National Policy Forum Consultation Document May 2003

Thank you for taking part in the process of making Labour Party policy – Partnership in Power. Partnership in Power is about how we examine our values as a Party and reapply them to the challenges we face ahead. This document is one of five “second year” documents for discussion this year.

They cover the future of the health service, Britain’s role in the world, raising industrial productivity, reshaping our welfare system to create opportunity for all, and improving the level of political engagement. In all these areas your contribution is crucial to our long-term policy development These documents were originally circulated in 2002 and the submissions we received have helped to shape these new documents in their second year. In them, we have included key challenges identified from the consultation process, and also cited real quotations from submitting organisations. These are real practical demonstrations of the impact of policy forum discussions in shaping party policy.

These documents will be discussed until the Autumn of 2003, and then will be redrafted in light of submissions from Party members and affiliated organisations. They will be debated at a meeting of the National Policy Forum in 2004 and then agreed by Labour’s Annual Conference in 2004.

Thank you again for your interest – and please do take the time to let us know your views on these important matters.

With best wishes,

Ian McCartney MP

Chair of the National Policy Forum

Introduction

If we win the next election, Labour will be responsible for the National Health Service during its 60th birthday in 2008. By that time we will have been responsible for its development between its 50th and 60th birthdays – turning it around to deliver higher standards and faster treatment. We must develop a clear vision for that 60th birthday and beyond, a vision for the nation’s health in the 21st century. Labour is the party of equality and social justice. It is not enough for us to focus on improving the state of our health service, vital though that is. Our goal must be to work with people to improve their health. The task in hand is one of prevention as well as cure, and we must deliver this for whole of the nation, not just the few.

For over 50 years, the health gap between the better off and the worst off has widened, not narrowed. Labour exists to create a society based on fairness and on justice, in which each citizen gets the opportunity to fulfil the potential of his or her talents. It is simply unacceptable to us that the opportunity for a long and healthy life today is still linked to social circumstances, childhood poverty, where you live, how much your parents earned, how much you earn yourself, your race and your gender. And if we are successful at reducing health inequalities within and between our communities, improving the lot of the most vulnerable in Britain, it also means we can achieve more from our finite resources. But improving the nation’s health needs a joined up approach across government. It needs a commitment from the whole government. A commitment to end child poverty, to work towards full employment and to provide decent homes for all.

Our starting point for all that we want to achieve is our belief in a publicly funded National Health Service, free at the point of need and accessible to all. The NHS treats one million patients every 36 hours and the overwhelming majority get good treatment. But the pressures are enormous, there are too many delays and the challenge must be to bring all health services up to the standards of the best.

For decades the NHS was starved of funding. Today it needs more investment, and reform, if it is to match the world’s best. We are now addressing that problem, putting the health service on a sustainable long-term financial footing. But this new money we are investing must be matched by reform to deliver a modernised service. The ten year NHS Plan published in July 2000 is our strategy for reform.

Our vision is of a health service fit for the 21st century with services designed around the needs of patients and improved health outcomes, particularly for the poorest in our society. We are making good progress. Staffing levels are up and we are increasing capacity through the biggest hospital building programme in the health service’s history. Waiting times too are improving – there is now not a single national waiting list indicator – in-patient or out-patient – that is not better today than it was in May 1997.

This is progress indeed. But there is still much more to do before we achieve the efficient, modern, patient-centred service that people expect and deserve. It’s a tough challenge and it will take time but thanks to the dedication of its staff, the NHS is on the road to recovery.

Standards of social care services need to improve too. Despite the best efforts of many devoted staff, some social care services are not of a good enough quality, or suited to the needs of the user. Sustained investment needs to be made. The need to eliminate inequalities is as pressing in social care as it is in health and health care. Similarly, we must provide a system that is convenient to use, responds quickly to emergencies and provides top quality services, and do this at the same time as creating better linkage and continuity of care when patients leave the wardship of the NHS.

Labour faces some big challenges in continuing to improve both the health service itself and the health of the people who depend on it. We must find a way to cut smoking further because it kills 120,000 people each year. We must strike the right balance between devolving power to frontline health services and maintaining the quality of those services through clear national standards.

We must ensure that our efforts to recruit more doctors and nurses into the NHS are fair and ethical and do not imperil the health systems of other, less developed countries. We must enlist patients in sharing responsibility for their own care, clearly explaining the necessity of the reciprocal nature of their relationship with the NHS, possibly by drawing up formal contracts between doctors and patients. And when we look to the future, eager to harness the great potential benefits of technology and the genetics revolution, we must do so by taking an informed and consenting public with us.

The NHS today

• More staff – 50,000 extra nurses, 5,500 more consultants and 1,200 more GPs since 1997
• Increasing capacity – 68 major new hospitals completed, underway or approved; over 1,500 more general and acute beds in last two years.
• Tackling our major killers – 13,000 more patients had heart operations in 2002 than in 1997. Over 96 per cent of people with suspected cancer seen by a specialist within two weeks of urgent GP referral

1. Addressing health inequalities

If we are to be successful in reducing health inequalities across Britain we must ensure that the health policies we implement dovetail with what we are doing across government nationally and in local government to eliminate poverty and its causes. Local government across all of its work – in every department – can make a sustained attack on health inequalities and health services need to work in partnership with them. A good education in the early years can give children a lift-up throughout their life. Employment and access to reliable transport makes people more economically active, helping to maintain the quality of that life. And decent housing and freedom from the fear of being homeless minimises the risk of ill health and brings security and peace of mind.

Schools naturally play a large part in the lives of our children – some submissions to the policy document asked whether this high level of pupil-school contact could be better harnessed to improve the health of our young people in addition to expanding their minds. Already free school fruit is being made available but there were calls for a return to free milk and the introduction of free fruit juice in schools. One contribution put forward the idea of moving towards a system where we provide a healthy breakfast in schools because so many children go to school without. Another pointed out that it is for schools to lead by example and that this could be initiated by requiring catering companies to provide only healthy food options and by removing the fizzy drinks and vending machines that can do so much to undermine attempts to give children a balanced diet.

Since 1998 the healthy schools programme has been a key part of the government’s drive to improve standards of health and education and to tackle health inequalities. By sharing best practice, its aim is to make children, teachers, parents and communities more aware of the opportunities that exist in schools for improving health.

