National Policy Forum Report 1998

Summary

Eighteen years of Conservative government left the NHS close to breaking point. Labour was elected to save and modernise the NHS. This means building a modern and dependable health service that offers people high-quality treatment and care when and where they need it. Labour’s approach to health is radically different from the Tories’ approach. We want to mould health services to meet the needs of patients – always looking at services first from the point of view of the patient or would-be patient. We are determined to increase public confidence in the NHS so that people do not feel forced to use private medicine to get what they want, when they want it.

Progress so far

• More spending on health with an extra £2 billion for the NHS across the UK.
• The biggest new hospital building programme in the history of the NHS.
• A White Paper setting out a far-reaching programme of modernisation.
• Plans to end the internal market and cut red tape to divert £1 billion into patient care.
• A new focus on quality including National Service Frameworks to improve access and quality across the country and a new National Institute of Clinical Excellence.
• A public health Green Paper setting out radical ideas on tackling health inequalities and reducing illness and premature death.
• Making a start on breaking down the barriers between health and social services.
• Mental health and coronary heart disease identified as the first National Service Frameworks to be developed.

The challenges ahead

The new Labour government has the opportunity to plan for the next 50 years in a way unimagined by our predecessors. By achieving at least a second full term of Labour government, we can put in place changes as radical and far-reaching as the founding of the NHS and the welfare state. This document explores some of the challenges ahead and invites views and ideas on how these can be met.

• Staffing the NHS – without a committed motivated staff, the NHS cannot operate – how can we ensure staff are equipped to implement change in the NHS?
• Changes in society – while talk of a demographic timebomb is misplaced, age and disease profiles will continue to change – how can we ensure these changes are planned for?
• Technological advances – we are on the brink of scientific advances that a few years ago people would have considered science fiction – how can the NHS harness these changes for the benefit of patients?
• Changes in expectations – people want prompt, high-quality services – how should people’s expectations be met with what people are prepared to pay in taxes?

Background

Modernising the NHS

Labour was elected to save the NHS. We will do so on the basis of the founding principles of the NHS – that if you are ill or injured there will be a national health service there to help. Access to it will be based on need and need alone – not on who your GP happens to be, or where you live, or your ability to pay.

Labour was also elected to modernise the NHS to meet the challenges of the next century. This means building a modern and dependable health service that offers people high-quality treatment and care when and where they need it. It means listening to people. And it means it is vital that NHS trusts, community health services, GP surgeries, health authorities and local authorities co-operate to deliver the people’s priorities. The government has made clear that it wants to see people in every part of the country have speedy access to:

• excellent and convenient primary care and community health services offering a wide range of services
• top-quality continuing care for elderly and infirm people, provided at home and in nursing and residential homes
• accessible, quality mental health services including care at home, in the community, in residential accommodation, in acute psychiatric wards or in a secure environment
• local hospitals, whether providing a full range of services or mainly day care, minor injuries and diagnostic/outpatient services
• dependable accident, emergency and ambulance services
• major specialist hospitals providing excellence in treatment and care, in teaching and clinical and scientific research.

Labour also wants to see services that are more responsive to the needs and preferences of the people who use them – an NHS that values patients’ experiences and uses those experiences to improve and develop services.

Preventing illness

Ensuring that the people of this country are fit enough and well enough to meet the challenges of the coming century cannot be achieved by the NHS alone. It is not enough to treat people when they fall ill – more should be done to stop them falling ill in the first place. That means tackling the root causes of the avoidable illnesses. Under the Tories the emphasis was on changing people’s lifestyles. Labour is doing more to tackle the things which damage people’s health which are beyond the control of the individual. The poorest in society are hit harder than the well off by most of the major causes of death. To tackle these fundamental inequalities we need an approach that recognises the powerful social causes of ill health. Labour has abandoned the old extremes of blaming individuals on the one hand or nanny state social engineering on the other. Instead our third way is to get the government, local communities and individuals to work together on tackling the deep-seated causes of ill health.

