Chapter 4: How do we lead healthier lives?
Introduction
In this contribution to the Big Conversation, the Socialist Health Association (SHA) welcomes much of the content of Chapter 4: How Do We Lead Healthier Lives? including:
- the commitment to provide health care that is equitable and efficient;
- the maintenance of NHS funding through progressive taxation;
- the devolution of power to local communities, citizens and patients;
- the intent to tackle the causes as well as the consequences of ill health;
- the acknowledgment of the patient as an equal partner in the individual’s health and health care; and
- the recognition of the NHS’s key role as a major economic player, particularly in areas of deprivation.
These aspirations all resonate with the core commitment of the SHA to promote health and well-being, social justice, and the eradication of inequalities through the application of socialist principles to society and government.
Rather than answer the questions posed, the SHA’s contribution to the Big Conversation seeks to address the key themes outlined in the consultation document.
A public health approach
It is fundamental to the SHA that health, health care and well-being should all be tackled from a public health rather than a medical perspective, because the application of medical technology alone will not optimise health and well-being.
Because the public health perspective is so important, the SHA believes that the Prime Minister should immediately appoint a Secretary of State for Public Health to the Cabinet. Public health is not a health care issue. It covers the widest spectrum of life experiences that can be influenced by government action. It requires joined-up thought and action across a whole range of government departments. Only a senior politician with Cabinet status will be able successfully to tackle this agenda.
Action to reduce health inequalities goes way beyond health care and involves services like housing, education, the arts, the environment, leisure and transport. Each major government department should therefore have its own health champion, and each department’s contribution to public health should be audited annually. National, regional and local government should undertake health and health inequalities impact assessments of any major new policy that is mooted.
Targets for improving the health of the population should take priority over targets for treatments, waiting lists and operations and they should be integral to the role of senior managers and members in local and regional government as well as in the NHS.
The SHA’s public health model of well-being requires government to focus far more on the prevention end of the spectrum than it currently does. Health care services do have a part to play, but only alongside a much wider range of activities.
Drugs, alcohol, smoking, inactivity and unhealthy eating habits between them account for a massive proportion of ill health, and differences in their prevalence reflect social and economic inequalities, which will be addressed as part of the government’s wider political project. Government should work with the food and drinks industry to help them develop an informed public health approach to the merchandise that they produce.
Some key determinants of ill health, such as poor educational attainment, income inequality, and child and family poverty are seldom mentioned in a health context, and the drive for new initiatives gets in the way of sustained follow through. The many excellent local initiatives to tackle poverty and deprivation must be accompanied by robust monitoring systems that can measure progress made in developing healthier communities.
Inequalities in dental health are even more marked, and the government should be pro-active in encouraging local authorities to use the provisions of the Water Act to fluoridate as much of the nation’s water supply as possible at the earliest opportunity.
A healthier nation begins with healthier babies. It is known that poor health and nutrition in pregnant women causes health problems throughout the lives of the resulting children, yet young women are expected to subsist on benefit levels that are too low to support a healthy diet. There should be an immediate increase in benefit levels for pregnant women, and policies should be put in place to help them consume healthy food.
Free, healthy school meals should be universally available, and the Hull initiative is to be commended. Many children entitled to free school meals don’t take them because of the stigma. Children should be able to drink water freely throughout the day, and free school milk should be available to all. Cooking is an important skill in its own right, and government cannot assume that this is learned in the home. Budgeting and shopping for healthy food, and then cooking it, should be a part of the National Curriculum.
The duty of care owed by schools to their pupils extends to their diet. Young children should not be given the freedom to eat too much fat, salt and sugar at school just because the damage done to their health is not immediately apparent. Diet can also be used to approach indiscipline problems in schools – a much sounder way than relying on medication for poorly defined conditions like “attention deficit disorder”.
Regular sports, dance and other exercise must be re-introduced to the school timetable to tackle the increasing problem of childhood obesity. Two hours of physical education per week will not suffice. Physical activity should also be complemented with a full arts curriculum to enhance self-esteem and mental well-being. Parents should be actively discouraged from taking their children to school in cars, and each school should be set a target to increase the number of children who get to school by walking or cycling where this can be done safely.
There should be a total ban on the advertising of unhealthy food that is directed at children, and machines selling fizzy drinks and unsuitable foods should be removed immediately from all schools and colleges. Commercial schemes that encourage children to eat unhealthy food to obtain “benefits” for their schools must also be outlawed.
Income and health
Healthier lifestyle choices must become easier choices.
Most poor people know what they must do to keep themselves healthy, but lack the means to do so. It is time for the UK to have a proper measure of the income level needed to avoid both absolute and relative poverty and ensure good health, satisfactory child development and social inclusion. This measure should determine benefit, pension and minimum wage levels and it should inform the practices of debt collectors and the courts.
