy for prevention:

i. Legislation rapidly to phase out all advertising of tobacco and sales promotion of tobacco products (except at place of purchase).
ii. Sponsorship of sporting and artistic activities by tobacco companies should be banned over a period of a few years. and there should be stricter control of advertisement through sponsorship.
iii. Regular annual increases in duty on cigarettes in line with rises in income should be imposed, to ensure lower consumption.
iv. Tobacco companies should be required, in consultation with the Trades Unions, to submit plans for the diversification of their products over a period of 10 years with a view to the eventual phasing out of sales of harmful tobacco products at home and abroad.
V. The provision of non-smoking areas in public places should steadily be extended.
vi. A counselling service should be made available in all health districts. and experiments in methods to help people reduce smoking should be encouraged.
vii. A stronger well-presented health warning should appear on all cigarette packets and such advertisements as remain, together with information on the harmful constituents of cigarettes.

8.90 We appreciate that cigarette smoking has a very strong hold on a large section of the population and that no Government can appear to be excessively authoritarian in its measures to eradicate it. Nonetheless, international comparisons have shown that Britain is particularly weak in the policies it has pursued. For example, in 1976 Britain was 17th among 20 European countries in provision of non-smoking facilities and bane on smoking in public places. (ASH, 1976; and see also House of Commons Expenditure Committee, report on Preventive Medicine, 1977). We would wish to stress the relevance of an antismoking campaign to any measures at district or national level to reduce inequalities in health.

iv. Screening programmes

8.91 In considering whether screening programmes should be advocated as a means of reducing inequalities in health, it is useful to distinguish between general screening programmes, based on a questionnaire, medical examination, and/or selected laboratory tests in varying combinations; and specific screening program dedicated to the early discovery of particular conditions, which can either be treated (eg diabetes mellitus, hypertension) or prevented (neural tube defects, Down’s syndrome).

8.92 In this country, general screening programmes have usually been offered to, and accepted by, special groups of high income such as business executives, in whom compliance tends to be higher than average. The question naturally arises, whether extension of such programmes to groups of lower income would carry a high priority. A field study in general practice in South-East London cast considerable doubt on this, since after five years there was no detectable benefit in terms of actual outcomes. On balance, the cost of population screening and the possible production of anxiety, might well outweigh any likely benefits, even where there is a known higher incidence of disease in lower income groups. A similar view on unselected screening is expressed by the Royal Commission on the National Health Service in Para. 5.7 of their report.

8.93 Advocacy of screening for specific disorders presupposes that the likely incidence of the disorder is high in the population to be screened; that there would be effective treatment available; and that under field conditions there would be adequate compliance, leading to the arrest of the disease (Holland, 1977). We are not satisfied that these conditions would be generally met; but there is an important exception in the possibility of averting congenital disability, with its burden to the family and the individual, by an antenatal screening programme. In this context, we would recommend ‘ that steps should be taken to educate women of child bearing age in the importance of reporting suspected pregnancy at the earliest possible stage, so that antenatal care can be provided early in pregnancy. The provision of antenatal services is of course a recognised priority, but has to be supplemented by educational measures to ensure that they are taken up.

8.94 Given early attendance at antenatal clinical there are practicable programmes for screening for Down’s syndrome and for neural tube defects in the fetus. These programme do, however, involve amniocentenesis which carries a small risk of damage to the fetus; and they lead to termination of the affected pregnancy, subject of course to the consent of the mother. In relation to adult disease, it is relatively simple to screen for hypertension, and also for diabetes mellitus for both of which effective treatment is available. Since a high proportion of patients are seen by their family doctors over a two-year period, taking the blood pressure and testing urine could be made standard at routine visits, and this is already quite a common practice; this might involve less difficulty and expense than the mounting of a special screening progranme, which would involve an additional visit by the patient, possibly followed by long-tem treatment with which he would not necessarily comply.

8.95 In the light of the present state of knowledge we recommend that antenatal screening for Down’s syndrome and for neural tube defects (especially in high risk areas) on the one hand, and in relation to adult disease for severe hypertension on the other. should be made generally available.

8.96 We have merely outlined some of the major ingredients of a universal district action programme. Scope should be left for local and voluntary initiative. In particular we hope that Community Health Councils might be invited to monitor developments in their areas. What is most important is that standards of health, and knowledge about health, should be raised thraugh face-to-face contacts and local group practices, clinics, day-centres and schools.