Labour is using the whole machinery of government to tackle the things that make people ill – pollution, unemployment, low pay, homelessness and poor housing. This will take time – the causes of illness were seriously neglected by the previous government, which failed to acknowledge inequalities as a problem. We know that poverty and social exclusion are just as important causes of ill health as smoking and drinking, and our new approach reflects that. The government’s programme is already under way. Joblessness is being tackled through the New Deal for young people, the long-term unemployed and lone parents. The worst excesses of low pay will be tackled through the national minimum wage. And housing will be improved through the release of £800 million under the government’s capital receipts initiative.

Social care

Over one and a half million of the most vulnerable people in our country depend on social care provided by their council social services department. They include children whose parents have deserted them or let them down, frail old people without family support, people with physical or mental disability or who are mentally ill. They are all people who find it impossible, or nearly impossible, to cope by themselves.

To help meet the cost of the services needed by these vulnerable people, the taxpayer pays out £8.5 billion a year. Nearly a million people work in social care. And of course a huge amount of care is provided by the seven million or more people who look after relatives, friends or neighbours. Yet despite the number and vulnerability of the people involved, the numbers employed and the costs, Tory governments have not given social care the attention it deserved. Under the new Labour government, social care is already getting more attention and it will get even more attention with the publication of a Social Services White Paper in summer 1998.

The government has set out a tough and challenging programme. There is much work to be done locally and nationally to deliver modern health and social services fit for the 21st century.

The health gap

Men of working age in the bottom social class are more than 50 per cent more likely to die from coronary heart disease than men in the overall population. (Source: Drever and Whitehead (eds) Health inequalities, ONS, 1997)

Childhood injuries are closely linked with social deprivation. Children from poorer backgrounds are five times more likely to die as a result of an accident than children from better-off families – and that gap is widening. (Source: Roberts I, Power C. BMJ 1996; 313: 784-786)

Death rates from lung cancer are about 20 per cent higher in the north of the country than the national average.(Source: Public Health Common Data Set 1997)

Women born in Sri Lanka, India and the East African Commonwealth are approximately 50 per cent more likely to commit suicide than women in the population as a whole. (Source: V Soni Raleigh, Ethnicity and Health, 1996)

The Labour government is working fast to renew the NHS and improve the health of the nation. But many changes will need to be approved by parliament and that will take time. However, many more changes have already been introduced. This section touches on just some of the action the government has already taken. It is not meant to be comprehensive – for full details the reader is directed to Department of Health publications and the website referred to in the introduction.

More spending on health

We promised to raise spending on the NHS in real terms every year. We have done so – and will continue to do so. Labour has given the NHS an extra £2 billion across the UK. For England this more than doubles the increase planned by the last Tory government:

• within a few months of taking office £10 million was spent to give women speedier access to breast cancer services
• a £10 million boost for bowel cancer treatment will help bring down waiting times
• £300 million was spent over the winter to help avoid a shortage of patient beds
• £19 million has been invested to improve access to NHS dentistry
• £500 million will be spent cutting NHS waiting lists, alleviating the pain and worry of waiting, and fulfilling our election pledge to cut waiting lists for hospital treatment by the end of the current parliament.

The NHS has a duty to patients and taxpayers to spend public money in the most cost-effective way. As promised in the manifesto, the government is carrying out a comprehensive review of departmental budgets. In the Department of Health this means looking at how well money is being spent for the benefit of patients and looking at future resource requirements. The result of this review will be published soon after the publication of this document.

Hospital building programme

The hospital building programme is a key part of Labour’s 10-year modernisation programme for the health service. We cannot build an NHS for the 21st century with hospitals built in the 19th century. The government is committed to providing the best new facilities for patients, and giving NHS staff the best environment to care for patients.

Labour has prioritised spending sensibly for major capital investment. We promised in the manifesto to overcome the problems that plagued the Private Finance Initiative (PFI) under the Tories. One of our first steps was to put a halt to wasted effort on PFI projects. Scores of business cases were being drafted without a hope of getting off the ground. So, on coming to office, the government focused efforts and made tough choices about priorities. Private finance is used only where it is demonstrated to meet local health needs and offers better value than a publicly funded alternative.

