The more closely health and local authorities work to-gether the less appropriate does it appear for local au-thorities to have control over public and patient involve-ment structures. The Department of Health’s present plan for Local Involvement Networks in England is that the support organisation is accountable to the local au-thority for the performance of the LINK. If the authority reach the conclusion that the LINK is not representing the local community properly, they can sack the support organisation. So that means that both the local authority and the support organisation are in a position to control the LINK. There are two very obvious scenarios where this arrangement will cause trouble. If either the PCT and the local authority agree on some plan which is un-popular with patients or the public or if the local author-ity disagree with some plan proposed by the PCT which the LINK are happy with then the local authority would be able to decide that the LINK was not representing the local community. Without a clear public perception of independence these new structures will not command public confidence and will fail.

Editorial:

Spring 2007

Learning from differ-ence

2

A fresh start 3

Keep NHS Public 5

Public and Patient in-volvement

6

Labour Health Policy 10

Future events 12

Inside this issue:

Socialism and Health, the magazine of the

Socialist Health Association

www.sochealth.co.uk

Page 2

For some years I have been fascinated by the differences in policy and practice, including in public health and health and social care, that have emerged since devolution in 1999. It is fair to say that Scotland has always been a little different to England and Wales because it has its own separate legal framework. But these differences have increased since devolution transferred responsibility for most domestic policy to the Scottish Parliament. I was lucky enough to do some of my postgraduate medical training in Edinburgh and developed a great respect for the Scottish approach.

Until devolution Wales followed the English model in most areas but now it is steadily diverging even though the ex-tent of devolu-tion to the Welsh Assem-bly is substan-tially less than to the Scottish Parliament. Having latterly worked in Wales until my retirement in 2005, I had a ring-side view of this phe-

nomenon.

Northern Ireland has also pursued different paths from the mainland in many areas – it has, for example, had integrated health and social care services for many years – but the picture is complicated by the unstable political situation in the Province over the last 40 years. Interest-ingly, some years ago I visited the Province to study the impact of its integrated health and social care system and came to the conclusion that administrative integration does not of itself guarantee better integrated care at the patient/client level when no attempt is made to inte-grate the very different cultures of healthcare and social care professionals.

The rigorous study of the impact of these

national divergences on the health of popula-tions that are in most respects very similar is in

its infancy; but it promises much if properly organised.

But so what? Does this have any relevance for the SHA? The answer is in the affirmative both in a general sense – after all the SHA is a UK wide organisation. But it is also in the af-firmative in two respects which are of particu-lar interest to us at the moment. Firstly, what is happening to the NHS in Scotland is markedly different to what is happening in England and may provide invaluable lessons for the new direction of travel for the NHS in England which the SHA is committed to exploring. The fact that Scotland has tried the purchaser/provider split experiment and found it wanting, preferring to go back to the previous model of direct provision by health authorities is re-markable and certainly appeals to someone like me who spent most of my NHS career working within this model.

More interesting still to me as a public health practitioner is what is happening in Wales in promoting its new health, social care and wellbeing agenda. This is a truly revolu-tionary development which conceives public health in terms of wellbeing and which posits that every aspect of human activity, organised or otherwise, impacts directly or indirectly on the population’s level of wellbeing. The key message of this approach is that public health/wellbeing is truly everybody’s business and that the promotion of wellbeing requires part-nership working at a new level of effectiveness and inclusiveness. Huge lessons here for the more limited approach being adopted for pro-moting a less holistic vision of public health in England.

The challenge to us in the SHA is to keep abreast of these divergences and to do what we can to promote a serious analysis of their im-pact on what we regard as the pivotal issue of reducing inequalities in health. I am aware of several groups which are looking at aspects of these divergences but I have learned from long experience that although the need to coordinate these various activities may well be recognised by the groups themselves this does not neces-sarily mean that any concrete steps will be taken to achieve this. And without such coordi-nation we will not learn as much from studying these differences as we might.