E. A PROGRAM FOR 10 SPECIAL AREAS

8.97 We recommend that the Government should finance a special health and social development programme in a small number of selected areas, costing about £30m in 1981-82 (the figure indicated in Table 8.4). The following 10 areas have the highest death rate, standardised for population and age/sex structure. (See also Table 8.9):

  • Salford
  • Tameside
  • Gateshead
  • Liverpool
  • South Tyneside
  • Tower Hamlets
  • Durham
  • Bolton
  • Wirral
  • North Tyneside

8. 98 It should be pointed out that within these areas wide variations in mortality rates are also to be found. In Gateshead, for example, the ratio of infant mortality in some wards to that in others in the mid 1970s was 3 : 1 (when standardised for numbers of births). Appendix 9 gives an illustration from the Central Health District of Birmingham of a ratio between wards which was nearly as high. It will be noted that the wards with highest mortality were also wards with the smallest proportions of population in classes 1 and II.

8.99 We propose that in each of the 10 areas experimental programmes within the 3 spheres of activity specified above for all districts (namely health and welfare of mothers and pre-school and schoolchildren; care of disabled people in their own homes; and prevention) should be introduced. We envisage that a proportion (say at least £2m) of the £30m should be reserved for evaluative research and statistical and information unite, and that the remaining sum should be divided among the 10 areas for development of the types of services listed below.

8.100 In order to gain a better sense of the problems to be found in these areas, two, Tower Hamlets and Gateshead, were visited by members of the Working Group. Appendices 2 and 3 summaries the problems as they are seen by the Area Health Authorities and the kind of measures which they consider additional funds would help to finance. Gateshead is in fact already one of the 3 beneficiaries of the Comprehensive Community Programme and Table 8.11 summarises the health service components of the AHA’s urban programme bid. There is no doubt that the health and personal social services (and especially the community health services) in such areas of high mortality (where there are also other indicators of severe health and social problems) deserve additional Government resources.

Table 8.11 Part of Gateshead AHA Urban Programme Bid

1979/80
1980/1
Capital Revenue Capital
Maternity Services
48 Extension of maternity department at Queen Elizabeth Hospital £150,000 £70,000
49 Aditional equipment £10,000
Promotional campaign to reduce smoking in pregnancy £10,000
Elderly patients
50 Improve services for elderly patients at home- 4 district nurses and 1 chiropodist £27,200
Upgrade wards 6 and 7 at Dunston Hill Hospital £95,000
Mental Illness
51 Develop community psychiatric nursing service and day hospital (community nurses and occupational therapists) £20,000 £27,200
Upgrade Occupational Therapy Dept at St Mary’s Hospital (especially to improve rehabilitation) £70,000
Deprived children
53 Consultant plus four specialised nurses (health visitors and a school liason officer) £27,000
Primary Care
54 Four additional health visitors £12,000
Total £345,000 £107,700 £70,000

Prices are at November 1977

8.101 It is perfectly true that many innovations in service, provision on a local basis (such as mobile clinics) are already being attempted in areas like the 10 listed above. Many of these may indeed be proving successful in reaching these in particular need (the mobile clinic may well be an example), but these innovations are rarely (if ever) the subject of rigorous experimental assessment. It is this essential element of experimental assessment, the equivalent of the randomised clinical trial of clinical procedures, that we wish to stress: certainly in relation to child health, but also in relation to disabled people. Without this not only can change be on no more than an intuitive basis, but learning (by one area from another) is inhibited. Although the precise form of the proposals will need to take specific aspects of the local situation into account (and there in inevitably an element of overlap among our 3 spheres of activity) the following mould appear to be among the candidates for action:

Making Clinics more responsive to needs

i. Developing clinics in group practice and dispensing hospital clinics dealing with large populations;
ii, Provision of child play facilities;
iii. Combining child welfare and ante-natal clinics;
iv. Evening and weekend clinics;
v. Setting up counselling cervices for mothers, covering pregnancy, infant and child care and family health;
vi. Provision of detailed nutritional counselling to pregnant women by trained nutritionists;
vii. Additional or special clinics for (1) lone and/or young mothers (2) handicapped children.
viii. Experiments to enable mothers to keep in touch with each other independently of antenatal, and post natal appointments by such developments as Young Family Centres and the provision of facilities to enable mothers and babies to meet together regularly.

Domiciliary services

i. More health visitors to

a. follow up all missed clinic appointments;
b. undergo special training in helping ethnic minorities;
c. provide better services at home for severely disabled people.

ii. Liaison between GPs and health visitors: GPs should notify health visitors of all pregnancies promptly, and all pregnant women should be visited. GPs can be encouraged either in existing partnerships or health centres or if single handed, collaboratively, to cot up special maternity and infant care groups (possibly, through notification of first births, for first-time mothers and, through child benefit registrations or schools, of mothers of 4 or more children).

iii. Active development of community nursing cervices so that nurses are trained to work in the community as well as hospital and prevent certain hospital admissions as well an provide services for disabled or chronically sick people when discharged;

iv. Planned joint services with (a) social service departments (b) voluntary bodies. Schemes should include attachment of social workers to primary care teams and use of voluntary visitors on a “Preventive” basis for disabled.