The result is the biggest new hospital building programme in the history of the NHS – 29 major new hospital building schemes to date in England alone, including three new developments using more than £100 million of public funds. Building has already begun at Dartford, Carlisle, Norwich, North Durham and South Buckinghamshire.

The new NHS – modern and dependable

The government’s White Paper The new NHS sets out a far-reaching programme of modernisation to ensure the NHS responds to a changed and changing world.

The government’s NHS modernisation programme aims to:

• renew the NHS as a genuinely national service. Patients will get fair access to consistently high-quality, prompt and accessible services right across the country
• shift the focus onto quality of care so that excellence is guaranteed to all patients, and quality becomes the driving force for decision-making at every level of the service
• rebuild public confidence in the NHS as a public service, accountable to patients, open to the public and shaped by their views
• get the NHS to work in partnership. By breaking down organisational barriers and forging stronger links with local authorities, patient needs will be at the centre of the care process
• make the delivery of health care against new national standards a matter of local responsibility. Local health professionals who are in the best position to know what patients need will be in the driving seat in shaping services
• improve efficiency through a more rigorous approach to performance and by cutting bureaucracy, so that every pound in the NHS is spent to maximise patient care.

Labour has put NHS staff back in the driving seat. Teams of local GPs and community staff will work together to raise standards. Annual contracts are being replaced with long-term agreements to improve patient care. Doctors, nurses and other health professionals will be much more closely involved in designing service agreements – which will generally be organised around a particular care group such as children or a disease area such as heart disease.

There will also be early, visible improvements to the quality of service people experience in their own homes, at their GP surgery or health centre, and in hospital. There are new plans to do this – shorter waiting times for suspected cancer patients, a 24-hour nurse telephone helpline (NHS Direct) and a huge new investment to electronically link GP surgeries and hospitals through NHSNet.

Ending the internal market

The Conservatives wasted spending on the NHS by creating an unnecessary and wasteful tier of bureaucracy – the competitive internal market. Competition drove up transaction costs and created unnecessary bureaucracy. Labour is ending the internal market and all its trappings – annual contracting, cost per case contracts and extra-contractual referrals – we are ending the unnecessary transaction costs imposed on trusts, health authorities, and GPs. Cutting red tape will divert £1 billion into patient care.

Focus on quality

Under the Tories, take-up of proven beneficial techniques was too slow. Labour has inherited a situation where the take-up of research findings of clinical cost-effectiveness is uneven and unsystematic. Best practice is not shared – often people are left to reinvent the wheel. The government wants to see a new drive on quality and effectiveness taking place at all levels in the NHS.

Labour wants to ensure that the most effective treatments and procedures are used in place of the least effective. That will be good for patients and save money. To achieve these aims the government will establish National Service Frameworks to help ensure consistent good access and high quality across the country; a new National Institute of Clinical Excellence to establish clinical standards; and a Commission for Health Improvement to ensure the spread of best practice.

The new national performance management framework will focus on what really counts for patients and staff – things such as fair access and successful treatment. They will link in with local service agreements, to tackle unacceptable variations in quality and efficiency so that there is fair and excellent treatment for all. New clinical governance arrangements will be developed in every NHS trust to guarantee an emphasis on quality.

A new National Institute for Clinical Excellence will promote clinical-effectiveness and costeffectiveness by producing clinical guidelines and audits for the whole NHS. This will ensure patients throughout the country will benefit from the rapid spread of best practice.

When quality standards are not met, the Commission for Health Improvement will be able to intervene. The Commission will both investigate and identify the source of the problem, and work with the organisation on lasting remedies.

Taken together, these initiatives are an important step towards meeting our commitment to ensure rising standards and better quality of care.

As part of the long-term commitment to modernise health care, the government is also looking at drug treatments. Labour recognises the importance of the pharmaceutical industry. It is a highly successful, research-based, high-tech industry, paying good salaries and competing profitably in world markets. We also recognise that next year’s research has to be paid for out of this year’s profits.

Over the past 40 years, advances in the use of medicines have helped to free up hospital beds by halving the number of admissions for 12 major disease areas including infectious diseases, ulcers, mental illness.