Some submissions raised concerns about the health inequalities that can develop and fester because of unequal access to care. Sometimes the most vulnerable in our communities – the worst off, the elderly and frail, the socially excluded, those without access to transport, those living in rural or isolated areas – are also those who suffer the most. Possible solutions included the introduction of mobile GP surgeries or care services, enabling people to receive treatment at or close to home. Lack of information (or a knowledge deficit) when it comes to healthy eating or an unhealthy lifestyle was also highlighted as a problem. A more innovative strategy of educating people was called for, greatly increasing government’s use of television advertising for example.

The NHS Plan committed the government to a platform of measures which together form a co-ordinated attack on health inequalities. We believe that, by 2010, if we can achieve the bold objectives we have set ourselves we have the opportunity of saving as many as 300,000 lives by reducing deaths from cancer, from heart disease and stroke, from accidents and from suicide. And we are increasing access to the health service from deprived communities. It is sadly still the case that too many communities in greatest need are least likely to receive the health services that they require, like heart surgery or hip replacements, for example. These communities are too often defined by social class, geography or ethnicity.

Health at the very beginning of life is the foundation for health throughout life. Evidence points to the great benefits of breastfeeding. A recent evaluation of a lay breastfeeding support group formed the basis of one submission strongly suggesting that such a group is highly successful at helping women to continue breastfeeding and provides much needed psychosocial support at a time when women can be very vulnerable to postnatal depression. Because the health of infants and their mothers is so important, new preventative programmes are being introduced. We are extending Sure Start so that all children, from birth until they are 14, can receive support from the new Sure Start Unit and the Children’s Fund will target projects towards children at risk of social exclusion.

Next year the national school fruit scheme will ensure that every four, five and six-year-old is entitled to a free piece of fruit each school day.

Furthermore, poor nutrition needs to be tackled. A lack of good nutrition of mother and child leads to low birth weight and poor weight gain in the first year of life, which in turn contributes to the later development of heart disease. The new ‘five-a-day’ programme is already educating and empowering people to eat a healthy balanced diet with enough fresh fruit and vegetables. Next year the national school fruit scheme will ensure that every four, five and six-year-old is entitled to a free piece of fruit each school day. And we are reforming the Welfare Food Scheme to give over 800,000 pregnant women, mothers and young children in low-income families greater access to a healthy diet. One submission said that, especially in isolated or deprived communities, government should consider supporting the introduction of mobile shops selling nutritious food and dispensing advice and education on healthy eating.

Our health inequalities targets – the first ever – concentrate on reducing infant mortality rates and the number of premature adult deaths in the poorest parts of England. Starting with children under one year, we aim by 2010 to reduce by at least ten per cent the gap in infant mortality rates between manual groups and the population as a whole. There is also a target to reduce, by at least ten per cent, the gap between the fifth of health authorities with the lowest life expectancy at birth and the population as a whole.

The health of the more vulnerable in society is hit harder by the dangers of substance misuse. Health inequalities can be exacerbated by the abuse of illegal drugs and the excessive consumption of alcohol. The damaging consequences of the misuse of these substances are felt most acutely by the young and in the least well off communities. Problematic drug use does not occur in isolation. It is often tied in with other social problems. Labour is tackling inequalities by getting people off benefit and into work and by reforming the welfare state, education services, the health service, the criminal justice system and the economy. The social exclusion unit focuses on many of the problems often associated with drug taking. The government’s strategy to tackle drugs is being implemented across departments, helping young people resist drug misuse, protecting our communities from drug-related anti-social and criminal behaviour, enabling people with drug problems to overcome them and live healthier lives, and stifling the availability of illegal drugs on our streets.

Most adults drink and the majority drink sensibly. For them, drinking alcohol is part of a pleasurable social experience which causes no harm either to themselves or to others. But there is another, less pleasant side. For some people the misuse of alcohol brings serious consequences for the drinkers themselves, for their families and friends, and for the community as a whole. Labour believes this is a legitimate area of concern for a responsible government and, under the terms of the NHS Plan, it is implementing a national alcohol strategy. The strategy will tackle the hazardous drinking by underage drinkers, who are more vulnerable to the detrimental health and other impacts of alcohol misuse, as well as the alcohol related problems faced by vulnerable or ‘at risk’ groups.

The challenge: cutting smoking -the leading cause of preventable death

The issues identified above with the problematic use of illegal drugs and alcohol are serious and the action we are taking to combat them is appropriately robust. But we know that it is smoking that is our single greatest cause of preventable illness and early death, with 120,000 deaths a year. Currently about 13 million adults in this country smoke – 70 per cent of whom say they want to quit. We smoke more cigarettes per person than the European average. Passive smoking kills hundreds every year and causes misery for many. Smoking costs the NHS almost £2 billion each year. It is a public health disaster, it, kills, and we are determined to defeat it.

‘Adults need to be fully informed and then make their own decision regarding smoking. It is not the (tobacco) industry’s position to stop informed adults smoking.’

Tobacco workers policy forum, hosted by Amicus in London

‘Ban smoking in public places with on-the-spot fines. Increase the smoking age to prevent children gaining access to cigarettes because of ‘looking 16′.’

Individual submission, Weston-super- Mare CLP

In submissions the idea of much greater restrictions on smoking was popular, with calls for legislation to ban smoking in public places or to require all new leisure venues to create no-smoking areas with a view to phasing in a complete ban over time. Other contributions urged a more cautious approach. Some argued from a civil libertarian point of view that this should not be the government’s role. Some believed that the downside of a ban would be a loss of business for eating and entertainment venues.

Disturbingly, large numbers of young people are still taking up the habit and we must redouble our efforts to tackle this. Labour has made it illegal to promote tobacco to children and toughened enforcement on under age sales. To further protect children, a number of submissions called for the legal smoking age to be raised from 16 to 18 years. It was noted, however that when adults attempt to make it more difficult for young people to do something it can actually have the effect of making that proscribed activity even more appealing.