Learning from difference – a potential cornucopia? Paul Walker, Chair

A Fresh Start - developing an alternative vision for the NHS in England

Page 3

Background The progressive marketisation of the NHS has been a cause for continuing concern to the SHA but did not provoke serious debate by Central Council until 2005 when the SHA was invited to affiliate to the newly established Keep Our NHS Public campaign (the aims and objectives of the KONP campaign are attached at Appendix 1). Central Council considered whether or not to affiliate at several meetings and having initially narrowly voted not to do so eventually, again by a small margin, voted to affiliate in April 2006. It was agreed to affiliate for one year only in the first instance and to review the decision at the end of this period in the light of what the KONP had achieved. This review will be carried out at the Central Council meeting in April 2007. Since the start of our continuing debate about the marketisation of the NHS and what should be done about it two things have changed. Firstly, any lingering doubts about the government's intentions in respect of marketisation have now disappeared in the face of incontrovertible evidence that it is fully intent on marketising all the public sector including the NHS. Secondly, there was a real concern that the KONP campaign was essentially a negative one which used any pretext to be critical of government action. It is now evident that the leadership of KONP have formed the view which we hold namely that we need to be positive and chart a new direction of travel for the NHS that does not involve marketisation but which is not simply a turning the clock back exercise. At its last meeting the KONP Steering Committee agreed to set up a working party, which included SHA representation, to look at the options for a new direction of travel. And the SHA Executive has been trying to do something similar with its Fresh Start paper. A version of this was considered at the last meeting of Central Council when the following comments and decisions were made: "It was agreed that the officers should redraft the section on key elements. This should start with positive comments: emphasis on the need

Agreed by SHA Central Council January 2007 Agreed by SHA Central Council January 2007 for strategic role of commissioning and a level playing field. The five points listed in the Health Composite motion moved by Unison at LP conference should replace the list calling for the discontinuation of PFI, payment by results etc.” The Executive, as instructed, has endeavoured to produce a revised draft Fresh Start paper but has formed the view that the issues involved are so major and the government's resistance to change is likely to be so great that a more considered and a more collaborative approach to defining a new vision for the NHS is the only one which has any chance of success. A Way Forward In terms of immediate action Central Council has already agreed that the policy on immediate action agreed by the 2006 Labour Party Conference, detailed below, should be promoted: 1. More time and flexibility be offered to Trusts and PCTs to achieve financial balance, to ensure that cuts are not made which damage local health provision and will incur wider costs later; 2. No further extension of payment by results until a full assessment of the consequences for the local health economy has been carried out; 3. The further outsourcing of services to the private sector, such as NHS Logistics, to be subject to review with full consultation throughout the Party and the NHS to consider the impact on trust budgets and the co-ordinated provision of services; 4. All NHS stakeholders, including patient groups and trade unions, to be fully consulted and included in policy discussions. 5. The Government to ensure that structures for patient and public involvement work effectively and that the public have a genuine say over commissioning and configuration decisions. For the longer term the focus must be on defining a new direction of travel - or even several new directions of travel - for the NHS in England in active collaboration with other organisations with a similar interest such as UNISON, AMICUS and of course KONP. The work done so far on this in

Page 4

developing the Fresh Start papers should be used as a starting point, particularly the set of principles agreed by Central Council and reproduced below: * We believe that healthcare must continue to be provided free at the point of delivery solely on the basis of clinically determined need and that it should be organised to meet explicitly defined individual and community needs; * We believe that it must be accountable to locally elected bodies answerable to the people they serve through elected representatives. * The reduction in inequalities in access to healthcare must be a prime objective for the NHS, as its contribution to the reduction in overall inequalities in health. * We believe in the principle that 'valued staff value people'. This means services should be delivered by staff with terms and conditions in line with the NHS Agenda for Change agreement; and that trade unions should be fully recognised in any unit or organisation providing NHS services. * Every healthcare encounter in each healthcare setting should take full advantage of the opportunities for lifestyle counselling in pursuit of the prevention of disease and the promotion of health and wellbeing.

* We consider that the public sector and particularly the NHS has, over the last 60 years, developed a culture and way of working, the public sector ethos, comprising among other things, compassion, pride in ones work, selflessness and a feeling of belonging to a worthwhile and much valued organization, which is uncommon in the private sector and which is worth retaining and developing because it adds value to the service delivered to the patient / user. Very helpfully, our Director has recently outlined some of the factors that he considers should be taken on board by the Labour Party in updating its Health Policy in readiness for the next Election. These factors, among others, should, we believe, be taken into account in developing a new future for the NHS in England. Two of these factors are particularly worth highlighting. Firstly, the desirability of looking at what is happening in the NHS in the three devolved administrations including particularly Scotland where the purchaser/provider model has been rejected in favour of a directly provided one. Although the contexts are slightly different in the other three countries of the Union there may well be lessons to be learned for the future NHS in England. And secondly, the pressing need to give greater priority to the prevention/public health agenda, particularly the wider determinants of health and the developing holistic

