Elected Members of Central Council Secretary: Huw Davies Treasurer: Gavin Ross Central Council: Dr Clare Bambra, Derek Marcus, Dr Neil Goulbourne, Dr Paul Walker, Tina Funnell, Dr Brian Fisher, David Pickersgill, Gavin Ross, Huw Davies, Mike Roberts, Dr Tom Smith, Dr David Joselin, Sally Young, Dr Doug Naysmith MP, Dr Dianne Hay-ter, Dame Jane Roberts, Seton During, Melanie Johnson, Ged Taylor, Suresh Pushpananthan, Vivien Giladi West Midlands: David Mattocks and Chris Bain. London: Patrick Vernon, Tom Fitzgerald, Huw Davies,& John Lipetz Scotland:Ali Syed and Dave Watson Wales: Dr Eddie Coyle and Tony Bed-dow North East: Lewis Atkinson Unison: Christine Durance. Unite: Barrie Brown

Scientists rule! 2

Democracy in the NHS 3

View from the heart 4

David Pickersgill 6

Brian Fisher 7

Access to Primary Care

8

Unequal from the start 9

Health Behaviours and Mortality

13

Future events 14

Inside this issue:

Spring 2008

Socialism and Health, the magazine of the

Socialist Health Association

www.sochealth.co.uk

This year is the first for many years when members have been offered a choice of candidates for Chair of the Association. You will find state-ments from the candidates on pages 6 and 7 and a ballot paper should be included in the mailing. Please post it back to arrive at the office by Friday 7th March or bring it with you to the AGM in Wesley’s Chapel on Saturday 8th March.

Page 2

I was struck the other day by something the recently retired Government Chief Scien-tist, Sir David King, said to the effect that he had been surprised and considerably hampered in doing his job by the scientific illiteracy of most Ministers and senior civil servants. My first thought was that we had never had a scientist prime minister and few if any in the higher echelons of govern-ment. But of course I was wrong in one re-spect. For Margaret Thatcher was a scientist – an Oxford graduate chemist if I remember

aright. Only Lord (CP) Snow comes immediately to mind in terms of sci-entist Minis-ters. I have to de-clare a per-sonal preju-dice. I had the great good fortune to go to an excel-lent LEA

grammar school whose headmaster was a physicist by background. His policy was that the brighter pupils were strongly en-couraged to do sciences with only the less able permitted to do arts subjects. Dutifully, I pursued sciences and developed a clear bias in their favour. This was reinforced at University where, once again, the brighter undergraduates seemed to be those reading science though there was a prevalent heresy that whilst reading history or English was a real education the pursuit of science consti-tuted merely a vocational study! Not surprisingly when I attended a class reunion recently there were only engineers plus a sprinkling of doctors and teachers. No bankers, media types or lawyers. In the 1950’s there was a great debate led I

think by the said CP Snow about the two cultures. The view seemed to be that the grammar school and public school systems were breeding two separate races who had difficulty in communicating with each other. The level of concern was great enough to provoke headmasters like my own to introduce so called general studies subjects into our sixth form curriculum to try to add a patina of “culture” to us scien-tists. Looking back I do not recall the arts types having to do extra “scientific” sub-jects to make them more “balanced” indi-viduals which rather suggests that the main worry was of producing philistine scien-tists by the shedload rather than scientifi-cally illiterate arts types. How things have changed. Now we seem to be producing increasing numbers of scientifically illiter-ate arts graduates many of whom find their way – as they always have – into the civil service and politics. In an age of declining scientific literacy in this country, we need to raise the profile of science. The Public Understanding of Sci-ence movement is a step in the right direc-tion but we also need to increase the num-ber of scientists in government and among our democratic representatives. Apart from the intellectual rigour and scientific under-standing that they would bring to bear wouldn't it be a refreshing change to listen to people schooled in the art of communi-cating to inform with precision rather than to bamboozle and obfuscate? Whatever her faults, and they were legion, Margaret Thatcher did not waffle. She knew what she wanted to say and she said it with great clarity and brevity. The prevalent practice today seems to be to say nothing at great length; words, words, words, signifying nothing. Evidence to my mind of flabby thinking untutored in the fact-based rigour of science. What I wonder would CP Snow have said today?

Scientists rule!

