What can local councillors do to protect patients from government policies on health and social care?

Councillors in England  have two formal routes to influence the NHS – the Scrutiny Committees and the Health and Wellbeing Board.  We need more discussion about good and bad practice in the running of these committees, which clearly varies widely.  There should be a Joint Strategic Needs Assessment and a Health& Well being Strategy which have been publicly discussed for each area.

Public Health

It’s very easy to get sucked into defending individual NHS institutions, but we think it’s more important in the long term to focus on health inequalities.  Local Councils can do a lot more to address inequality than NHS services can.  Even in prosperous Kensington and Chelsea life expectancy in the poor part of the borough is 12 years less than in the poshest ward.  From April 2013 local councils take over public health.  We hope to organise some events to share experience in this area, as its still a bit unclear how it will work.  Most councils claim that they are not getting enough funding to continue existing public health measures

Sir Michael Marmot’s review of Health inequality made 6 specific recommendations:

  • Give every child the best start in life
  • Enable all children, young people and adults to maximise their capabilities and have control over their lives
  • Create fair employment and good work for all
  • Ensure healthy standard of living for all
  • Create and develop healthy and sustainable places and communities
  • Strengthen the role and impact of ill health prevention

In the White Paper Healthy Lives, Healthy People the Government accepted five of these.  The idea of ensuring a healthy standard of living for all seemed to cause them a problem – and it may not be within the power of local authorities to deliver either – but it is clearly the most important.

We think Councillors can helpfully address some of these issues, and in particular should demand information about inequalities at ward level, and at super output area level to expose differences in life expectancies, infant mortalities, obesity rates etc., and what strategy there is to address them. Stories about differences in small areas can be very dramatic and generate a lot of media interest.  We can also compare these things between districts.  Councillors should focus questions on (a) the effectiveness of local policies that have a beneficial impact on the determinants of health (so, education, housing and employment – particularly employment) as this potentially provides a platform to (i) oppose central Govt. austerity whilst also (ii) offering a challenge to Councils that would prefer to focus solely on the local NHS, and (b) the integration of social care and health services in the face of austerity – this might help shift focus from the social care to NHS cost-shift, to honesty about the consequences of reduced social care spending.

Goal-directed community development – strengthening community groups and establishing cross-sector partnerships can be very effective in addressing inequalities.  Is that included in local strategies? Do staff of health agencies participate in those partnerships and can they engage directly with residents and community groups to solve mutual problems?  The condition of the local community sector (not just the community as individual residents) should be in the JSNA?

We need to be much more aggressive in challenging poor eating, drinking lifestyles and the manufacturers and retailers who are making profits out of selling unhealthy products – tobacco, fast foods, coca-cola and fizzy drinks, confectionary, alcohol and crisp manufacturers. This should include all public services and commercial organisations who supply them such as the conference trade who could all be persuaded to adopt healthier policies.

Social Care

Local Authorities still have responsibility for social care, and this stretches into many areas of healthcare including substance misuse, childraising practices, mental health, as well as care in the community.  Starving social care of resources leads to more NHS expenditure.  We should be looking much more at joint funding, but also making it clear that cuts in social care are the direct responsibility of central government.  We could encourage joint local authority/nhs community ventures which actually involve local people.

Care staff are paid too little, are often untrained, unsupervised and sometimes allowed to remain in the job despite offences to patients. Health & Wellbeing Boards need to take responsibility to ensure quality Health & Social Care and  to remedy shortfalls in staffing, inadequate quality and patient satisfaction.  Social Care is undervalued and therefore achieving less than it could.

Health services for people in residential and nursing care are particularly problematic.  This is not just about good, prompt, proactive GP services, but inputs from physiotherapists, occupational therapists, falls prevention teams, dieticians, and particularly community psychiatric nurses to help manage dementia-related problems.  Some residents may also need specialist nursing services visiting (eg stoma care, tissue viability).  And all these professionals need to work in partnership with home staff to help the latter deliver good quality care. It’s an area that is still, very sadly, completely overlooked and where there’s a lot of blame and buck passing.