Modern anaesthetics have made day surgery possible and operations a much less unpleasant experience for patients.

But new drugs cost money, and the NHS drugs bill must be scrutinised – just like all aspects of spending. We want to refocus attention onto appropriate and effective prescribing. That will mean looking at the overall benefits as well as the costs of drug treatment. Drug companies will have to be more forthcoming with information on their products. In the future the NHS will be looking for further and better particulars about the effectiveness of drugs and their cost-effectiveness. The NHS will also want to know how best to target the new drugs towards the patients who will benefit most.

Meeting our key pledge

Our commitment to reduce NHS waiting lists to at least 100,000 lower than we inherited will be delivered over the lifetime of this government. Action already taken has ensured that no patient is waiting more than 18 months for treatment and that by next year waiting lists will be shorter than they were when we came into government.

This key election pledge symbolises our commitment to refocus the NHS on patients. The length of time patients wait to be seen or treated by the NHS is what matters most to people. By putting people’s concerns first and tackling waiting lists and waiting times, Labour has put patients first.

• An extra £500 million has been given to the NHS to tackle waiting lists this year. In England £320 million will go directly into cutting waiting lists, with more surgical and medical sessions, more doctors and nurses and more flexible seven-day working.
• As part of the drive to tackle waiting times, £97 million will also be invested in better primary, community and mental health services and modernising the whole approach to providing patient care.
• Regional Waiting List Taskforces will provide practical advice and support to hospitals and health authorities which are having problems tackling waiting lists.

Best practice is being identified and disseminated, so that standards can be driven up across the whole country. Some of the extra money will go into pioneering new streamlined appointments systems so that day case patients can choose the date of their operations. The aim is to ensure that those people waiting who are most in need of attention get treatment soonest. No one waiting for an operation wants to be kept waiting, but those in most pain and at most risk should be treated first. That is why we have promised that by the year 2000 everyone with suspected cancer will be able to see a specialist within two weeks of their GP deciding they need to be seen urgently.

A healthier Britain

Labour has appointed Britain’s first Minister for Public Health. The Green Paper Our Healthier Nation sets out Labour’s radical ideas on how local and national government, the community and individuals can best work together to narrow health inequalities and reduce avoidable death and illness. The government’s third way – rejecting the old extremes of victim blaming and nanny state social engineering – is a contract for better health.

The government’s proposals have two key aims:

• to improve the health of the whole population by increasing the length of people’s lives and the number of years people spend free from illness
• to improve the health of the worst-off in society and to narrow health inequalities.

Three settings have been identified for action:

• healthy schools – focusing on children
• healthy workplaces – focusing on adults
• healthy neighbourhoods – focusing on older people.

Clear national targets have been proposed to reduce deaths from heart disease and stroke, cancer, mental health problems and accidents. In addition, 11 areas of England – including inner cities, coalfield communities and rural areas – have been selected as Health Action Zones (HAZs). For the first time, funding has been focused on a concerted multi-agency approach to overcoming the barriers between health authorities and local authorities, and between professions. Particularly in areas of high deprivation, these barriers stand in the way of improvement. Good practice developed in HAZs will inform multi-agency working throughout the country. A new Food Standards Agencyhas also been established to set tough guidelines for food safety and protect consumers. And, as promised in our manifesto, tobacco advertising will be banned.

New strategy for NHS dentistry

Labour believes in NHS dentistry, which the Tories almost destroyed. Already, with Labour, an extra 250,000 people will gain access to NHS dental services through the government’s £19 million “Investing in Dentistry” scheme. And a new NHS strategy document will be published later in 1998. The strategy will aim to meet the challenges of:

• reducing inequalities in oral health
• improving the population’s access to NHS dental services
• playing a part in providing more integrated health services to patients
• guaranteeing the high quality of service patients expect
• allowing all members of the dental team to use their full potential to improve patient services.

Quality social services

A White Paper on social care will be published in summer 1998. It will set out the government’s plans to ensure that people in need of care have access to high-quality local services.