Paul Walker, Chair

Democracy in the NHS Gavin Ross

Page 3

The SHA has long campaigned for a de-mocratically accountable NHS at local level. But what this means in practice is by no means clear. When unpopular decisions are made we ask who it is that makes the decisions, how were they appointed, and what interests they may have that might in-fluence the decisions. Apart from local councillors there is no tra-dition in Britain for public elections of local officials or members of boards. Compared with the USA where large slates of candi-dates are to be voted into public office at the same time as congressional elections, we have no history of this kind of democ-racy. It is also assumed that few people know or care enough about any of the can-didates until things go badly wrong, and that there is anyway a shortage of suitable talent to fill these posts, and that it is impor-tant to have knowledgeable specialists rather than local politicians with little ex-perience of the complexities of health ad-ministration. If, for example, democratic elections were to be held, say every four years at the same time as County or Re-gional elections, there is every likelihood that candidates would be selected by politi-cal parties and that the results would reflect the political majority of the area. The idea that unpopular decisions would be avoided because those elected feared the conse-quences is hardly credible. However, that does not mean that we should not continue to press for elected representatives on boards, backed by effective publicity and debate on the issues involved. Apart from the ability to choose representa-tives to boards, democracy can also mean the right to influence decisions on particular topics. At present this is done formally by

announcing draft proposals on which com-ments are invited from the public during a reasonably long consultation period. Infor-mally this is done by meeting with and writ-ing to selected interest groups such as the BMA, the unions, local authorities and Friends of Hospitals, possibly even remem-bering the duty to consult with Patient Fo-rums or their equivalent. Outside this proc-ess the public and political parties may take up the issue and organise petitions, demon-strations and protest letter campaigns. In a sense people would like a referendum on decisions they care about, rather than the chance to replace one set of representatives by another set. Democracy, therefore, means honest consultation and full explana-tion of the factors influencing any contro-versial decisions. Much of the day-to-day administration and small decision-making is of little interest to anyone beyond the few people concerned, and the public are content to leave this to the professionals or to those few self-appointed volunteers who attend meetings and comment on proposals. If there is extra money, everyone is pleased and there is lit-tle public debate about where it should be spent. It is only in the climate of cuts and closures that people demand a say in the process. The most difficult cases are where the professionals believe that concentration of services in centres of excellence is neces-sary, whereas the public believe that closure of an older local hospital is a loss of service if they have to travel further to a more mod-ern facility. So while the SHA is asking for a democ-ratic health service, we need clarity about exactly what this will entail.

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When first established in 1948, the NHS was to pro-vide free health services from a redistributive income tax policy, irrespective of patients’ ability to pay, “in place of fear” of costs that patients couldn’t pay during ill-health. The desire to reform the UK healthcare system is para-lysed by fear of political ruin engendered by a perceived threat to universal coverage. In fact, numerous examples now exist of healthcare sys-tems in the developed world that perform far better than the NHS, and provide; uni-versal coverage, safe ac-cess to care for the vulner-able, no waiting lists and a minimum of political interfer-ence. In the summer of 1991, I av-eraged 135 hours a week for 6 weeks. The fatigue was great, but the experi-ence was greater. District referrers were happy with the service, which seemed to provide tax-payers with excellent value at very low cost. It seemed that Bevan’s objectives were being met, “my job is to give all the fa-cilities, resources, appara-tus, and help I can, and then leave you alone as profes-sional men and women to use your skill and judge-ment without hindrance”. The last 10 years has been very different. There has been unprecedented growth in funding, unprecedented interference in the delivery of care by politicians and

managers, imposition of elective care targets which crowd elective patients into the space and resources previously used for the sick-est patients, and much con-flict. Hardly a week passes without a new medical tech-nology or technique being announced, and more and more money must be raised in order to preserve the fun-damental principles of the NHS. Now the UK has the world’s 29th best healthcare system, and productivity is falling. New contracts for GPs and hospital doctors were drawn up without any attempt to assess what work they were already doing, and conse-quently, these contracts cost £450m more than an-ticipated, leaving little money for service improve-ment. New hospital build-ings were ordered with costly borrowing schemes just as revenue was being diverted into independent hospitals and the govern-ment was calling for more care outside of hospitals. It is hard to escape the view that government should have taken Bevan’s advice and left us to get on with the job. Patients need more choice, and the service needs to be more client orientated. In the first 10 years of my career we provided excel-lent care for the sickest pa-tients first, at low cost. But very long elective waiting times, unheard of in other