Smoking widens health inequalities and hits poorer people harder. Quite simply this is an affront to Labour values. Labour has already taken action to reduce smoking. We negotiated an EU-wide ban on tobacco advertising. In the UK tobacco advertising on billboards and in press and magazines is now banned. Our tobacco strategy seeks to reduce the number of under-16s who smoke, help adults – especially the disadvantaged – to stop smoking and give special support to pregnant women. But we will do more. We will require the tobacco industry to come clean on the additives they put in cigarettes. From autumn 2003 the front and back of all cigarette packets will, by law, have to include graphic new health warnings. And the misleading double-speak on cigarette packets, such as ‘mild’ and ‘light’, designed to pretend some kinds of smoking can be safe, will be banned altogether. The NHS has already helped 200,000 people to kick the habit and over the next three years we will increase that to over one million. We all accept that reducing smoking – both the number of people who smoke and the amount of tobacco smoked by those who choose not to quit smoking – is essential to improving the health of the nation.

Smoking costs the NHS almost £2 billion each year. It is a public health disaster, it kills, and we are determined to defeat it.

But it is not the role of government to ban individuals from exercising their freedom of choice to smoke if that is their decision. It is the job of government to educate and to properly inform people as to the risks of smoking. Our challenge then is to take every reasonable step to discourage smokers, reduce smoking and tackle the hazard of passive smoking at the same time as respecting people’s right to choose how they live their own lives.

‘The media should be encouraged to promote the negative consequences of smoking. Regulation of smoking in public places is required, possibly under an extension of anti-social behaviour orders.’

West Midlands regional policy forum

‘Perhaps cigarettes should be available only on prescription, in a brown wrapper. Some people like smoking and are addicted and cannot give it up, so we should make it much harder to obtain them. On the other hand, a loss of tax revenue and jobs would be damaging economically. Moreover there are issues of personal liberty.’

Birmingham policy forum

Questions

Is this the right way forward to tackle smoking, one of the most pressing public health problems the UK faces?

Have we got the balance right between personal liberty and social responsibility?

What future measures should we consider to reduce smoking yet further?

And in what ways can we tackle the problems associated with substance misuse that affect our communities and worsen health inequalities?

2. Investing in the NHS, rewarding NHS staff

Funding a 21st century health service

The National Health Service that Labour introduced is one of Britain’s greatest achievements. Labour believes that a publicly funded NHS free at the point of need and accessible to all is the best insurance policy in the world. With Labour the NHS has a long-term future.

The government has demonstrated how it believes investment in the NHS should be financed. In April 2002, the Wanless report into the long-term funding of the health service concluded that the principle of an NHS publicly funded through general taxation, available on the basis of clinical need and not ability to pay, remains both the fairest and most efficient system for this country: the whole community funding the whole community’s health services.

The Tories disagree. They believe that the public should subsidise private insurance for the few. This will be one of the main dividing lines at the next election: between those who want a publicly funded health service, available to all irrespective of their wealth, and those who want to do the system down because they want to privatise the NHS.

The government has accepted the conclusions of the Wanless report. The 2002 Budget announced the largest ever sustained increase in National Health Service resources – a 7.5 per cent average annual real terms growth until 2008. That means a rise in NHS cash spending per household from £2,370 in 2001/02 to £4,060 in 2007/08 – a 48 per cent real terms increase. The Budget also delivered a six per cent a year increase in social services funding for the next three years providing over £3.2 billion extra by 2005/06.

Our position is based both on economic efficiency and social justice. A universal system of payment does away with the inefficiencies inherent in systems of personal payment. Investing the money through general taxation provides much better value. But just as importantly,a universal system provides much greater social justice. The system used in the United States, for example, excludes 40 million US citizens and it is their exclusion that helps to create one of the worst set of health inequalities in the world, where pharmaceutical prices are on average 75 per cent higher than in the UK. This is at least partly due to the fragmentation of health care purchasing. These inequalities mean that for some in the US they receive the best health care anywhere in the world while others receive amongst the worst in any developed country.

Those who work in health and social care are the greatest resource for the NHS and we must recognise that by increasing our attention to and investment in the staff.

Working for health and care services

Those who work in health and social care are the greatest resource for the NHS and we must recognise that by increasing our attention to and investment in the staff. We must learn to use our staff in a much better way. Health staff can be held back by restrictive practices but with more investment in education and training and more involvement in the development of care they could all play a much bigger role. The National Health Service University (NHSU), as part of Labour’s commitment to lifelong learning, will increase the opportunities and qualifications of staff who have previously been excluded. Our NHS foundation trusts will have staff as owners and members of the board. The NHS will remain under public ownership, We need to explore other mutual forms of public ownership for primary care as well as secondary care. Most care workers are undervalued and excluded from qualifications and we must involve the NHSU in developing their capacity. NHS staff are our greatest asset and as the NHS Plan says, ‘NHS staff, at every level are the key to reform.’ It is our belief that we will never be able to achieve the modern NHS the nation needs without the active involvement of staff. This was emphasised again and again throughout the submissions, as was the feeling that too often change is imposed from the outside, rather than building on local knowledge and talent. We recognise that the modern NHS we want and that staff and patients deserve cannot be achieved by the traditional top-down management approach. Instead we intend to give frontline staff greater control over how local health services are delivered. This is at the heart of our reform programme.

If we are to expand the health service’s ability to treat more patients we need to increase the number of staff the NHS employs. As well as frontline staff this means also those staff who provide essential clinical support services, such as radiographers, physiotherapists, occupational therapists and speech/language therapists. But in tandem with increasing numbers there must also be change in the way staff are employed and paid. At the moment the NHS remains overly demarcated and inflexible in employment – this needs to change and to be linked to appropriate rewards and incentives. Our aim must be for all staff to be able to take more responsibility for improving the patient experience.

The Agenda for Change negotiations between government, NHS employers and staff bring the most radical modernisation of the NHS pay system since its foundation in 1948. The Agenda for Change negotiations between government, NHS employers and staff (including nurses, therapists, porters and support staff) bring the most radical modernisation of the NHS pay system since its foundation in 1948. In essence the deal is about paying more to get more, so that staff who take on new responsibilities get extra rewards. If agreed, this means that more than one million NHS employees – who every day show such professionalism and dedication to their duty and to their patients – are to receive a ten per cent basic pay increase over three years. When the costs of the reform package are factored in over the next three years, it will be worth an average increase of 12.5 per cent in basic pay.

And the NHS has much to be proud of in terms of the quality and reputation of its doctors too. The aim of any new contractual arrangements will be to recognise the need for modern reformed organisation of their work and to maximise the rewards for those who provide the most care for NHS patients.