NHS Services

Monitoring quality of NHS services is difficult because healthcare is a complex business.  There is lots of information available, but making sense of it is difficult.  The performance of one part of the system is affected by other, especially by what goes on in primary care, which is very variable. Councillors need to listen to the experiences of their constituents. The patients view of the system may be very different from the official account.  Local Healthwatch should be helpful in finding out patients’ experience, especially those unable to speak for themselves.

Some issues we think are worth investigating:

Clinical Commissioning Groups should be consulting and involving patients and the public in their strategy.  Some are doing it well, some not – ask searching questions about who is consulted and how. It’s not been done well be most of the NHS in the past and councillors may be able to make dramatic improvements.  We should be pushing very hard for transparent decision making processes in a situation where large sums of public money are in the gift of a club of private businesses.

Commissioning services are the part of the NHS most disrupted by Lansley’s reforms. There are now many players and the relationships between them are not always clear.  The local Clinical Commissioning Groups are accountable, other than for services commissioned by the NHS Commissioning Board, and that is where councillors should direct their attention.  They should deliver Quality control and action on complaints and significant events.  Don’t get too sucked into questions about patient choice.  Sicker patients are not much interested in choice of where they are treated.  They are more interested in how they are treated.

Ask questions about commissioning, contracting and tendering.  It’s easy to see price but it’s hard to see quality, especially in services for the most disadvantaged people. Tendering in health care disadvantages both smaller local services and public services who don’t have a tendering department. There are already huge issues about transparency in the awarding of contracts to the private sector. Loads of public money goes on consultancy and legal advice with no prior public debate about the desirability of outsourcing or the shape of the tender brief. The advice and contractual discussions are then concealed on the pretext of commercial confidentiality until a preferred bidder emerges – by which time it’s realistically too late to stop the bandwagon. There should be open discussion before the process is embarked upon and full disclosure throughout.  There should be an agreed process where the question of whether a tendering process is appropriate is considered. There should be proper consideration of whether a publicly provided service is likely to be better, or not, and if an existing service is thought not good enough whether it could be improved.

There is nothing to prevent full transparency being imposed on contractors by contract, even though some of the legislation does not bite on them.  We should be arguing that the price of a contract includes full disclosure of all its terms and monitoring information, once it is awarded.

Cherrypicking contracts – it’s easier and cheaper to run services for healthier younger patients.  If there is a tendering exercise make sure services for the entire population are considered. Less qualified and experienced staff are cheaper to employ.  Temporary staff, even if well qualified, often give a poorer service because they are in an unfamiliar situation. A well run service with permanent experienced and well trained staff will usually be better value for money.

The future of hospital provision is always a big political issue, and it’s difficult not to defend your local hospital, but the reality is that many smaller hospitals are trying to deliver services which are beyond their capability. Clinicians know this but don’t tell the local population. Clinical redesign will probably shut large numbers of A&E depts at night. The idea of the District General Hospital which provides all services is no longer defensible. Serious surgery needs to be concentrated on far fewer sites. Most hospitals in future won’t do surgery, especially urgent surgery at night.  Similar arguments apply in paediatrics. Hospital care for children is now rare and also needs to be on far few sites. There are too many acute medical admissions of confused old people for no specific reason, some of whom are clearly at the end of their life. Local GPs will all have stories about  how their plans to care for people at home at the end of their life are frustrated by pointless and expensive hospital admissions. There are decent arguments about travel times, but they don’t apply at night. Even central London isn’t usually congested after 9pm.  Of course different considerations may apply in remote areas.  We may have to think seriously about community hospitals.

We should be arguing for major hospitals to be properly open 7 days a week with diagnostics, imaging etc, and if all that is open why not outpatients too?

You may go out on the hospital picket line but don’t promise that the next Labour Government will reopen things that are shut. It won’t.  These changes are driven by clinicians and they will continue whatever government is in power.  But it is perfectly reasonable to ensure that there are adequate facilities within the community before any acute facilities are withdrawn.