Western European coun-tries, were inevitable. A tax-payer with an elective ill-ness deserved better. How-ever, the NHS answer to this has been to create mul-tiple tiers of staff to choose on a patient’s behalf, not to give a patient portable healthcare entitlement with which they can choose for themselves. As a conse-quence, the client and the service are disconnected. One agency pays for care, another allocates it, a third prescribes it, and the patient receives it. Small wonder that the final service may not be what the client was hoping for. However, they cannot complain, and they cannot take their custom elsewhere. We still have an irrational system of delivery that separates client and service. On the supply-side, much hope is being placed in competition between provid-ers, public, independent and private. However, health-care requires efficient verti-cal integration of primary, secondary and tertiary care to work well. What is being created is vertical competi-tion between providers of different levels of care, along with horizontal com-petition between providers of similar care. This is a damaging free-for-all. To use a sporting analogy, two football teams take the field to compete, but to be effec-tive, the defence, midfield and attack need to work to-gether to overcome the op-

View from the heart Dr A P Fitzpatrick Consultant Cardiologist Manchester

position. The competition being fostered in the NHS pits one team against an-other, but in each team, the defence, midfield, and at-tack are also competing for the ball. GPs see district hospitals sucking in re-sources that they could use more effectively, district hospitals see tertiary cen-tres and want to emulate them. Instead of NHS com-petition creating efficiencies, it creates waste. UK healthcare needs radical thinking to correct the struc-tural problems afflicting the demand for, and supply of healthcare services. Univer-sal coverage is taken for granted in the 28 countries above us in the healthcare league, and is not negotia-ble here. It is difficult to see how patients can genuinely exert demand-side choice pressures on the system without some kind of port-able cover that they can use as an individual, independ-ent of layers of expensive bureaucracy to make deci-sions for them. Such client-choice should shake provid-ers out of complacency. However, providers will be

limited in their ability to cre-ate economies of scale, and efficiencies in delivering care, unless they have natu-ral allies in the care-pathway. For district hospi-tals to compete for patients with GPs and terti-ary providers makes no sense, but the system being developed encourages this. Far better for primary, sec-ondary and tertiary provid-ers to be allied together against similar organisa-tions, competing for patients with a portable healthcare cover. Bureaucrats engaged in choosing care for a pa-tient would be much better employed in streamlining collaboration between pro-viders in vertically integrated care pathways.

Politicians urgently need to grasp these principles. If they cannot, or will not, then an independent com-mission should be allowed to plot a course for the fu-ture. If changes are not made then taxes will rise inexorably, or free universal coverage will be sacrificed.

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Page 6

About me … I have been a member of SHA for around 20 years and of Central Council for around 18. I am currently a Vice Chair. My decision to stand as Chair was in re-sponse to requests from senior Central Council members that I consider do-ing so. For people who do not know me my work roles are as a community mental health nurse and trade union activ-ist. I’m an RMN and Spe-cialist Practitioner, have a first class BSc in Commu-nity Health Nursing and cur-rently do clinical work two days per week with the Cri-sis Resolution Service for working age adults in Wake-field. The rest of my working week I’m Branch Secretary of a medium sized (just un-der 2000 members) UNI-SON health branch with Mental Health Trust, PCT / other primary care and vol-untary sector membership. I sit on the Yorkshire & Hum-berside Regional Commit-tee of UNISON as one of two representatives from health branches. A few years ago my trade union work led me to seriously contemplate a change of career to law and I com-pleted both the Common Professional Examination and Legal Practice Course, but eventually decided I pre-ferred my current career in the NHS.