Reform of pay systems will help the NHS make optimum use of the talents of every member of staff and will bring better career opportunities. In addition, every member of NHS staff eager to train will be entitled to individually-tailored professional development programmes through the new NHSU. Equal access to training for all grades of staff is essential and is enshrined in the work plan of the NHSU. The NHSU will start work later this year and will begin by delivering common induction and communication skills for all NHS staff. There will be innovative common learning programmes across professions both pre- and post-registration. Lifelong learning for the whole workforce will support staff to extend their skills and knowledge and take on new roles and responsibilities.

Through the new Postgraduate Medical Education and Training Board for the first time the NHS, working with the medical royal colleges, will be able to better balance the training needs of future doctors with the service needs of local communities.

We know that the quality of the health service depends crucially on the staff who deliver those services. It is important that they are valued and are properly paid. For too many years, this was not the case. Many submissions were concerned that contracting out of health services and staff should not lead to a worsening of terms and conditions for employees not covered by normal TUPE regulation. Labour has agreed a best value code of practice which aims to tackle this problem. We will monitor closely the impact of the code which for the first time offers protection for low paid but vital workers providing public services.

Submissions also supported further improvements in recruitment and retention of staff. Improving the working lives of staff contributes directly to better patient care, and patients themselves want to be treated by well-motivated, fairly rewarded staff. We have shown over the last 18 months that intensive action to bring back professionals into the NHS can succeed. Since February 1999 over 13,000 nurses and midwives have already returned to work in the NHS, and more are preparing to do so. But we have to go further and faster. That means more – and more accessible – return-to practice courses, a willingness across the board to offer flexible working practices, and effective support and mentoring of newly returned staff.

To further boost retention there were also calls for extending to other staff the opportunity that we have created for consultants to take sabbaticals. This new system will be phased in and will support and refresh the careers of experienced consultants. Initially, by 2005/06 we want to enable around 800 consultants per year to enjoy sabbaticals from their work of between two and three months. As NHS capacity expands the numbers of consultants benefiting from sabbaticals will also grow.

Submissions identified a number of other ways in which the NHS could both boost recruitment and increase retention levels of existing staff including competitive starting pay levels, more flexible working hours (particularly an end to the long hours culture) and an evolutionary career track. In addition a secure working environment, and other support facilities such as help with housing, car parking and transport were all flagged up as potential areas for improvement.

The challenge: ensuring a fair system of international recruitment

The NHS is now getting the substantial investment it needs to expand and modernise its services. It is now the fastest growing health service of any major European country. We want it to be one of the best.

‘One of the biggest problems that the NHS faces is a severe shortage of qualified nurses. Labour should make solving this its highest priority so that we can carry out more operations and reduce waiting lists and times.’

Coventry North West CLP

‘In increasing the number of nurses in UK hospitals you must not recruit nurses from your former colonies. Rather I would suggest that you go to these countries and recruit school graduates and train them here in England. You can maybe offer them contracts whereby they can pay back the money (spent on training them) over a period of time after having graduated and being employed in England. This will ensure that our already understaffed hospitals in Africa are not drained of their staff.’

Individual submission

That requires us to increase the number of doctors, nurses and other key professionals as fast as possible. More staff are being trained and recruited within Britain. But that takes time. So we are now working with other nations to welcome well-qualified health professionals from other countries to work in the NHS – whether it be for a short stay or an extended period. This can be a mutually beneficial arrangement: work experience, travel and continuing education benefiting the individual, whilst the NHS can fill its vacancies and increase productivity. But those countries who can least afford to lose their health professionals must be protected. While some countries are happy to export staff on a short-term basis to the NHS, others see the ‘brain-drain’ of qualified nurses and doctors from their own health services as a significant problem.

Labour is acutely aware of the ethical issues involved in recruiting nurses and doctors from overseas and in government has issued guidance to NHS employers to ensure that international recruitment does not damage health care in developing countries who can ill afford to lose domestic medical expertise. Not only this, but the guidance is also designed to prevent unscrupulous recruitment agencies from exploiting foreign workers coming into the country. International recruitment is highly beneficial to the NHS. It also provides an excellent learning opportunity for overseas health professionals which in turn can enhance the provision of treatment and care in their home countries. The challenge for us is to recruit more nurses and doctors – often from overseas – so that we can expand the NHS, delivering faster treatment to more patients, but to do this responsibly and with due regard to the domestic health service needs of other countries. The guidance the government has issued to NHS employers already means that the NHS does not actively recruit staff from developing countries, either directly or through commercial agencies, unless the country is in agreement. Of course, individuals may still choose to come to the UK from Europe or developing countries independently on a voluntary basis.

‘Labour’s ideals are the ideals of a socially responsible party. Whilst we believe that we should do all we can to get more staff working for the NHS we also urge the government to act responsibly when it comes to recruiting staff from other countries. Some of these countries have much greater health problems than the UK and can ill afford to lose qualified nurses and doctors.’

Corby CLP

Questions

Is this the right approach?

Are the principles we are applying to international recruitment the right ones?

What more can we do that would underline our commitment in this area?

How can we ensure the reciprocal nature of any relationship with overseas health services to the benefit of the NHS and UK health professionals who want to work abroad?

How can we boost recruitment into the health service from within the UK?

3. Reforming care and the health service

Labour recognises that a centrally run, one-size-fits-all approach is no longer the most appropriate way to get the best out of a National Health Service that employs over a million people.

In the 21st century people expect their public services to be up to date. Since they pay for their services, they expect to receive services that provide them with good value. The NHS Plan set out ambitious plans to create a health service that is more responsive to the citizens who pay for it and the patients who use it. The increased investment provides us with the opportunity to provide modern equipment and modern staff, but to meet public needs there must be reform which will include people in these services.

Many submissions took up the argument for greater convenience and a better patient experience from the health service. Consequently several innovative ideas came through from the previous policy document. One submission, concerned that patient care in hospitals should come as an integrated package, suggested the development of a corps of volunteers to assist in, for example, out-patients wards, helping and guiding patients to departments rather than leaving them to wander alone. In a similar vein, and helping to remind us of the importance of the voluntary sector in health care provision, another put forward the idea of ‘national public service’ as a means of giving young people experience of work in parts of the public sector like the NHS. And to round off the patient’s health service experience the suggestion was made that evaluation forms be given to patients to fill in after leaving hospital or visiting doctors’ surgeries.