V. Special counselling services (including services on income rights, heating and housing problems) for severely disabled (especially elderly and mentally handicapped) people and their relatives.

School health

i. Special programs of assessment of health of school children;

ii. Special health education programme in schools as an integral part of the curriculum.

Food

i. Special welfare food provision on greatly increased scale;

ii. Enhanced (free) school meals programme.

Smoking

Experimental anti-smoking programmes (educational and therapeutic).

Screening

Experimental services aimed specifically at older mothers, and middle-aged people.

8.102 It should not be supposed that an additional area programme would simply add to existing resource allocation. It would contribute to better balance between necessary and less necessary services and hence would contribute to the more economical satisfaction of the aims of the health and personal social services.

CONCLUSION AND SUMMARY OF RECOMMENDATIONS

8.103 We have identified 3 objectives for the administration of health and person social services and recommend their adoption by the Secretary of State. They are:-

i. To give children a better start in life

ii. For disabled people, to reduce the risks of early death, to improve the quality of life whether in the community or in institutions, and as far as possible to reduce the need for the latter.

iii. To encourage good health among a larger proportion of the population by preventive and educational action.

8.104 We believe that if these 3 objectives are pursued vigorously inequalities in health can be reduced. To fulfil them we recommend a shift in the allocation of resources (Table 8.4). However this in itself is not enough. It must be combined with an imaginative (and in part necessarily experimental) approach to the nature and delivery of care. District Action Programmes,(by which we mean general programmes for the health and personal social services to be adopted nationwide and involving necessary modifications to the structure of care) should be developed in each area; and an additional experimental Programme should be funded in 10 areas of high mortality and adverse social conditions.

8.105 We have first argued for changes in the planning of the development of health services and especially resource allocation. We believe that allocation of resources should be based on need. We recognise that there are difficulties in assessing need, but we agree that standardised mortality ratios (SMRs) are a useful basis for broad allocation at regional level. At district level, further indicators of health care and social needs are called for. These should be developed as a matter of urgency, and appropriately to reinforce, supplement or modify allocation according to SMRs.

8.106 Resources within the National Health Service and the Personal Social Services should be shifted more sharply than so far accomplished towards community care particularly towards ante-natal, post-natal and child health services, and home help and nursing services for disabled people. We see this as an important part of a strategy to break the links between social class or poverty and health.

8.107 In building up revenue targets it is not the current distribution of expenditure between services which should be used, but that which is aimed at in the planning of services. In particular, this process should reflect the higher share of resources for community care which (along the lines of DHSS planning guidelines) we have recommended.

8.108 While we are aware of the problems of conceptualising and measuring “need” we consider there is no better alternative conceptual basis for developing a coherent rationale for the allocating of health care and resources, and recommended accordingly.

8.109 Our main recommendations for a District Action Programme can be listed under the 3 objectives set out above.

(A) Health and welfare of mothers and pre-school and schoolchildren

i. A non-means-tested scheme for free milk should now be introduced beginning with couples with their first infant child and infant children in large families.

ii. Areas and districts should review the accessibility and facilities of all ante-natal and child health clinics in their areas and develop plans to increase utilisation by mothers, particularly in the early months of pregnancy.

iii. Savings from the current decline in the school population should be used to finance new services for children under 5. A statutory obligation should be placed on local authorities to ensure adequate day-care in their area for children under 5, and a minimum number of places (the number being raised after regular intervals) should be laid down centrally. Further steps should be taken to reorganise day nurseries and nursery schools so that both meet the needs of children for education and care.

iv. Every opportunity should be taken to link revitalised school health care with general practice, and intensify surveillance and follow-up both in areas of special need and for certain types of family.

Some necessary developments apply to other groups as well as children and mothers.

V. The professional associations as well as the Secretary of State and the Health Authorities should accept responsibility for making improvements in the quality and geographical coverage of general practice, especially in areas of high prevalence of ill-health and poor social conditions. Where the number or scope of work of general practitioners is inadequate in such areas we recommend Health Authorities to deploy or redeploy an above-average number of community nurses, attached where possible to family practice. The distribution of general practitioners should be related not only to population but to medical need as indicated by SMRs, supplemented by other indicators, and the per capita basis of remuneration should be modified accordingly.

vi. An assessment which determines severity of disablement should be adopted as a guide to health service priorities, and this should be related to the limitation of activities rather than loss of faculty or type of handicap.