In party terms I have been a Labour Party member for 25 years this year, and early last year was elected as Chair of the re-organised Wakefield CLP. I have pre-viously been District Party (LGC) Chair, Labour Group Observer, agent, council candidate in an un-winnable seat, etc.. My vision for the SHA: In all the activities I have outlined above I have found the SHA to be an incredibly stimulating resource, help-ing develop my thinking about health, NHS and gen-eral political / Labour Party issues. We are a rather unusual space where people with very diverse backgrounds can come together to ad-dress common issues and interests. This is our ‘unique selling point’. Where else can politicians, health pro-fessionals, patient advo-cates, trade unionists, health planners and aca-demics, NHS board mem-bers (and even the odd member of the public) come together on equal terms? I feel strongly we need to both retain and promote this feature of the SHA. Politically I am opposed to the current government ini-tiatives to introduce compe-tition and a greater role for the private sector in the NHS – so called marketisa-tion. Most health care is de-livered in primary and com-munity care settings, com-

monly to people with com-plex and multiple needs. Im-proving this care requires greater cooperation be-tween providers, not com-petition, as does both the development of clinical knowledge and mainte-nance of professional stan-dards in high tech hospital settings. I’m also enough of a 1980’s leftie to believe that the NHS is not only the state provider of health care, but a - far from perfect - living example of what socialism is about: collective organi-sation to meet people’s needs irrespective of their ability to pay, making us all better off as citizens of a fairer and safer society as a result.. I hope you will consider supporting me. I am also a candidate to remain a Vice Chair.

David Pickersgill: Statement in support of nomination as Chair of Socialist Health Association

Page 7 Brian Fisher Statement in support of nomination as Chair of Socialist Health Association

The future of the SHA and the NHS We have a chance to shape the NHS. Labour has achieved a lot - but is now uncertain. Current plans are neither popular nor delivering. The SHA must propose a practical socialist programme and continue to campaign for it, merging ideas, logic and emotion. We need to fuse:

• the founding principles of the NHS, • the commitment of the population to the ideals of the NHS • concrete, workable evidence-based, socialist plans • a commitment to an NHS that listens to, responds to and is respectful of both communities and individuals. The emotional side of the NHS is key. • a refutation of the market base of the current programme.

John Lipetz, Paul Walker and I have helped to write such a document which will be used as a ba-sis for SHA programmes and campaigns. We need to raise the profile of the SHA to achieve influ-ence. To build on our history, experience, friends and contacts. We need to ensure that the gov-ernment hears these radical but sensible ideas. We need to take them to the public in a way that builds consensus and confidence. A public face carries risks, but we have the experience and the capacity to do it well. So, if I were chair, I would encourage us to:

• learn from other groups such as Compass, other parts of the UK and internationally • focus on involving patients both in their own care and in designing and developing improved approaches to care. I would advocate a national debate on accountability • develop non-marketised, non-competitive approaches to commissioning and planning • offer a clear, evidence-based, practical programme for prevention, public health and reduc-ing inequalities • develop a clear programme for involving staff in improving services

About me A London GP since 1976, I will reduce my clinical work soon, allowing more time for the SHA while remaining in primary care. I am involved in day-to-day NHS politics: I am on the Lewisham PCT Professional Executive Committee and the PCT-wide practice-based commissioning federation. As Patient and Public Involvement lead for the NHS Alliance I have brought our two organisations together. I have worked with and been consulted by the DH, Connecting for Health, Lord Darzi, the Healthcare Commission. I have links with national voluntary agencies and primary care. I regularly publish research. Although a new member of the SHA, I have influenced our development. My roots are not in the traditional Labour movement but I have been a union member and socialist throughout my career, expressed through active community development work and a commitment to patient and citizen accountability, with publications on these topics. After years of experience of record sharing with patients, I have set up a company enabling patients access to their full GP record online. This will transform care. Chairing committees in the voluntary sector, PCT, Health Authority and national level, my leader-ship comes through working cooperatively and building on mutual strengths. I take decisions when needed and like to get things done. I have a track record of achieving practical improvements in the PCT, in patient and public involvement nationally, and in the field of IT. I want the SHA to make a difference – to impact on the thinking, the feeling and the doing of

the NHS. We can build the organisation, make a real impact – we have the links, the ideas and the leadership

Page 8

The BMA fought tooth and nail against the es-tablishment of the Na-tional Health Service and some of our mem-bers still remember that campaign. They now claim that opening three extra hours a week will lead to the end of the NHS. We find the logic of their posi-tion hard to follow. A substantial minority of patients find it diffi-cult to access primary care services. Problems about access have not been cooked up by Gordon Brown. They are not just about extended hours, although that is a real issue in places where there is wide-spread commuting. Plenty of practices have poor access arrange-ments, some because of efforts to comply with the 48-hour target. Peo-ple in low paid jobs find it difficult to get time off to attend a GP. Manchester Health Watchdog completed a survey of patients' ex-perience of general practice last month. Most reported an excel-lent service, but some of the stories were ter-rible. Eighty per cent re-port that they have to ring the GP practice first thing in the morn-ing to make an appoint-ment. Not everybody can do this:

"I just cannot get an appointment!" reported one patient. "I hang on the phone for up to half an hour and then I have to go to work. I ring later and am told there are no appointments left and I have to ring back next day. They do not allow you to book for one or two days hence, you have to ring on the same day. It is a nightmare. Once the doctor asked to see me in a week's time. I tried for three weeks to get an appointment and then wrote to the doc-tor explaining why I hadn't returned to see her." The BMA are worried about the possibility of big corporations provid-ing a poor service for less money. Their claims would be more convincing if they were more concerned about poor standards in tradi-tional self-employed general practice. Large corporations are not likely to offer a better service, but GPs are also undermining the traditional model of pri-mary care. Many prac-tices employ salaried doctors, partnerships are getting hard to come by, and some tra-ditional practices seem happy to set up satel-lites and staff them with locums. We support the idea of

practice flexibility to meet the needs of peo-ple who find current opening hours difficult. The government needs to recognize that pro-viding these services may mean more costs to primary care: to ensure enough cover for staff in the extremes of the day to ensure adequate diagnostic and backup facilities to make those extremes useful to patients. Many GPs work very long hours. But opening the surgery for three extra hours a week is not an impossible bur-den. We don't like Brown's rhetoric when he says "you should be able to see your doctor when you want to". People should see the health professionals they are seeing as peo-ple - not as distant fig-ures to be deferred to in the old model, not as servants either, but as partners. This is an is-sue which should be de-cided locally. Needs for access in Penge are not the same as needs in Penzance. Access is not just about doctors. Some people who want non-urgent appoint-ments out of hours really need a nurse. Most people have little information about the availability of walk-in centres and other facili-ties which might meet their needs.

The case for greater access - SHA press release

political situation in the UK, in particular the leverage ex-erted by a small number of middle class voters in a few middle class constituencies, makes talk about redistribu-

tion very unwelcome amongst politicians who have to face the electorate. Political leader-ship which is capable of making a coherent and convincing case for a more equal society has not emerged. Although there are many politicians in all parties who appear to genu-inely espouse the idea of redistribution none have managed to resist the pressures from the articulate middle classes to, for example, re-duce the burden of inheritance tax. There is little absolute poverty in the UK other than the destitution which is used as a political weapon by the government against asylum seekers. Those failed asylum seekers, who are literally destitute, are of course often of childbearing age, and may make a decision that it is better for them and their families to be destitute in London than in Mogadishu or Ha-rare. We are not convinced that the decision to withdraw both support and free medical care from this group is rational from the per-spective of the tax payer. If their babies end up in paediatric intensive care, or the mothers die in childbirth that will cost a great deal more than will be saved by denying them primary care. However this problem raises much wider questions than can be dealt with here. There is, however, a great deal of relative pov-erty in the UK, and its burden falls particularly on those of childbearing age. The weekly rates of means tested benefits for a person aged 16-17 are £35.65, for a person aged 18-24: £46.85. For people over the age of 60 the rate is £119.05 a week. Rates of payment for those supported by the National Asylum Sup-port Service are about 70% of that. It is hardly surprising that some of these young people are socially excluded and live unhealthy lives. Of course it would be better if they were work-ing or studying, but there are often reasons which make these ambitions difficult to realise, and pregnancy is one of them.

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Inequality in health is at its most pronounced around the time of birth. Our gov-ernment is committed to re-ducing health inequality in the population and is devot-ing considerable resources to the problem. Has the Socialist Health As-sociation any new ideas to contribute? This paper attempts to consider issues around inequality from before birth and in the first year of life. Infant Mortality The infant mortality rate among the “Routine and Manual” group was 17% higher than in the total population in 2004-06, compared with 18% higher than in the total population in 2003-05, and 19% higher in 2002-04. This compares with 13% higher in the baseline period of 1997-99. So it is clear the target for reduction of this difference is not going to be met by 2010 unless something more is done. Wider determinants of health The most fundamental issue, which neither the Labour Party nor the Government cares to discuss is whether individual focussed ef-forts to improve behaviour have any chance of success when the wider causes of ine-quality are not confronted. The work of Sir Michael Marmot and Richard Wilkinson dem-onstrates very clearly that inequalities of wealth and income even among people who are not in any normal sense of the word “deprived” have a very strong influence on the health of the population and life expec-tancy. The other side of this debate, which some people in the public health community don't seem to want to discuss, is what can be done to counter these powerful forces in the short term. We remain convinced that a programme of redistribution of wealth along the lines which have evolved in the Nordic countries would do more to improve the health of the popula-tion than any other measures. However the