concept of Wellbeing. The current focus on the NHS has inevitably tended to relegate public health even further down the agenda. Recommendation 1. That the SHA continues to develop its thinking on an alternative future for the NHS in England BUT in active collaboration with other organisations such as UNISON, AMICUS and KONP and incorporating the key principles set out above. As far as possible this should be integrated with the Labour Party policy making structure. 2. That the programme of Conferences for 2007/08 be used to inform the development of an alternative vision. In particular, we should look at what might be learned from what is happening to the NHS in Scotland, Wales and Northern Ireland. A rigorous evaluation of what is happening in the other countries is essential so that lessons learned that might be applied in England are evidence based. A framework that might be applied in such an evaluation is detailed in Appendix 4 3. That the Executive report back at each Central Council meeting on progress with the alternative futures work with the expectation that significant progress will be made by the time of the AGM in 2008.

Principles We believe that the most equitable and efficient way of providing health care is by: Using the simplest and therefore most cost-effective system of administration of the NHS based on planning and co-operation rather than market forces. Removing the purchaser provider split introduced in 1990. Re-integrating the service with each area having a single administrative body democratically elected and responsible for providing all primary, secondary, community and ambulance services for its population. This centrally allocated budget should be on a per capita basis with

adjustment for deprivation. Minimum care standards of provision should be set based on good public health information. Stopping further use of the private sector until proper data about the effect of existing projects have been evaluated by independent researchers. Proper governance procedures and openness about costs (ie removal of commercial confidentiality clauses) is necessary. Not embarking on major reconfigurations of services away from the network of District General Hospitals without consultation with the local population and a proper evaluation of both medical and economic benefits and costs, including transport costs to the environment.

Page 5 AIMS AND OBJECTIVES OF THE KEEP OUR NHS PUBLIC CAMPAIGN

To inform the public and the media what is happening as a result of the government's 'reform' programme. To build a broadly based non-party political campaign to prevent further fragmentation and privatisation of the NHS. . To keep our NHS Public. This means funded from taxation, free at the point of use, and provided as a public service by people employed in the NHS and accountable to the public and Parliament. To call for a public debate about the future of the NHS possibly by setting up a genuinely independent Royal Commission and to halt further use of the private sector until this has reported.

Page 6

.Response (edited) by the SHA to the Health Committee What is the purpose of public and patient involvement? There are many possible answers to this. And or course there are many sorts of involvement at different levels and for different purposes. Firstly there seems to be good evi-dence that in a more diverse society it has become difficult for health-care providers to devise services which are appropriate for all sec-tions of the community without explicitly involving them in plan-ning the provision and ensuring that effective mechanisms exist to com-municate their concerns and experi-ences of services. The second answer is that citizens are entitled to have a voice in the expenditure of large sums of public money on their behalf. Existing systems of local democratic ac-countability are grossly inadequate. PPI might not be so necessary if there was sufficient local democ-ratic accountability. For any organi-sation providing services to the gen-eral public, whether government owned, a voluntary organisation, or a commercial enterprise, it is vital for its success to have its perform-ance constantly reviewed by its us-ers. At a collective level, it is about patients being involved in designing new services and improving current ones. At an individual level, it is about shared decision-making. Be-cause of the difficulty of getting informed responses from many pa-tients (because of their condition) the involvement of a robust, knowl-edgeable and independent public & patients organisation is a necessity. Furthermore health is not a com-modity to be purchased or just a service to be passively enjoyed. People need to be positively and actively involved with their own health and this requires opportuni-ties for both collective and individ-ual involvement. There is wide-spread evidence that the informa-

tion component of healthcare in the UK is the part which is least effec-tively delivered and improving this requires active patient involvement. What form of public and patient involvement is desirable, practical and offers good value for money? The idea that PPI structures should relate to an area, rather than to spe-cific healthcare institutions seems sound, but there will some opera-tional complications: if the LINK for Cumbria, for example, wanted to investigate services for premature babies then those services are largely provided in Manchester and Newcastle. The network of LINKs will need to spread out beyond the area of an individual LINK. The blocks at the shared –decision making level are partly to do with doctors/clinicians. Clinicians need incentives and training to get better at supporting patients in making more decisions themselves and car-ing for themselves better. Patients do actually find this quite difficult territory, too. The system does not incentivise people on the ground to make use of PPI. If it was moni-tored vigorously, if it really in-volved local people on the ground, if it was structured to make a differ-ence, it would work much better – it could change the face of the NHS. The solution for both doctors and patients is to acknowledge the truth that nobody can look after anybody-else’s health, and, whoever you are, your health is your own responsibil-ity. This is the message in the Ex-pert Patients Programme course. However, doctors are resisting it as they see it as the end of their ability to dominate their patients. Histori-cally, doctors have had a monopoly on their knowledge of diseases. They have guarded this jealously as their stock in trade which gave them power over their patients. However, with the growth of the internet and complementary and alternative ther-apy, their monopoly is breaking, and many patients are now more knowledgeable than their doctor on their particular condition. The de-velopment of self care requires