Although we attach priority to the implementation of this recommendation in the case of disabled children we believe that it must ultimately apply to all disabled people. We are aware that since 1977 most local councils have adopted classification of severity of disablement of people on their registers of the handicapped. We hope that this can be extended to people with all types of handicap and to patients in the Health Services.

(B) The Care of Disabled People in their Own Homes

i. A Working Group (to include representatives of voluntary organisations concerned with relevant client groups) should be set up to review:

a. whether sheltered housing should be a responsibility of social service or housing departments, and to make recommendations; and

b. the present functions and structure of hospital, residential and domiciliary care for the disabled elderly in relation to their needs, and to decide the best and most economical balance of future services.

ii. Joint funding should be developed and further funding of a more specific kind should be introduced, if necessary within the existing NHS budget, to encourage joint care programmes. A further sum should be reserved for payment to authorities putting forward joint programmes to give continuing care to disabled people – for example post-hospital follow-up schemes, pre-hospital support programmes for families, and support programmes for the severely incapacitated and terminally ill.

iii. Clear criteria for admission to, and continuing residence in, residential care should be agreed between the DHSS and the local authority associations, and steps taker to encourage rehabilitation, and in particular to prevent homeless elderly people from being offered accommodation only in residential homes. Priority should be given to expansion of domiciliary care for those who are severely disabled in their own homes.

iv. The functions of home helps should be extended to permit a lot more work on behalf of disabled people; short courses of training, specialisation of functions and the availability of mini-bus transport, especially to day centres, should be encouraged.

(C) Prevention: The role of Government

i. An enlarged programme of health education should be sponsored by the Government, and necessary arrangements made for optimal use of the mass media, especially television. Health education in schools should become the joint responsibility of LEAs and health authorities. However, we do not believe that an effective programme of preventive health can be a matter entirely for personal initiative and responsibilities. Commitment on the part of Government is required, and has not so far been demonstrated especially in so far as it involves (as it must) departments other than the DHSS. For example, there has been no major attempt at making more adequate provision for physical recreation in inner city area developments, as recommended by the Expenditure Committee in 1977. Additionally, the decline in recourse to vaccination and immunization (eg in the case of poliomyelitis) is worrying. Doctors and others in the NHS must be encouraged to convince members of the public of the importance of these preventive measures.

ii. National Health Goals should be established and stated by Government after wide consultation and debate. Measures that might encourage the desirable changes in people’s diet, exercise, and smoking and drinking behaviour should be agreed among relevant agencies.

Legislation, and fiscal and other financial measures may be required and a wide range of social and economic policies involved. We see the time as now opportune for a major step forwards in the field of Health and Prevention.

iii. Stronger measures to reduce cigarette smoking must be adopted. Our recommendations here should be seen not only as a priority in themselves, but as illustrative of the determined action by government necessary in relation to all essential elements of a strategy for prevention. Measures should include:

a. legislation rapidly to phase out all advertising of tobacco and sales promotion of tobacco products (except at place of purchase);

b. sponsorship of sporting and artistic activities by tobacco companies should be banned over a period of a few years, and meanwhile there should be stricter control of advertisement through sponsorship;

c. regular annual increases in duty on cigarettes in line with rising income should be imposed, to ensure lower consumption;

d. tobacco companies should be invited to submit plans in consultation with Trades Unions for the diversification of their products over a period of 10 years with a view to the eventual phasing out of sales of harmful tobacco products at home and abroad;

e. a stronger well-presented health warning should appear on all cigarette-packets and such advertisements as remain, together with information on the harmful constituents of cigarettes;

f. the provision of non-smoking areas in public places should be steadily extended, and

g. a counselling service should be made available in all health districts, and experiment encouraged in methods to help people reduce smoking.

We have already recommended that steps be taken to increase utilization of antenatal clinics, especially in the early months of pregnancy. Given early attendance there are practical programmes for screening for Down’s syndrome and for neural tube defects in the foetus. In relation to adult disease screening for severe hypertension is practicable, and effective treatment is available.

iv. In the light of the present state of knowledge we recommend that ante-natal screening for neural tube defects (especially in high risk areas) and Down’s syndrome on the one hand, and in relation to adult disease for severe hypertension on the other, should be made generally available.

Additional Funding for 10 Special Areas

8.110 We recommend that the Government should finance a special health and social development programme in a small number of selected areas, costing about £30m in 1981-82. At least £2m of this sum should be reserved for evaluation research and statistical and information units. The object would be both to provide special help to redress the undeniable disadvantages of people living in those areas but also to permit special experiments to reduce ill-health and mortality, and provide better support for disabled people. Some possibilities have been illustrated particularly in connection with the development of more effective ante-natal services.

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