One object must be to try to reduce dependency. This would involve for example fuller and more careful rehabilitation and support for old people discharged from hospital, more and better-targeted domiciliary support and more active support for carers. Our commitment to getting people off benefits into work will impinge on social care for younger age groups – giving younger people, people with physical disabilities or learning disabilities a better chance of a job.

Many local authorities and health authorities are doing excellent work in this area. But in many parts of the country a “Berlin Wall” divides the NHS from social services and a lot of vulnerable people are denied the best solution to their problems. Some are left in no-man’s land – getting help from neither. With the new government these walls are already coming down. In due course we will legislate to make it easier for the NHS and social services to work together – with access to common budgets and pooled resources.

The government is looking at standards in social care. The best are a boon to the vulnerable people they serve and a credit and a source of pride to the people who provide them. But poor standards and bad management are the reverse. They can harm the people they are intended to help and bring the rest of social care into disrepute. And they usually cost more than well run services. So it is in everybody’s interests to have high but achievable standards, and to have them monitored and enforced.

Another area being examined is the funding of long-term care. As people approach old age many become anxious about how they will meet the cost of care. They are often unsure of how they will be looked after, who will pay and how much it will cost. At the general election Labour promised to establish a Royal Commission to work out a fair system of funding long-term care for the elderly – that promise has been met and the Commission will report within a year.

Labour also promised to introduce an independent regulation service, not only for residential care as at the moment, but also for domiciliary services. We will make good that promise.

Improving mental health services

The government is determined to improve mental health services, learning the lessons of past failures in the system and building public confidence. We want to ensure the full range of services is available to provide a balanced range of mental health services. This includes an appropriate mix of both hospital places and community support, including more 24-hour nurse care. Mentally ill people must be cared for in safety and security and we must tackle the concerns of the public, who lack confidence in systems which fail to provide proper support for many patients.

Mental health has been identified by the government as one of the six medium-term priorities for the NHS; one of four target areas in the public health strategy; and one of the first two National Service Frameworks to be developed. An Independent Reference Group has been set up to advise ministers on a range of issues to improve mental health services. One of the group’s first tasks has been to vet closure plans for long-stay hospitals to ensure that alternative care in the community is in place before closures go ahead.

Opening up the NHS

Under the Tories, hospitals became “self governing trusts” run as businesses. NHS Trust Boards met in secret – making it almost impossible for local people to find out what their local hospital was planning. In the new NHS, openness and public involvement are key features. All trusts must now open up board meetings to the public, and appointments to boards will more accurately reflect the communities they serve. Already, with a Labour government, the number of appointees drawn from ethnic minorities has almost doubled to 9 per cent and more than half of appointees are women compared to only 42 per cent under the Tories.

Driving up standards for patients

• Explicit quality standards in long-term service agreements will replace annual contracts.
• National Service Frameworks will help ensure consistent good access and high quality across the country.
• A new National Institute for Clinical Excellence will establish clinical standards.
• A new Commission for Health Improvement will ensure the spread of best practice.
• A new NHS Charter is being developed to replace the Patient’s Charter.
• A national survey on patient/carer experience will be undertaken.

The new NHS

Three developments will symbolise the new NHS:

• At home everyone will be able to contact NHS Direct, a new 24-hour telephone advice line staffed by nurses. It will give on-the-spot advice and help. Pilot helplines are already up and running. By 2000, the whole country will be covered.
• In the community patients will benefit from quicker results, up-to-date specialist advice in the doctor’s surgery and online booking of outpatients’ appointments by connecting every GP surgery and hospital to NHSNet – the NHS’s own information superhighway. There will be demonstration sites in 1998. By 2002 these services will be available across the country.
• In hospital everyone with suspected cancer will be able to see a specialist within two weeks of their GP deciding they need to be seen urgently, and requesting an appointment. These arrangements will be guaranteed for everyone with suspected breast cancer by April 1999; and for all other cases of suspected cancer by 2000.