Submissions also looked at the actual service that the NHS provided, with ‘imaginative’ new concepts such as walk-in GP services being welcomed, and with calls for dentistry to also provide an equivalent service. In addition another submission reflected on the 24-hour culture of modern life asking why it was not possible to introduce more flexible appointment times in the early morning, the evenings and at the weekend to suit people’s convenience.

Until last year choice in health care was restricted to those people who could afford to choose to pay for it. There are those who claim that a tax funded national system of health care can never deliver choice for patients. The example of Scandinavia proves those critics wrong. In Sweden and Denmark patients have access to information on waiting times and options for treatment, and patients who have been waiting for treatment have the choice of an alternative provider.

People now expect to be able to choose the right services for them. The NHS is responding by providing more and better information and greater choices for patients. It is doing so in order to increase the good experiences that patients have of the NHS and to demonstrate that we can offer choice within public services. We are starting with patients with the most serious clinical conditions. Patients who have been waiting six months for a heart operation are now able to choose from a range of alternative providers – be they public or private – who have capacity to offer quicker treatment. By December 2005, at the point of referral, all patients will be able to chose the time and date of their appointment and choose from a range of different doctors. In the next parliament we will extend choice even wider across health and social care services.

Choice will be underpinned by new incentives as those hospitals that are able to treat more patients receive greater funding. This is a sensible way of identifying and using spare capacity and, through the choices that patients make, providing new incentives for hospitals to treat more patients more quickly and to higher standards. In turn choice will create new incentives for hospitals not to build up long waiting times as they seek to expand activity.

We must extend local public ownership to more NHS and social care public services. The idea that uniformity in some way creates equality of outcome is contradicted by the nature of health inequalities in England. After 50 years of an attempted uniformity of NHS services health inequalities have widened. A boy born this year in Manchester will live nearly ten years less than a boy born in other parts of England. We have failed to ensure that services are locally targeted to people’s specific health problems.

Because it is important that local people feel ownership of the health service that they pay for, the real power and resources are moving to the NHS frontline – to the staff delivering services each day. Locally run primary care trusts (PCTs) will be responsible for spending 75 per cent of the NHS investment. By 2008 we expect PCTs to control a larger share of the NHS budget. They will be free to commission care with decisions on providers increasingly informed by the choices which patients themselves make. One submission wanted primary care trusts to be yet more proactive about involving local people in decisions about local services. One idea, it suggested, might be to require the PCT Chair to appear on television or radio in a ‘Question Time’ type setting.

As well as placing power and resources in local hands, and getting in place the right incentives to raise standards, the people who work in the NHS say that the reward they most appreciate is having the freedom to get on and improve their local services to patients. NHS foundation trusts will provide such additional freedom and will usher in a new era of public ownership.

Labour recognises that a centrally run, one-size-fits-all approach is no longer the most appropriate way to get the best out of a National Health Service that employs over a million people. We also recognise that frontline health staff and local communities have a unique viewpoint from which to determine local service need. It is for that reason that we want to decentralise the health service, removing central control over local hospitals and creating a new form of local mutual public ownership. And because patients expect and deserve a minimum level of service we will do this within a framework of national standards.

The creation of NHS foundation trusts will strengthen the link between local communities and their local health services. They will be established as public benefit corporations – an entirely new legal entity – that will have direct control and ownership of local hospitals. Local communities rather than the Secretary of State for Health will exercise this power, and they will directly elect hospital governors. Before a hospital is able to apply to obtain foundation status there will be local consultation. This is provided for in the health and social care (community and standards) bill currently before parliament.

NHS foundation trusts will be not-for-profit organisations, wholly part of the NHS, treating NHS patients to NHS principles and subjected to NHS standards and inspections, but no longer directed from Whitehall. Local staff and communities will be put in charge of local hospitals because they are the ones who are best placed to decide which services are better able to tackle local health problems and inequalities.

For the first time since 1948 the public experience of ownership will be at the heart of the NHS – our key public service. This reform will help bridge the democratic deficit that has for too long kept the public out when they should have been brought in. NHS foundation trusts are the start and we would expect most if not all hospital trusts will have the opportunity to become foundation trusts.

Expanding capacity

Our vision, then, will see greater and greater control of the health service shift from the centre to the local level. It will see greater diversity in the provision of treatment and care and more choice for patients. We will expand the capacity of the NHS to enable more people to get faster access to diagnosis and treatment and, in particular to get waiting times down – to a maximum of three months for inpatient treatment by 2008. We expect to have opened 42 additional major hospital schemes mostly delivered through the private finance initiative with 13 more major schemes under construction. The extra investment will allow us to plan for an increase in treatment capacity equivalent to over 10,000 beds. Existing NHS general and acute bed capacity currently stands at around 135,000 beds.

We also expect that by 2008 the NHS will have increased the number of operations carried out as same day cases to over 75 per cent of all operations – the equivalent of adding an extra 1,700 general and acute beds in hospitals. And we expect to have opened 42 additional major hospital schemes mostly delivered through the private finance initiative with 13 more major schemes under construction.

Delivering at the local level

But our strategy is not simply to rely on expanding hospital capacity. It will also be important to ensure that those elements of health care that should more appropriately take place within primary care but are at the moment taking place in hospitals should take place locally. This will reinforce our commitment to giving patients greater local choice. There will be more fully operational diagnostic and treatment centres (DTCs), for example – the new generation of fasttrack surgery centres which separate routine from emergency surgery. DTCs are a more appropriate way of delivering planned care, with non-emergency work being done in dedicated units, often on the same ‘campus’ as emergency and complex and critical care but not disrupted by them. That means the chances of operations being cancelled are reduced and patients on waiting lists get seen quicker.

In addition, the amount of activity which takes place in primary and community settings will be increased with, for example, millions more outpatient appointments taking place in the community rather than hospital. And around 750 primary care one-stop centres across the country will be established to offer a broader range of services, backed by more primary care nurses and specialist GPs, pharmacists, therapists and diagnostic services. Intermediate, home care and residential care provision will be extended to offer alternatives to unnecessary hospital admissions and reduce ‘bed blocking’. Extra social services resources will allow local authorities to increase care home fees where this is necessary to stabilise the care home market and increase choices for older people.

Social care

Social services are one of the major public services. They are provided by those local councils designated with responsibility for providing social care support to the people that need it most. At any one time there are up to 1.5 million people in England relying on their help. Social services help and support many of the most vulnerable people in society. They also make a major contribution to tackling social exclusion. And social services that interface smoothly with the NHS, in reducing the problem of ‘bed blocking’ for example, create an altogether better patient experience. The social care agenda, like that of the health service, is focused upon modernisation.