There should be an urgent review of all current charging schemes, including the recommendations of the Royal Commission on Long Term Care, the perverse incentive of intermediate and domiciliary care charges that drive people into residential care rather than remaining at home, and dental, optical and prescription charges. The SHA would like to see the abolition of all prescription charges, and in the meantime government should introduce an immediate flat fee for a whole prescription, and exemptions for all medications for chronic and communicable diseases.
Health education
At school, learning to live healthy lives should have a place in the National Curriculum, where young people can discuss their own and their community’s health. Informing children about the realities of drugs, the dangers of smoking, the need for healthy eating and sensible drinking, and the social, interpersonal and health aspects of sex should all form part of a broader health and social education.
Sensitive issues must be tackled head on. The topics of drug, alcohol and tobacco abuse are often avoided because they are controversial, yet children respond well to factual information on such matters. Education in sexual health and teenage pregnancy issues must not left to the discretion of heads, school governors and parents, and the Dutch experience indicates that this should start early in primary school.
PCTs and local authorities should jointly employ community health advisers to provide practical outreach support to schools and communities, drawing in additional support from the voluntary sector.
Government must mount regular healthy living campaigns through the media, supported by high quality public information material on healthy lifestyles suitable for a wide range of audiences available at local and community outlets.
Prescription not persuasion
The SHA recognises the dilemma the government faces in striking the right balance between persuasion and prescription over individual lifestyles. However, it believes that at the moment the government errs too far on the side of persuasion. Individuals are often denied the information they need to make informed choices. Manufacturers do their best to confuse the public about health risks of many foods and drink, and the Government does too little to stop them.
The food industry should be encouraged not to use excessive amounts of sugar and fat in prepared foodstuffs, and salt should be excluded altogether where practicable. The addition of salt to any food should be a matter of individual choice. All food and drink should be clearly marked with the percentage of salt, fat and sugar that they contain.
Evidence from California and elsewhere suggests that banning smoking in public and in the workplace can halve the population prevalence of smoking. Local authorities here should therefore be encouraged to introduce similar bans, and pending the introduction of primary legislation, there should be support for local authorities to do what they can now through existing by-laws.
Common Agricultural Policy subsidies to support the production of tobacco and sugar should end forthwith. They give very mixed messages when government is exhorting people not to smoke and to reduce their consumption of sweet foods.
Strengthening PCTs
The creation of foundation hospitals contradicts the important principle that the PCT is in the NHS driving seat at local level. PCTs make the key decisions about local priorities and the allocation of resources, and creating a more democratic and accountable NHS should have started with them. Since almost all PCTs are co-terminous with local authority boundaries, communities can vote at the same time as the local government elections for their PCT board. This would strengthen the PCTs, increase public participation, and enhance their local credibility.
Focusing instead on foundation hospitals will only strengthen the already powerful secondary care sector at the expense of primary and community care, cut across the planning role of the strategic health authorities, and inhibit the development of clinical networks between and across trusts. These shortcomings in turn will diminish the ability of PCTs effectively to plan and fund the care that reflects the needs and preferences of their local residents.
The suggestion that PCTs should devolve budgets and power to GP practices should be resisted. This could interfere with the PCT’s crucial local planning role, and risks recreating the failed GP fundholder system.
The new GP contract does not provide sufficient safeguards to ensure that all practices will observe common standards. For example, some PCTs have received legal advice that the Race Relations (Amendment) Act does not apply to independent health care practitioners, and they cannot therefore require GPs to carry out the ethnic monitoring that is crucial to planning and improving health care for minority ethnic communities. Government should advise all Chief Executives at once that this interpretation of the Act is faulty, and that all providers in receipt of public funds are obliged to observe the Act’s provisions.
Choice
The discussion around “choice” assumes that ever expanding choice is the right direction for the NHS, and the SHA has reservations about any “choice” programme that treats health care as a commodity. The introduction of true “choice” will also require a system change whereby commissioning follows choice rather than pre-empting it, as it does at the moment.
At first glance “choice” appears attractive, but it should not be exercised at the expense of high quality, comprehensive and responsive health care that is locally provided. Patients will need much more information so that any choice they exercise will be based on a sound knowledge of alternatives, outcomes, and benefits. Patients should exercise choice as a part of the overall management of their own condition in partnership with health care professionals. Choice will be particularly important in the arena of mental health care, and it is in this arena that it should begin.
Currently, choice is exercised mainly through the power to go elsewhere. Choice pilots have been in large conurbations, and the ability to exercise that sort of choice outside metropolitan areas can be difficult. Choice needs to be made a realistic option for those who are socially excluded if it is not to be merely an extension of the privileges of the middle classes. And if active patients exercise choice by shunning a local provider because it cannot offer high quality care, it is likely that this provider would be allowed to fail, to the obvious detriment of those people who are unable to travel elsewhere.
The best way to improve health care is through the universal application of the principles of clinical governance, supported by new NHS investment where needed, that ensures everyone has access to local comprehensive, high quality health care services, managed and provided by the NHS. The SHA would therefore prefer government to concentrate on developing National Service Frameworks (NSFs) across the widest range to deliver services that meet needs defined by NSFs, to standards set by NSFs. Those areas where capacity does not permit services to be delivered to NSF standards should have priority for expansion.