from clinicians: ♦ to trust the patient ♦ a new way of handling con-

sultations ♦ a new way of handling their

practice ♦ sharing power It is not clear at present whether equalities legislation applies to the activities of organisations like Pa-tient Forums which are composed of volunteers. We think that it should, but there are clearly re-source implication if people with for example sensory disabilities or lack of English language are to be fully involved. It is very hard to demonstrate value for money in PPI because of the difficulty of connecting outcomes to processes and structures. The De-partment of Health apparently spent £1M on the “Your Health Your Care Your Say” process, and this does seem to have reached people who are not often involved and been regarded as a success, but we cannot expect resources on that scale very often. Involving people from very disadvantaged groups can be very expensive, but the most disadvantaged people are exactly the people whose voices need most to be heard. A great deal of money is presently spent by individual NHS institu-tions on one off consultation proc-esses. Often the outcome is prede-termined and the consultation is a waste of time and money. Often there is little useful information provided (especially about money) and the consultation documents are bland and evasive if not downright dishonest. We would argue that PPI structures need to demonstrate first independ-ence and second continuity. We deal with independence below. Continuity should extend in time, in personnel, in place, across institu-tional boundaries, and across com-munities. What is needed is a mechanism which can connect com-

Public and Patient Involvement

munities of various kinds to the decision making structures and which transcends institutional boundaries in a way which provides resources independent of the inter-ests of the various institutions. Only small numbers of people will have a continuing involvement with these mechanisms but there need to be ways for the wider community to raise concerns and to enable com-munication with the public. Organ-isational stability is important for structures largely populated by vol-unteers. It requires a considerable input of time and effort by lay indi-viduals to begin to comprehend the NHS. It is particularly important for the PPI organisations to have a col-lective memory given the transient nature of many health organisations and this is largely provided by the employment of professional staff. We would like to see some investi-gation of differing practices in Scot-land and Wales to see if lessons can be learned across the national boundaries. Why are existing systems for pa-tient and public involvement be-ing reformed after only 3 years? Because Ministers like to give the impression they are doing some-thing, because the systems they es-tablished in England in 2003 have not been very effective and because it is now quite clear that the aboli-tion of English Community Health Councils was an expensive mistake. Regardless of the reason for this change we hope that more care will be taken over the process this time. It is important to retain the skills and experience of staff and volun-teers and the records of organisa-tions. We see no reason why CHCs could not have been reformed, nor why Patient Forums have to be abolished and cannot be reformed How should LINks be designed? Remit and level of independence The remit of LINKs should extend to health and its wider determinants, as well as health and social care.

If LINKs are not perceived to be independent they will have no credibility. Under the present pro-posals the most obvious threat to their independence is their relation-ship with the sponsoring local au-thority who will be responsible for managing the contract under which the support staff are to be em-ployed. Experience tells us that some local authorities are capable of manipulative behaviour when local political interests are involved. Under the CHC regime it was not unknown for voluntary organisa-tions’ funding to be threatened if their representatives did not vote the way the local council wanted them to. It is therefore important that the process of managing the contract is protected from political interference by establishing a trans-parent process and a fixed timetable – we suggest contracts should nor-mally last for five years and any change should be agreed by the LINK, and not just by the local au-thority. . Membership and appointments It is not clear what is meant by membership of a LINK organisa-tion, given that there are to be both individuals and organisations in membership. The Department of Health envisage a LINK as a net-work. For many purposes a flexible participative process will be neces-sary and desirable, but there may be times when a decision will have to be made about which there will be different points of view. It may be necessary to define a core mem-bership in order to permit democ-ratic decision making. There should be a requirement that every person who participates in the work of a LINK should be required to be normally resident in the area of that LINK We would not want to see a system whereby people repre-sent organisational interests as a member of a LINK nor any kind of block voting system. The collective voice of a LINK would only have more weight than the voices of the individual mem-bers if it could demonstrate wider