If patients are to receive the best care, then the old divisions between health and social care need to be overcome. Despite the best efforts of dedicated and professional staff, the NHS and social services do not always work effectively together as partners in care, so denying patients access to seamless services that are tailored to their particular needs. The division between health and social services can often be a source of confusion for people. We recognise that fundamental reforms are needed to tackle these problems. We have put in place the building blocks of a programme for modernising social care and in particular, for improving service quality and affording the vulnerable greater protection. We set up the independent National Care Standards Commission to regulate all care homes, private and voluntary healthcare, and a range of social care services in accordance with national minimum standards. The General Social Care Council is raising professional and training standards for the million-strong social care workforce. And the Training Organisation for Social Services is improving both the quality and quantity of practice learning opportunities for social work students.

These steps will see real improvements in the quality of social care. But recent events have shown us that they are not sufficient and we will do more. The tragic case of Victoria Climbie has brought to the fore the issue of protecting our vulnerable children in care, and submissions have demonstrated that people expect us to take action. The government is studying Lord Laming’s report into the tragedy with great care and its response will form part of this spring’s green paper on children at risk. But immediate steps, including increased joint monitoring of the health, police and social services in the north London authorities concerned, have been implemented. In addition, duties towards vulnerable children have been re-emphasised to all local health and social services chief executives. And there will be more robust training for frontline professionals, with a new three-year social work degree to be introduced from September.

All patients, but particularly older people, need health and social services to work together. They rely on good integration between the two to deliver the care they need, when they need it. The government has begun to address the problems that currently exist in the system. Budget 2002 delivered a six per cent a year increase in social services investment providing over £3.2 billion extra by 2005/06. The significant new investment going into intermediate care will help build a bridge between hospital and home for older people and delayed discharges (blocked beds) have been reduced. The community care bill currently making its way through Parliament will build on what has been achieved so far, introducing a reimbursement system similar to the successful schemes operating in Sweden and Denmark.

At present the discharge of some hospital patients who are well enough to no longer need hospital care is delayed because the social service support they need when they leave is not ready on time. The bill will provide local authorities with a financial incentive to ensure that, using the extra social services investment, appropriate community care services are already in place so that people can be discharged from hospital on time and into the most appropriate care setting for their needs.

And we must not forget the many people – daughters, sons, parents, relatives and neighbours – who act as carers, giving help and support in many ways to those they care for.

A number of submissions criticised the government for failing to provide free personal care for the elderly in England, although some did appreciate the balance that the government needed to strike. They wanted to see free care for the elderly along the lines of the policy proposed in Scotland but recognised that with an ageing population the cost is likely to be prohibitive. One contribution came to the conclusion that whilst appropriate care for the elderly should be our aim, financial help has to be targeted to those with the lowest incomes.

And we must not forget the many people – daughters, sons, parents, relatives and neighbours – who act as carers, giving help and support in many ways to those they care for. The national strategy for carers, the first ever by a government in Britain, is one example of Labour’s commitment to the needs of carers as well as the cared for and means carers will have better information, they will be better supported and have better access to the health service. What carers do should be properly recognised, and properly supported. Labour takes pride in what carers do and in government is helping make sure that carers can take pride in themselves.

Mental health services

Mental health is a top clinical priority for Labour. But for years, mental health services were the Cinderella of the NHS, despite the fact that millions of people – perhaps as many as one in four of the population – face a problem at some point in their lives. Each year, 600,000 adults with serious mental health problems are cared for by specialist mental health services. Thousands more young people and tens of thousands of elderly people also receive care.

To get the range of mental health services and provision right, three changes are necessary. Firstly, we are making changes in the law which as it stands today dates back to the 1950s and does not adequately protect the public, patients or staff. Secondly, we are reforming services through new national standards. The mental health national service framework that the government published three years ago has been widely welcomed, not just by clinicians and managers, but even more importantly, by carers and users of the services. And thirdly, underlining our commitment, we are putting in the right investment to provide the right range of services – whether in community services or acute services. Until 1997, no special funding was available for mental health services. That funding is now there, over the long-term, and will mean that by 2008 every person who needs it will have access to comprehensive community, hospital and primary mental health services with round the clock crisis resolution and assertive outreach services available to all who need them.

The challenge: giving greater local autonomy to deliver the most appropriate health services whilst maintaining clear national standards that guarantee the quality of those services.

Labour recognises that one of the surest ways to help local NHS organisations deliver on the frontline is to devolve to them more power and to allow them greater freedom to innovate and to plan local services according to local need. But the quality of service provision must be maintained at the same time through clear national standards. To make the best use of the extra resources we are making available to the health service it will be necessary to strike the right balance between the two.

Greater local autonomy sees more power in the hands of the people best placed to know the most appropriate way to deploy resources. Through measures such as devolving control of 75 per cent of the NHS budget to primary care trusts, and through the creation of locally owned and run NHS foundation trusts, we want to bring a sense of greater responsiveness to local needs. We want managers and staff to operate in more flexible and innovative ways, raising service quality. And as local NHS organisations demonstrate their ability to perform to a higher standard, they will be given greater freedom from central control – they will earn autonomy. Of course, this must all take place to certain standards. We aim to reduce variations in service quality and must be mindful of any perverse effects that could be created locally without adequate oversight. In government, we have established national organisations like NICE and CHAI to establish, monitor and deliver standards within the health service. Together with our national service frameworks, these measures are spreading best practice and also reducing variations in quality across the NHS. But we must be careful when setting targets not to tie the hands of local staff, undoing the good that giving them greater responsibilities can bring. Our target that no patient should wait longer than four hours from arrival in accident and emergency to referral or discharge, for instance, is creating a better and swifter patient experience and helping to reduce long trolley waits. But at the same time, it is important to ensure that the pressure to meet this target does not mean that doctors feel rushed into making clinical decisions.

The challenge, then, will be to strike the right balance between devolving enough power and adequate resources for frontline staff to be increasingly effective, and retaining enough control centrally and enough influence over direction to ensure that core NHS services remain of the highest quality.

‘Have fewer, ‘bigger’ national targets: these should be strategic in nature leaving more scope for local energy, imagination and autonomy in how they are delivered.’