Unequal from the start: How can we give babies a fair chance of health? Report from an SHA policy seminar London Tuesday 22nd January 2008

This document will form the ba-sis of an SHA submission to the Labour Party National Policy Fo-

rum, and we would welcome comments from members.

Page 10 Reducing inequalities in the popula-tion, even if it is attempted, will take

time. Globalisation makes the problem of ine-qualities far more difficult to tackle. So in the short term at least we need to focus on initia-tives which are more politically acceptable. Evidence of what works The Combined Impact of Health Behaviours and Mortality in Men and Women: The EPIC-Norfolk Prospective Population Study seems to provide a quite convincing basis on which health intervention at the level of individual be-haviour could be evaluated. These findings indicate that the combination of four simply defined health behaviours predicts a 4-fold difference in the risk of dying over an average period of 11 years for middle-aged and older people. They also show that the risk of death (particularly from cardiovascular dis-ease) decreases as the number of positive health behaviours increase. Finally, they can be used to calculate that a person with a health score of 0 has the same risk of dying as a person with a health score of 4 who is 14 years older. These findings need to be con-firmed in other populations and extended to an analysis of how these combined health behav-iours affect the quality of life as well as the risk of death. Nevertheless, they strongly suggest that modest and achievable lifestyle changes could have a marked effect on the health of populations. Armed with this information, pub-lic-health officials should now be in a better position to encourage behaviour changes likely to improve the health of middle-aged and older people. (Public Library of Science 2008) This important study was conducted among middle aged people and clearly does not apply directly to young women. But it would be very surprising if the same factors (smoking, drink-ing, diet and exercise) did not affect younger people and if the multiplier effect did not apply to them. Policy issues 50% of conceptions are unplanned, so it is dif-ficult to identify which women are (or may soon be) in early pregnancy. There are many valuable interventions which can be under-taken with different groups to address aspects of early pregnancy, eg alcohol consumption,

diet, smoking. We need to develop more creative approaches to promoting good health in pre-conception and early pregnancy. Teenagers, especially girls, need a diet rich in calcium and iron, but they often don't have one. Problems relating to body image are critical at this time in a woman's life, and of course relate chiefly to self esteem and the behaviour of boys. Messages from health pro-fessionals are drowned out by commercial and social pressures to conform. Young mothers tend to present late to mater-nity services. We need to try to make services more welcoming to them and more relevant to disengaged young people. We need a longer period of paid maternity leave, a significant extension of paid leave for fathers/partners, and the right to request flexi-ble working for all parents. Improving rights at work for parents are of little help to young peo-ple who are not in legitimate employment, and there is reason to believe that young people are disproportionately affected by vulnerable employment. There is still considerable preju-dice amongst employers (and some employ-ees) against women who exercise their rights to maternity leave. In relation to health and safety issues, few employers have a good un-derstanding of their obligations to undertaken and act on risk assessments for pregnant em-ployees and those returning to work within six months of the birth or is breastfeeding. Rely-ing on employees to request a risk assess-ment and insist on appropriate changes to their work places an unreasonable burden on mothers and is likely to impact on the health of mothers and their babies. There is a continuing rise in the proportion of births to mothers born outside the UK: 21.9 per cent in 2006. There is a similar rise in the numbers born to BME mothers who were born here. Both the stillbirth rate and neonatal mor-tality rate are higher in women of Black, Asian or Other ethnicity. Vitamin D deficiency is a widespread problem among BME women. Healthy Start women's vitamin supplement contains folic acid and vitamin D for precon-ception, pregnancy and throughout breast-feeding. We think this should be made freely available without charge. The fact that some women have to pay makes it much more diffi-cult to distribute. Given the low cost and high