Page 7 involvement, particularly of disadvan-taged groups, or enhanced expertise. In reality the response of a LINK to many consultation processes will be based on the experience and knowledge of its members. There will never be sufficient resources to involve the wider public and the most disadvantaged people in every issue. If LINKs make official responses they should be required to state what processes informed the production of that response. We would envisage that all lay people who have any sort of representa-tive role in the arrangement of health or social care services in the area would automatically be a member of their local LINK. It is important to recognise the increasing diversity and fluidity of the voluntary sector if these organisations are to be brought into LINKs. Many voluntary organisations will have financial interests in the provision of services in their area and it is important that these interests are declared and that these interests do not contaminate the voices of voluntary or-ganisations representing their communi-ties. Under previous legislation NHS employees and contractors were not al-lowed to be members of CHCs or Patient Forums. If such a prohibition is to con-tinue then it should probably extend to any person with a financial interest in the provision of health or social care services in the area of the LINK. If the prohibition is abandoned then there will need to be a mechanism to register the declaration of interests. It will be very important that LINKs adhere to the Seven Principles of Public Life established by the Nolan Committee and it will be necessary to ensure that there is some mechanism for dealing with complaints about this. We think that there is considerable po-tential for using internet based mecha-nisms for collecting the experience of patients, helping people to communicate with each other and to enable, for exam-ple, people who are housebound to par-ticipate. Funding and support LINKs need to be in a position to employ professional staff with experience in community development and of how the NHS and social care work. They will also need people with good IT skills. There needs to be organisational stability

Page 8

and a career structure if highly skilled staff are to move into this work. We would want to see a very trans-parent funding regime. If there is a national budget of say £25 million for the population of England that works out as approximately 50 pence per head per year. We sug-gest that if it is thought proper to make specific funding provision for particular sorts of deprivation or activity that this should be provided separately. We do not see that it would be possible to produce a for-mula which would take account of all the different factors which might make involving people in a particu-lar area more expensive than the average. We see no reason why service providers or commissioners should not pay LINKs to conduct consultations or other projects on their behalf just as they often pay freelance consultants now, although we might need to ensure that the independence of the LINK was not compromised. Areas of focus We would envisage LINKs as hav-ing a particular role in fostering the development of local involvement mechanisms, in particular localities, among particular communities or with individual practices or provid-ers. This should certainly extend to an involvement with Practice Based Commissioning which up to now has had little patient involvement. Statutory powers LINKs should in themselves have some statutory powers over and above the powers available to the public in general. They need statu-tory rights to sit on, speak and vote on all NHS committees concerned with patient care. Patient represen-tatives need support in what is a tough job. On each committee there should always be establishment for at least 2 patient representatives, so that they can support each other. If for any reason a PPI rep cannot be present at any meeting, they should

have power to appoint a deputy or a substitute so that there is never a vacant chair. In addition we would want each LINK to have access to the detailed terms of any contract for the provi-sion of health and care services to people in its area. We understand that there will be objections to this on the grounds of commercial con-fidentiality but openness is part of the price of undertaking publicly funded work. We would have no objection to some provision making commercially sensitive information subject to confidentiality for a lim-ited period. We think that the pro-posal to give nominated LINK rep-resentatives rights of access to health providers premises on the basis that only those nominated will have CRB checks is a sensible com-promise, and that right of access should extend to any provider of services. One problem which may inhibit the relationship between patients and a LINK is the existence of the sys-tems to regulate medical research. We would wish it to be made clear that enquiries made to competent patients who are capable of under-standing by a LINK about their experience of health and social care services does not constitute medical research and does not normally re-quire ethics committee approval. Relations with local health Trusts If the NHS is truly going to em-brace diversity of provision then we would want to see LINKs relate primarily to the commissioning bodies and for their remit to em-brace providers of all sorts. This will clearly include existing NHS Trusts and these Trusts may not necessarily be located in the area of the LINK. The remit of each LINK should relate to the services pro-vided to people resident in their locality, wherever those services are provided. We would expect NHS Trusts to establish positive relation-ships with local LINKs but in our experience these relationships need effort from both sides. We are glad