Socialist Health Association

‘National standards should be about measurable outcomes. Decentralising is not about power, but about finding the most appropriate means to deliver those outcomes. There should not be a conflict.’

Welsh Local Government Association

‘Central control may be necessary where a trust is failing, but is not a long-term solution, and should not exclude the involvement of local people.’

Teignbridge CLP

‘Centralise power to ensure national standards.’

Windsor CLP

‘How do you devolve a national health service?’

East Midlands policy forum

Questions

How can we ensure the right local/national balance?

What principles should guide us when determining the split between greater freedoms and powers locally and maintaining service quality through common standards nationally?

Are there examples we can draw upon of best practice in managing the tensions that can arise?

4. Rights and responsibilities

The government will back prosecutions against individuals who persistently make hoax calls to the ambulance service.

As we increase the capacity of the NHS we must extend people’s rights to services at the time and the place that they want them. If we also involve people much more in their own health services this will benefit their own health and will lead to a real gain in national health improvement. There are those that argue that the extension of rights to everyone will in some way disenfranchise working people because only middle class people will actually claim these rights. This is not the case. Working people have demonstrated that they can make choices as well as any one else. What is important is that all members of the public and patients have the same information. We must ensure that choice is a universal right, not just available to those that have the money to buy their own health care.

All patients have a right to expect access to services that are improving, that are free and that are based on their clinical need and their informed choice. But in return for these increased rights people have responsibilities. As citizens we all have a responsibility to ensure that we use health resources fairly and appropriately. So as the rights and experiences of patients improve, so too must their responsibilities be strengthened. For example when we can offer people the right to make an appointment at a time of their own choosing then they have the responsibility to turn up at that time rather than waste the resource. In social care, we are implementing our 2001 manifesto commitment which will extend direct payments for older people giving them, if they choose, the right to select their own social care services.

More will be done to reduce the inappropriate use of valuable health care resources, starting with ambulance services. Some studies of 999 calls to ambulance services have shown that 46 per cent of all callers had medical needs, but did not require an emergency response, and that 12 per cent of callers have no injury or illness at all. Alongside reminding ambulance trusts that there is no obligation to attend 999 calls where sending an ambulance is clearly not the best way of helping the patient or using NHS resources, the government will back prosecutions against individuals who persistently make hoax calls to the ambulance service.

Submissions underlined the importance of a secure working environment for NHS staff. More will be done to protect staff from violent patients. Doctors and nurses are rightly the most highly respected and trusted professionals in the country. Sadly there is a minority of patients who verbally or physically assault NHS staff who are there to help them. Significant progress has been made with our zero tolerance policy in acute trusts but more must be done to ensure that all GPs also have access to secure services for the treatment of violent patients. Extra resources will be provided to primary care trusts to deal with violent patients. Persistently violent patients will find that they can be denied treatment.

And each primary care trust will negotiate a new contract on rights and responsibilities through consultation with their communities so that these values are reinforced throughout the health service. The new contract could be agreed upon the point of registration, and form the basis for a mature doctor-patient relationship based on mutual rights and responsibilities.

The challenge: reminding patients of their own rights and responsibilities in accessing the health service

The concept of reminding patients about the limits of the National Health Service and about their responsibility in using its resources sensibly, is one we want to take forward. It may be the case that this could mean formalising the relationship between doctor and patient, between the NHS and those in the communities it serves. There may be other options but this is one way forward that would underline our vision of a society where our duty, collectively, is to provide for all and our duty, individually, is to show responsibility to all. When it comes to the health service patients will be able to expect greater rights – increased choice, faster service, higher standards of care. But they must also recognise the duty they owe in return.

Not only could this new agreement set out clearly the standard of care the patient can expect to receive, but it would also remind the patient of the reciprocal nature of their relationship with their doctor. It would involve people in their own care, asking them to share the responsibility for their own health care and well being. Agreements could be drawn up to help people to cut down or quit smoking, to lose weight, to take more exercise or to eat a more nutritious diet. The agreement could provide a formal channel of redress should the level of service fall below an acceptable standard – doctors have responsibilities to their patients too, in keeping to appointments and in keeping delays to a minimum. But it could also bind the patient into honouring their duty to the health service, putting the relationship onto a statutory footing.

Of course asking people to sign up to a novel type of agreement in this way may present a challenge, especially if we ask patients to actively participate in the relationship. To win support for this we need to be clear about what it is that we are trying to do – we must emphasise that in return for free, convenient, high quality care the patient is being asked to use this resource responsibly. This type of agreement would not be legally binding. It could take the form of a joint statement of ‘mutual good intent’. The idea being not to exclude patients from care but to remind them of the need to use the health service – a free yet finite service – responsibly.

‘Introduce fines for people who don’t turn up to appointments.’

Worcester policy forum

‘We need to look at the inappropriate use of casualty departments and GP facilities.’

Merton local policy forum

‘Patients should be told the reason that their operation has been postponed and given a new date, and they should be told in person. It is important that they should be treated as people and not merely as part of a list.’

Labour South East regional conference

Questions

Is this approach a sensible way to formalise the two-way relationship between the patient and their doctor in which rights are expected and responsibilities are owed?

How far should the health service develop specific contracts with members of the public which lay responsibilities on them for improving their own chances of good health?

What principles should form the basis for such contracts?

If this idea were not to be workable, what other ways can we look at of achieving a similar outcome?

5. Genetics, technology and health improvement

Labour is determined to ensure modern, fully integrated IT infrastructures for the NHS. The electronic booking of appointments currently being trialled will be extended.

Science and technology have been an enormous boon to improving health services. The unrelenting development of computer technology has revolutionised the amount of information the NHS can hold and process, significantly increasing its productivity. Common antibiotics in the immediate post-war period, the capacity to carry out mass vaccinations for TB and polio, changes in the understanding of cancer and coronary heart disease have all had a dramatic impact upon improving people’s life chances. Alongside these, the changes in interventions in reproduction have meant that many more people can have children than ever before.

It is the case that the advent of information technology (IT) means the health service can do much more, more quickly for today’s patients than for previous generations. But the NHS still maintains a poor record in exploiting to the full the advantages that IT can and should bring. Reform is necessary and Labour is determined to ensure modern, fully integrated IT infrastructures for the NHS. The electronic booking of appointments currently being trialled will be extended. The pilot of electronic transfer of prescriptions between GPs and community pharmacies will be rolled out across the country next year to give patients faster access to care. Electronic health records will avoid patients having to constantly remember and repeat their medical history.