Page 10

benefits we think that every-thing possible should be done to ensure that the vitamins reach all at risk women. It is by no means clear that services are always culturally appropriate for BME women. Nor is it clear that government policy initiatives sufficiently ad-dress the position of mothers in BME communities. There has been a lot of talk about choice in maternity services over the last 15 years, but not a great deal of delivery. There is plenty of evidence about the long term costs of low birth weight babies and the effect of maternal deprivation, but the resources devoted to dealing with the problem are not in pro-portion to those costs. Measures which are officially promoted – such as nicotine replacement therapy for pregnant women - are not delivered consis-tently. The most obvious is the promotion of breastfeeding. It is clear that even within NHS organisations the messages about the importance of breastfeeding have not been accepted or implemented. Breast feeding has immensely beneficial effects, but the resources needed to help women to do it are not forthcoming. Another neglected is-sue is the spacing of births. In other parts of the health service the principle of “invest to save” is well established. Why not here? There are still problems with social and re-lationship education, which seems to be handled better in other European countries. Secondary schools, and parents, are still very anxious about discussing issues relat-ing to sex. It is pretty unclear who, if any-one, takes responsibility for developing life skills in this area. This leads to more risky behaviour among young people. Girls are blamed for “getting pregnant” and boys know little or nothing about issues like breast feeding. Sex education should start much earlier, in primary school, and the idea that it is an optional extra for schools must be abandoned. The country in Europe

with the lowest teenage pregnancy level is Holland – the country which starts sex edu-cation earliest.. Training in diversity for health staff does not extend to issues relating to poverty, and many well meaning health initiatives fail be-cause social issues (such as the impor-tance of territory on housing estates) are not taken into account. Government Initiatives 1.Support for families through Children's Centres: currently over 1,750 centres are open, with 2,500 planned for 2008 so that all the most disadvantaged areas have a centre, with 3,500, one in every community, by 2010. Will these centres just provide childcare, or will they address other needs? 2. Extended schools offer pupils, families and community members quick and easy referral to services, including health ser-vices, on and off site and Healthy Schools take a whole-school approach, including parents, to promoting better health through national standards in healthy eating, physi-cal activity, emotional health and wellbeing, and personal, social and health education. 3.Family-Nurse Partnership demonstration sites, - parenting support delivered by

Page 11

health visitors can improve life outcomes for young first time

mothers and their children. All first-time mothers under and up to the age of 20 are referred to the demonstration sites but the sites aim to focus on the more vulnerable: factors taken into account include age, in-come, family support and marital status. 4.Early identification of at risk families and plans to make breastfeeding the default op-tion for mothers. 5.Investment in healthy schools, increasing participation in physical activity, and making cooking a compulsory part of the national curriculum. 6.A £75 million marketing campaign to sup-port and empower parents to make changes to their children's diet and increase levels of physical activity. 7.£190 the Health in Pregnancy Grant, from April 2009 8.Child Benefit from the 29th week of preg-nancy – we would like to see this start much earlier 9.Sure Start Maternity Grant £500 at week 29 10.Healthy Start Vouchers £2.80 per week from week 10 Workforce There are difficulties in the management of the public health workforce. While it is now established that medical qualifications are not required for Directors of Public Health, health visitors are being suppressed as a profession by the Nursing and Midwifery Council, which is insisting that Health Visi-tors who came through the midwifery route must continue to practice as midwives for 450 hours a year. At the same time spear-head PCTs are being encouraged to employ health trainers directly recruited from disad-vantaged communities. This initiative may be productive, but at the same time various public health specialist interventions are be-ing planned. The specialists and generalists need to be formed into coherent teams so

that those without clinical training can access spe-cialist support when necessary and those without the benefit of roots in local communities can ac-cess that knowledge and experience. The way that public health budgets have been systemati-cally raided to prop up acute services has left the workforce demoralised and disorganised. There should be sensible career pathways in public health. Let’s get rid of the notion that the only peo-ple who can join the profession at a level with de-cent pay, or progress in their careers are those who have already qualified in clinical work. At present nobody seems to be taking any responsi-bility for the coherent development of a public health workforce.