to see that effective PPI skills are beginning to be regarded as impor-tant to NHS managers. We would expect a LINK to establish a group to relate to each significant provider of services for its local area. National coordination A national and regional organisa-tion will be very important for the success of LINKs, and the lack of it has contributed to the weakness of Patient Forums. However the na-tional and regional organisations must be answerable to the local LINKs, and not the other way around. Members of LINKs must be enabled and encouraged to commu-nicate with each other across the country so that specialist issues can be addressed. We would envisage mechanisms whereby representa-tives of patients of all kinds, includ-ing voluntary organisations, at re-gional and national level would relate to these bodies. We also hope to see the emergence in due course of regional and national leadership capable of expressing the patients’ voice and of coordinating and di-recting campaigns relating to pa-tients experience so that if some future Secretary of State wants to declare that the NHS has had its best year ever there will be a credi-ble patient voice able, on the basis of evidence, to confirm or deny such a claim. How should LINks relate to and avoid overlap with: Local Authority structures in-cluding Overview and Scrutiny Committees In our experience Overview and Scrutiny Committees’ effectiveness in relation to health varies very widely according to local political and geographical circumstances. We would like to see measures to bring more of these committees up to the standards of the best, and often this is down to the nature of the officer support provided. We would not want to see the effective-ness of a local LINK impeded by a

Public and Patient Involvement (continued)

local authority structure which is determined by

its own political interests but we do think that there is potential for LINKs and Scrutiny Committees to work together constructively. How-ever in some local authorities the Scrutiny Committee is incapable of providing an effective challenge to service provision of indifferent quality. Foundation Trust boards and Members Councils As yet the impact of the democratic arrangements for Foundation Hos-pitals is difficult to assess, but most of those involved report that as members or governors of a Founda-tion Hospital they perform a purely decorative function.. There is clearly potential for using those mechanisms to improve consulta-tion and involvement of patients with hospitals and this may be use-ful for the relatively small number of people whose care is delivered primarily by a hospital. We would expect Members Councils to relate to their local LINK. However the central political problem in health is the excessive political power and visibility of hospitals, particularly acute hospitals, as opposed to the invisibility of primary and commu-nity services. Inspectorates including the Healthcare Commission

The efforts the Healthcare Commis-sion and CSCI have made to date to involve patients in inspection ar-rangements are very encouraging and merit further development. We see the Commission as a powerful ally in the development of involve-ment and we want to see this role strengthened. We would like to see other bodies with inspection rights emulate their approach. LINKS should be recognized as working alongside the professionals in pro-viding lay members for formal in-spections. We would hope to see LINKs developing an independent voice for patients who may want to raise concerns different from those developed by official bodies. We also see LINKs as able to react much more quickly to local prob-lems and much more able to deal with problems which cross institu-tional boundaries. Formal and informal complaints procedures The separation of complaints work from the work of patient forums has been a source of weakness as com-pared to the regime of the best CHCs where complaints contrib-uted to a detailed picture of the per-formance of local health services. We understand that there are con-cerns about the confidentiality of complaints procedures but we con-sider that some mechanism must be devised to ensure that local LINKs has access to information about

complaints which is sufficiently detailed to enable LINKs to know which specific services give rise to complaints. There may also be a role for LINKs to protect patients who complain as there are still widespread allegations of victimiza-tion. In what circumstances should wider public consultation (including under Section 11 of the Health and Social Care Act 2001) be carried out and what form should this take? The proposed amendments to what is now section 242 of the National Health Service Act 2006 appear to envisage much more general con-sultation than has previously been required, and we welcome that. We hope that the shameful practice where changes required to be intro-duced by the Department of Health are excluded from the duty of con-sultation will now cease. We would like to see decisions about the arrangements for consultation under section 242 taken locally in conjunction with the local LINK which could take into account a wide range of factors, including the capacity of local communities to respond and the relative signifi-cance of various proposals. We would certainly like to see the end of the ritual publication of glossy consultation documents relating to decisions which all those concerned know have already been taken.

Page 9

These are my own reflections on the current state of play. Health inequality, and public health in general, is still very low profile. The targeted individualised approach which HMG are taking does not upset anyone outside Public Health. The fact that there is little evidence to support some of these initiatives doesn’t seem to be a cause for concern. It is difficult to get politicians worked up about the fact that the life expectancy of the rich is rising more rapidly than that of the poor. The most important, and most difficult, task for the SHA is to raise the profile of the wider determinants of health and income ine-quality in particular. There is still a great deal of work to be done to raise the profile of health as op-posed to illness.

There is very widespread agreement that further centrally directed structural change is to be avoided at all costs.