How Labour is replacing the internal market with integrated care

The Tories’ internal market meant:

• Patients passed from pillar to post. Fragmented responsibility between 4,000 NHS bodies. Little strategic planning.
• Competition between hospitals. Some GPs get better service for their patients at the expense of others. Hospital clinicians disempowered.
• Competition prevented sharing of best practice, to protect “competitive advantage”. Variable quality.
• Perverse incentives of Efficiency Index distorting priorities, and getting in the way of real efficiency, effectiveness and quality. Artificially partitioned budgets.
• Soaring administrative costs, diverting effort from improving patient services. High numbers of invoices and high transaction costs.
• Short-term contracts, focusing on cost and volume. Incentive on each NHS Trust to lever up volume to meet financial targets rather then work across organisational boundaries.
• Unrepresentative boards. NHS trusts run as secretive commercial businesses. Only legal duty to make a financial profit.

Labour’s integrated care will mean…

• Health services moulded to meet patients’ needs. Health Improvement Programmes jointly agreed by all those planning or providing health and social care.
• Co-operation will replace competition. Patients treated according to need, not who their GP is, or where they live. Hospital clinicians involved.
• Best practice shared and spread. New performance framework to tackle variable standards of quality.
• Measure the things which matter to patients – like successful treatment. Efficiency Index replaced. Broader set of performance measures. Budgets unified for maximum flexibility and efficiency.
• Management costs capped. Number of commissioning bodies cut from 3,600 to 500. Transaction costs cut.
• Longer-term service agreements linked to quality improvements. NHS trusts to share responsibility for appropriate service usage.
• Representative NHS boards and an end to secrecy. New legal duties on quality and partnership.

Consultation – the challenges ahead

Some of the changes envisaged by the architects of the NHS are only just coming to fruition under a Labour government – for instance the emphases on primary care and preventing ill health.

And many of the changes of the last 50 years were not planned for – such as changes in the pattern of family life, “new” diseases, and the medical advances that have transformed modern medicine.

The new Labour government has the opportunity to plan for the next 50 years in a way unimagined by our predecessors. By achieving at least a second full term of Labour government, we can put in place changes as radical and far-reaching as the founding of the NHS and the welfare state.

This section of the paper explores some of the challenges ahead and invites views and ideas on how these can be met:

Staffing the NHS – without a committed motivated staff, the NHS cannot operate – how can we ensure staff are equipped to implement change in the NHS?

Changes in society – while talk of a demographic timebomb is misplaced, age and disease profiles will continue to change – how can we ensure these changes are planned for?

Technological advances – we are on the brink of scientific advances that a few years ago people would have considered science fiction – how can the NHS harness these changes for the benefit of patients?

Changes in expectations – people want prompt, high-quality services – how should people’s expectations be met with what people are prepared to pay in taxes?

Staffing the NHS

The interests of staff and the interests of patients are inextricably linked. Treat staff well and they will be able to treat patients better. Yet previously the NHS failed to consider how to get the best from this huge and vital resource of close to one million people. For Labour to improve the standard of patient care, we need to make sure that all NHS staff, from the porter to the professor, are looked after. Staff efforts in delivering high-quality health care to our communities need to be recognised and rewarded. For any successful organisation, fair pay and conditions are essential components in attracting and retaining good staff. These issues are subject to continuous discussion between representative organisations and government and as such are outside the scope of this consultation. But “rewarding” staff goes far wider than just getting the pay system right. It is about addressing broader staff concerns.

NHS staff need to feel valued, respected and involved.

Being valued means recognising the important role that everyone working in the NHS plays in the delivery of health care. This includes ending the bullying macho culture encouraged in some parts of the NHS under the Tories.

Being respected means appreciating public service ethos, professional values and the importance of individuals reaching their full potential. This includes tackling widespread discrimination against black and Asian staff and working to prevent assaults on staff – as identified in the government’s action against racism and against violence to NHS staff.

Being involved means an open approach to the governance of the service. This includes an end to gagging clauses and a recognition of the positive role that staff and their professional organisations and trade unions can make.

The introduction of competition into the NHS and the devaluation of public service have seriously damaged staff morale. While the Labour government is taking action to repair the damage suffered by every sector of NHS staff, longer-term solutions may be required to ensure lasting change.

Of particular concern is the effect of stress on staff and the difficulty in recruiting and retaining health professionals such as GPs, specialist and community nurses, therapists and scientists.