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Page 13 Combined Impact of Health Behaviours and Mortality in Men and Women: The EPIC-Norfolk Prospective Population Study

Every day, or so it seems, new research shows that some aspect of lifestyle—physical activity, diet, alcohol consumption, and so on—affects health and longevity. For the person in the street, all this information is confusing. What is a healthy diet, for example? Although there are some common themes such as the benefit of eating plenty of fruit and vegetables, the details often differ between studies. And exactly how much physical activity is needed to improve health? Is a gentle daily walk sufficient or simply a stepping stone to doing enough exercise to make a real difference? The situation with alcohol consumption is equally con-fusing. Small amounts of alcohol apparently im-prove health but large amounts are harmful. Why Was This Study Done? There is another factor that is hindering official at-tempts to provide healthy lifestyle advice to the public. Although there is overwhelming evidence that individual behavioural factors influence health, there is very little information about their com-bined impact. If the combination of several small differences in lifestyle could be shown to have a marked effect on the health of populations, it might be easier to persuade people to make behavioural changes to improve their health, particularly if those changes were simple and relatively easy to achieve. In this study, which forms part of the European Prospective Investigation into Cancer and Nutrition (EPIC), the researchers have exam-ined the relationship between lifestyle and the risk of dying using a health behaviour score based on four simply defined behaviours—smoking, physi-cal activity, alcohol drinking, and fruit and vegeta-ble intake. What Did the Researchers Do and Find? Between 1993 and 1997, about 20,000 men and women aged 45–79 living in Norfolk UK, none of whom had cancer or cardiovascular disease (heart or circulation problems), completed a health and lifestyle questionnaire, had a health examination, and had their blood vitamin C level measured as part of the EPIC-Norfolk study. A health behaviour score of between 0 and 4 was calculated for each participant by giving one point for each of the fol-lowing healthy behaviours: current non-smoking,

not physically inactive (physical inactivity was de-fined as having a sedentary job and doing no rec-reational exercise), moderate alcohol intake (1–14 units a week; a unit of alcohol is half a pint of beer, a glass of wine, or a shot of spirit), and a blood vi-tamin C level consistent with a fruit and vegetable intake of at least five servings a day. Deaths among the participants were then recorded until 2006. Af-ter allowing for other factors that might have af-fected their likelihood of dying (for example, age), people with a health behaviour score of 0 were four times as likely to have died (in particular, from car-diovascular disease) than those with a score of 4. People with a score of 2 were twice as likely to have died. What Do These Findings Mean? These findings indicate that the combination of four simply defined health behaviours predicts a 4-fold difference in the risk of dying over an average period of 11 years for middle-aged and older peo-ple. The risk of death (particularly from cardiovas-cular disease) decreases as the number of positive health behaviours increase. Finally, they can be used to calculate that a person with a health score of 0 has the same risk of dying as a person with a health score of 4 who is 14 years older. These find-ings need to be confirmed in other populations and extended to an analysis of how these combined health behaviours affect the quality of life as well as the risk of death. Nevertheless, they strongly suggest that modest and achievable lifestyle changes could have a marked effect on the health of populations. From PLoS Medicine January 2008

Future Events

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

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

NHS 60th anniversary Tredegar 5th July

Personalisation in health and social care services

Professor Caroline Glendinning Social Policy Research Unit, York University

Dr Guy Daly Coventry University London Wednesday 7th May 2008

Future of Primary Care

Michael Sobanja Chief Executive NHS Alliance Mo Girach,

Former Chief Executive South East London Doctors Co-operative Prof Steve Iliffe University College London

Nottingham Friday 11th April 2008

Lord Darzi's plan for the NHS Dr Donal Hynes, NHS Alliance

Exeter Thursday 3rd April 2008

Lord Darzi's plan for the NHS Chair David Pickersgill

Dr Ken Jarrold, former chief executive of County Durham & Tees Valley Melanie Johnson, formerly Minister for Public Health

Dr Hannah Cooke University of Manchester Ruth Marsden National Association of Patient Forums

Leeds Wednesday 12th March 2008

SHA Annual General Meeting Saturday 8th March 2008

Wesley's Chapel, City Road London, (Old Street is the nearest station) Starts at noon with a discussion with Mario Dunn, political adviser to the Secre-

tary of State

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 2008 edition is 30th May. Tel/Fax 01582-715399 or by e-mail to gavros.ross@btopenworld.com