Pluralism, privatisation and competition has still got a considerable head of steam in it. Much more from the staff side than the patient side. It is difficult to find a patient who cares much whether they get care or treatment directly from NHS staff or from some agency paid for by the NHS. But it is equally diffi-cult to find a patient who is much impressed by the choices currently being offered. Patients are quite interested in certain sorts of choice, but they are not very keen on going further away from home for treatment and they want a lot more information if they are to be given the opportunity to make deci-sions. There is a good deal of rubbish produced by both sides of the argument about choice and compe-tition. Those who embrace competition do not seem able to produce much evidence of its supposed beneficial effects in a healthcare setting. There is a lot of talk about payment by results, but inability to comprehend that for many medical problems the only measurable result is eventual death, that many medical conditions are poorly defined and that what we have to pay for generally is that ill defined com-modity “care”. Those who denounce privatisation use the term so widely that it loses any precise meaning and attribute all difficulties to it without any attempt to demonstrate causation. KONP con-veniently forget some of the effects of the NHS mo-nopoly – in particular the manipulation of the sys-tem by surgeons for their own personal profit. The SHA might be able to improve the quality of the debate by challenging both sides. Traditionally the word privatisation was used when some government run service was transferred to the private sector,

usually with its premises and staff. That is not what is happening generally in the NHS, although it did happen in the NHS Logistics case. The word Mar-ketisation is more appropriate for what is generally being introduced because the services being pro-vided by commercial organisations are in the main additional to what was previously provided by the state.

KONP make a comparison between ITV and BBC – both free at the point of use - which is worth explor-ing a bit more widely. If we are arguing that there is a difference between services provided directly by the NHS and those provided under contract we need to provide a coherent explanation of what that is. Although perhaps KONP do not realise that these days quite a lot of BBC programmes are commis-sioned, not made by their own staff. If we object to the idea of the NHS becoming just a logo, a brand which carries a guarantee of certain quality stan-dards, we need to make a case which will appeal to patients, not just the staff of the NHS. Patients cer-tainly are concerned about quality and safety, and there is a growing lobby of dissatisfied patients which has realised that hospitals are not the safe places they might be. Is there any UK evidence to suggest that private healthcare is less safe or of lower quality? Points suggested which we might make about commercial healthcare providers (NB these do not generally apply to the not for profit sec-tor:- ♦ loss of altruistic ethos ♦ profits/shareholders make services more ex-

pensive ♦ if the profits go, the company will go. The

system will become very unstable. Takeovers, etc. (though hardly less organisationally sta-ble than the NHS has been for the last 20 years)

♦ gaming becomes the norm - anything will be

done to make profits rise There may be other points we can make, but we need to substantiate these points with evidence that there is really a difference from public sector or-ganisations.

The procedures provided by the NHS for dealing with complaints and medical harm have in the past been seriously inadequate. There have been re-peated changes and the NHS Redress Act has just

Political perspective on developing Labour Health Policy Page 10

been passed. We need to revisit this area. The advent of the NPSA has raised

the profile of untoward incidents considerably. The general public has yet to realise that the chance of acquiring further medical problems as a result of admission to hospital is more than 10%.

There is no evidence that the NHS is becoming less free at the point of need. No political party is pro-posing to introduce more charges. There is no point in us campaigning on this point. There has always been a problem with long term care, and I think that the situation now is slightly better than it was. In any case issues about long term care are nothing to do with marketisation. There are however some in-creased costs associated with choice – principally travel costs for patients, and these merit some inves-tigation.

There are also considerable worries about whether the principle of universalism will continue to be de-fensible. There are clearly a great many new and expensive treatments becoming available and there will at some point be discussion about whether it is acceptable to permit people who have the means to pay for services which are not provided free by the NHS.

Local accountability has always been very weak, and we should be demanding new and better mecha-nisms, not pretending things were better in the past. Individualised choice – if it ever happens in a sig-nificant way - is not a substitute for community voice because there is never going to be much choice about the handling of urgent or long term care. We need to continue to develop policies in this around local accountability especially in relation to commissioning. We should try and persuade our members to help make the LINKs idea work – and at the same time look to see how things are done in Wales and Scotland. This might be the key to many problems.

If local decision making is genuinely accountable and robust it seems unlikely that there will be wide-spread introduction of profit making providers, but if a local population can really be convinced that a profit making provider will give them a better ser-vice than an NHS provider then it is hard to see why we should object. Equally the only way the NHS will ever be able to close hospitals and survive po-litically is by setting up some system whereby the local community can be convinced that this is the right thing to do.

We can talk about accountability at an individual level – the individual patient and their relationship with those who treat them.