Of course it is not just the NHS that is becoming more IT literate. Patients themselves now have at their fingertips a vast and instant bank of medical knowledge via the internet. In consultations with his or her doctor, today’s patient is increasingly likely to know more about their particular medical condition and consequently can play much more of a role in their treatment. This emerging phenomenon of the ‘active patient’, concerned about their care, is to be welcomed. But we must encourage this trend cautiously. There is no regulation of medical information that can be gleaned from the web. It may be misleading, biased towards the interests of some in the pharmaceutical industry, or it may be plain wrong. Patients tempted into self-diagnosis on the basis of this information must be warned of the dangers.

We are now at the threshold of a number of new developments which could once more revolutionise health and health care. By 2010 the application of genetics will have changed the ability not only to treat diseases but to predict them and deal with them. There are profound moral questions to deal with here.

Advances in genetics have huge implications for us all. Few people now deny that genetics is changing the world in which we live – holding out the potential for new drugs and therapies, new means of preventing ill health and new ways of treating illness.

It is our ambition to put Britain at the leading edge of advances in genetic technologies and to develop in our country modern genetic health services unrivalled anywhere in the world. This is a long-term ambition but the genetics revolution is already underway. The implications of the advances in genetic knowledge have as great a potential to conquer disease as the discovery of antibiotics. In time we should be able to assess the risk an individual has of developing disease, not just for single gene disorders like cystic fibrosis but for our country’s biggest killers – cancer and coronary heart disease – as well as those like diabetes which limit people’s lives. And we will be better able to predict the likelihood of an individual responding to a particular course of drug treatment. Down the line, we will even be able to develop new therapies which hold out the prospect not just of treating disease but of preventing it.

Labour believes that there is no other health care system in the world better placed to harness the potential of genetic advances than the National Health Service. The values on which the NHS is based – providing care on the basis of need, not ability to pay – are uniquely suited to capturing the benefits of the genetics revolution. They provide a bulwark against the inequalities and inefficiencies of insurance-based health systems where the prospects of a ‘genetic superclass’ of the well and insurable, and a ‘genetic underclass’ of the unwell and uninsurable, unable to pay the premiums for medical care, is for many a very real threat.

The values of Britain’s NHS mean citizens can choose to take genetic tests free from fear that should they test positive they face an enormous bill for insurance or treatment or become priced out of care or cover altogether. Already in the United States, where 40 million people have no medical cover, developments in genetics have stirred precisely these concerns.

The challenge: building a consensus for harnessing the potential of the genetics revolution

It is the government’s job to help prepare Britain to harness the benefits of genetic advances and to avoid its dangers. That can only be done in achieved if scientific breakthroughs are matched by public support and understanding. It can only happen if we are open and honest about the potential and the pitfalls which the genetics revolution presents.

We believe there are huge potential health gains in genetic advances. The government respects the need for science to stretch the boundaries of human knowledge and understanding in this field in the interests of human health but will draw those boundaries with care in order to gain public consent to realise the full benefits of genetic science.

With scientific discovery and innovation surging forward at such a pace, it is not surprising that public opinion and political debate are finding it a challenge to keep up. Many submissions raised the issue of safety and controls on the future development of these technologies as issues that need to be dealt with. But the genetics revolution is opening up a whole new area of debate, introducing us to a number of profound issues we will need to address: the treatment of life-threatening diseases, the screening of unborn children, the commercialisation of genetic techniques, the exploitation of embryos, the cloning of human beings.

People had some understandable concerns about the use to which genetic tests would be put by insurance companies. And it was the perceived threat that any advance in genetic science must necessarily herald a further step towards human reproductive cloning which was so corrosive of public support. That is why the Health Secretary acted to ban such human cloning and to put in place protections for the public over misuse of genetic test materials in insurance. The way is now open to us to have a more rational debate about how best our country can be at the leading edge of advances in genetics technologies.

The challenge for us now is to chart a path for the future that allows us to reap the great health benefits that the genetics revolution will undoubtedly generate. And we must maintain Britain’s place in the front rank of the world’s scientific and research community. But we recognise also the potential for misuse and misunderstanding of this new technology. We will take time to examine the ethical issues involved with great care, educating the public about both sides of the debate and legislating where necessary.

Questions

Do these approaches form an appropriate basis for moving forward?

How can we take the confidence of the public with us?

The challenge for us now is to chart a path for the future that allows us to reap the great health benefits that the genetics revolution will undoubtedly generate.

The questions in the document are intended to encourage responses to the policy documents. We welcome submissions from all members and Labour Party affiliates – please make your submission via our website by visiting http://www.labour.org.uk/submissions. When making your submission online you will be asked for your full name, address, your position and submitting organisation (where appropriate), and your contact email address. If you are submitting on behalf of a group of individuals you will also be asked for their details and email addresses. All submissions with email address(es) will receive a response by email. If you do not have access to the internet please send your submissions to: The Policy Unit, 16 Old Queen Street, London SW1H 9HP.

The consultation period for this document extends until 12 November 2003, after which the submissions will be used to redraft the document before it is agreed by the National Policy Forum.

If you are not already a member of the Labour Party, please join us by phoning 08705 900 200 or visiting http://www.labour.org.uk. You can also use this number or our website to renew your membership subscription or to switch your membership to Direct Debit.

Policy Commission Health

Membership:

Government Alan Milburn* John Hutton Hazel Blears

National Executive Committee Margaret Wall* Nancy Coull Shahid Malik

National Policy Forum George Brumwell Lesley Hinds Sandra Samuels Sue Stirling

*Co-convenors

Devolution

Devolution within the UK requires different policies that reflect the particular needs of England, Scotland and Wales. This policy document addresses policy in England, but is a statement of values and goals throughout the UK, and develops English policy alongside the Welsh and Scottish policy forums which are responsible for policy development on devolved matters. We must work in partnership with the policy commissions in both Wales and Scotland to develop unifying themes and build on successful policies. This partnership should include learning from Welsh and Scottish experience in policy development at the UK level and vice versa.

0089.2_03 Promoted by David Triesman, General Secretary, The Labour Party, on behalf of The Labour Party, both at 16 Old Queen Street, London SW1P 9HP.

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