Obtaining genuine diversity of supply
The political focus on hospitals makes no sense, even in healthcare terms. Greater genuine diversity of supply will best be achieved by concentrating resources on developing the extent and scope of NHS primary care services, on community care, and on health promotion.
The greatest gains in health are made through reducing educational, economic and social inequalities, promoting healthier lifestyles, and offering universal high quality care as close to home as possible.
The health and community care professions
The NHS must engage with its entire staff, develop their vision and utilise their unique experience of delivering health and social care. The SHA believes that at the moment government does not acknowledge the depth and strength of the commitment of all NHS staff to the ethos and values of public service.
Increasing the supply of well-trained and qualified nurses, allied health care professionals, social workers, care assistants, and ancillary workers will make a huge difference to the provision of equitable services across all parts of the health care system, and also take the pressure off doctors. Encouraging the large pool of qualified nurses doing other jobs, or not working, to rejoin the service could increase the supply of nurses relatively quickly. Offering better terms and conditions of employment across the board to all NHS staff will also assist recruitment and retention.
Government and the NHS must address urgently the institutional racism that under-values black and ethnic minority nursing staff and discourages recruitment from some minority ethnic communities that was identified by the recent Royal College of Nursing study. Action must also be taken to tackle the high drop out rate from training. Raising the status of nurses, and changing the medical culture that treats them as second-class citizens will take longer, but clear signals should be given now. In the meantime, better pay and conditions, and more attention to team building and morale will be popular with both the public and the nursing profession.
Although money alone will not raise the morale of health workers, neither is there any sense in contracting out support services to an underpaid workforce. Securing the lowest tender price at the cost of impoverished workers should be recognised as the poor long-term bargain that it is. Contractors make profits by cutting the terms and conditions of the lowest paid staff, many of whom are female and from ethnic minorities, whose own health suffers as a result.
Health care cannot be considered separately from social care, and greater co-operation between the NHS and social services is essential. The poor image of social workers has become acute, and there should be regular campaigns to counter the low morale of social workers and the negative and unfair media coverage they often receive.
The integration of health and social care under a single administration, or a statutory duty on local authorities and primary care organisations to produce a single integrated strategy for health social care and well-being, as recently enacted in Wales, are necessary developments if seamless, high quality community care is to become a reality rather than an aspiration.
Personal care also contributes greatly to keeping people out of hospital, yet the role of carers is greatly neglected. They also need proper support and sufficient resources.
Finally, much more could be done to enable migrant and refugee health care professionals to update their qualifications and language skills where necessary. The BMA now actively participates in this process. The BDA should be encouraged to do likewise.
New technology
There are areas where new technology can drive improvements without requiring increased capacity – for example, direct booking of appointments for consultations, diagnostic tests and elective procedures from GPs.
The SHA welcomes the imminent roll out of the HealthSpace electronic health record links.
European examples
The government must beware of European examples, which can often lead to comparisons between “apples and pears”.
The two European examples that the government should emulate are the ratio of GPs and hospital doctors to patients, which is far higher in those EU countries with which the UK compares itself, and the percentage of GDP that funds health care.
Mental health care services
Psychiatric and mental health services are still very under-developed. There are many mental health issues beyond those around risk that need addressing. Mental health policy appears to be in the grip of the law and order lobby, whose policies are misguided, counter productive and damaging to service users.
The SHA welcomes the government’s decision to delay publication of the new Mental Health Bill as a sign that it has listened to the overwhelming opposition to previous proposals. The SHA looks forward to a new draft Bill that incorporates the constructive suggestions made by so many mental health organisations. In particular, the SHA believes that mental health care services should be the place where the government first implements its commitment to provide a wider range of choice of care and care providers for patients.
The SHA welcomes the government’s commitment to expanding advocacy services for mental health service users.
Pharmacological and genetic advances
The government should ensure that the NHS provides those pharmacological advances and genetic developments that are deemed ethically and clinically desirable freely to those patients who would benefit from them.
There is some concern that foundation trusts will in future be permitted to market any innovations in health care they have developed to the highest bidder/s rather than to share them at no cost with the rest of the health service. If this is the case, then this anomaly in the foundation trust arrangements must be addressed.
Personal lifestyles
Schools and universities should make their sports facilities widely available to their local communities. Local authorities should also ensure that their sports and leisure facilities are affordable for everyone. More specialist children’s gyms should be established, since most of the equipment in adult gyms is not suitable for younger people.
Both national and local government should campaign to reduce the use of cars, encourage people to walk, and promote facilities for safer cycling. Many cycle lane initiatives are half-hearted and do not make it any easier for cyclists.
All alcohol advertising, like tobacco advertising, should be banned except at the point of sale.
Conclusion
Ministers underestimate the disruption caused by structural change, and should make a policy statement that there will be no more significant structural changes to the NHS for at least five years.