At a Practice level: Local committees running the practices, with the partners. This would link closely with PBC, if that continues.

In a locality community development is a key approach that will link local people, patients, disease groups and account-ability in an organic whole that leads to both better health and better PPI. Extend Foundation Trusts to PCTs but en-sure better arrangements?

There has been a lot of concern about marketisation “fragmenting” the NHS, and about maintaining its “structural integrity”. I am not sure what people mean by this. As a patient I have always experienced the service as fragmented. When I go to a different part of the NHS they usually know nothing about me and do not accept any con-clusions reached about me or my care by a different institu-tion. Perhaps people who live all their life in one village and only ever attend one hospital experience the system dif-ferently, but the NHS needs to cope with a more mobile population. If this Fragmentation point is important then it needs to be articulated more clearly. One obvious way of connecting up the different parts of the system is Connect-ing For Health. We should be supporting this and pointing out to all the paranoid opposition that the stuff that worries them about all and sundry having access to their medical records and those records being full of inaccuracies which they cannot correct is exactly what goes on now with paper records.

There is clearly mileage in comparing the situation across the internal borders of the UK. For one thing it provides a defence against the charge that the Blair Government are conspiring to demolish the NHS. If that were so why would it be left in place outside England? There are however im-portant differences which might make it difficult to apply lessons across borders. The most important is that there is no private healthcare industry worth mentioning outside England and so little incentive for consultants to manipulate waiting lists. It may also take time before significant differ-ences between the countries can be demonstrated.

The purpose of the Labour Party’s policy consultation is to produce a policy for 2009. It is difficult to get people to think so far ahead. Much attention has been given to un-pleasant deficit reduction exercises which clearly do not constitute long term policies. Unpleasant though it may be to watch a variety of long term investments which we value sacrificed on the altar of immediate financial balance we need to try to avoid getting sucked into short term debates where we have little influence. We must not be sucked into managerial debates about how things are run. We do not have sufficient expertise to contribute anything useful. In particular the question of whether one way of doing things costs more than another is, in health, almost entirely a ques-tion of how various sorts of overheads are allocated. It is not a matter of principle. We do not have to defend the principle of value for money, but we may need to point out how little discussion there is about cheap and effective measures as compared to the endless discussion of the im-portance of expensive medication which is often not very effective.

Martin Rathfelder

Page 11

Future Events

Costs for the events above vary but are reduced or free for SHA members (and delegates from affiliated organisations, including Amicus and Unison).

Further details will be on our website www.sochealth.co.uk or available from the office.

Cartoons in this issue are kindly provided by Peter Rigg.

Eat Local -Think Global Thursday 8th March 10am - 4pm

Mumtaz Restaurant, Great Horton Road Bradford BD7 3HS

Bradford was dubbed the obesity capital of the United Kingdom by Men's Fitness magazine in 2006. Although the people of Bradford indignantly refute their method-ology it is true that the people of Bradford are getting steadily fatter. Like most of the UK. The local council Health Improvement Committee made a very detailed

study of obesity in Bradford in 2005, and there has been a lot done to tackle this problem - more than in most cities. Now seems a good time to consider whether

there is more that could or should be done.

People of Asian origin are particularly at risk from diseases associated with obesity, which is one of the reasons be have chosen to discuss this topic in Bradford, and in

the Mumtaz restaurant.

Heema Shukla, UK Public Health Association - Food special interest group Andrew Hill, Professor of Medical Psychology University of Leeds

Dr Ann Hobiss The School of Health Studies University of Bradford Dr Liz Dowler, Department of Sociology University of Warwick

Socialist Health Association 22 Blair Road Manchester M16 8NS Tel 0870 013 0065 admin@sochealth.co.uk

Articles, Letters, Announcements and Comments should be sent to the editor Gavin Ross, 21 Connaught Road, Harpenden, Herts AL5 4TW.

The deadline for contributions to the Summer 2007 edition is 1st May. Tel/Fax 01582-715399 or by e-mail to gavros.ross@btopenworld.com

Can you take politics out of the NHS and leave it to the professionals?

An open debate with contributions from Paul O'Shea, Regional Secretary, UNISON

Simon Jones, Chair Cardiff and Vale NHS Trust Eddie Coyle, Socialist Health Association Cymru

Monday 19th March 2007 6 p.m.

SHA West Midlands AGM Saturday 24th March 10am

Brandhall Labour Club, Tame Road, Oldbury, West Midlands B68 0JT