Changes in society

Since the NHS was founded, the shape of society has changed. People are living longer, healthier lives and many more people are living alone. Although the numbers of elderly people are rising, this country is not facing an unmanageable “demographic timebomb”. In the next ten years the NHS will deal with only a third of the size of increase that it dealt with in the last ten years. And the NHS has ample time to prepare for when the post-war baby boomers reach their 80s.

As the population becomes healthier, lives will lengthen and many more people will be requiring support outside the traditional hospital setting – for instance support recovering from cancer or heart disease; or support living with a degenerative or debilitating disease eg Alzheimer’s or arthritis. And a longer life will mean longer exposure to toxic agents, like tobacco, alcohol, pesticides and pollution. Solutions to health problems will increasingly rely on disease prevention, encouragement of healthy lifestyles and improvement of environmental conditions.

However, as medical science has progressed this century, people have increasingly looked to the medical professions for advice and treatment. In the public mind this gradual shift towards medical intervention or “medicalisation” has been associated with health care in hospitals and with treatment by doctors. In reality, the vast majority of health care takes place in the community – at home or in clinics and surgeries.

Stress in the NHS

Twenty-seven per cent of NHS staff reported significant psychological distress compared to 18 per cent in other occupations.

(Source: Firth/Cozens The Mental Health of the NHS Workforce)

Why do nurses leave the NHS?

A recent Institute for Employment Studies Report Taking Part: on Registered Nurses in the Labour Market in 1997 gave five main reasons why nurses leave the NHS:

1. promotion;
2. gaining broader experience;
3. better training or development opportunities;
4. better or more suitable working hours;
5. wanting a job with less stress.

Labour’s Health Policy Commission invites views and ideas on improving the recruitment, retention, training and motivation of NHS staff.

Key questions:

Restrictions on extending opportunities account for the top three reasons why nurses leave the NHS Is there too much rigidity between professions, eg between doctors and nurses – would more flexibility between professions enhance job fulfilment?

Family-friendly employment policies are essential to allow the NHS to make the best possible use of resources as well as increasing the attractiveness of the NHS as an employer – how might this be achieved?

Stress is a major problem in the NHS but working in the NHS is inherently stressful – how should we recruit, train and support staff to lessen the effect of stress?

Technological advances

Modern medicine is on the brink of scientific advances that a few years ago people would have considered science fiction. New health technologies will make the screening and diagnosis of many conditions quicker, safer and more accurate. New techniques for drug delivery will improve people’s quality of life. And advances in information technology and telecommunications will speed up diagnosis and treatment.

Developments using the body’s biological processes to make useful products (biotechnology) and research into understanding the body’s basic building blocks (the human genome) mean that we are on the brink of breakthroughs in pharmaceuticals that make the discovery and development of antibiotics pale in comparison.

To maintain public confidence, the NHS must harness new developments rather than being driven by them. Advances in information technology (IT) and communications will offer new opportunities to improve the speed, accessibility and quality of patient care. People will be able to book hospital appointments at a time convenient to them and their family at their local health centre. Patients can be involved in and helped to understand their own treatment with the use of interactive computer programmes. And sophisticated video cameras (telemedicine) can be used by world-renowned specialists to examine patients hundreds of miles away in their own GP’s surgery

To grasp these opportunities, substantial changes in the delivery of healthcare may be required. For instance the skill mix and training of staff must be considered. The confidentiality of patients’ records must be protected. And some new treatments may pose important ethical questions.

Until very recently stomach ulcers were diagnosed and treated with painful, potentially dangerous surgery. Today most people are diagnosed without surgery and are successfully treated with tablets.

Labour’s Health Policy Commission welcomes views and ideas on how society’s demand for leading-edge technology can be reconciled with the increasing care needs of individuals and disease prevention strategies for whole communities.

Key questions:

How could people be made more aware of the importance of preventing ill health?

How much responsibility should people take for maintaining their own health?

How could community health services be improved to help those who want to take responsibility for their own health?

Which public policy decisions are relevant to preventing disease?

What is the most appropriate mechanism for determining a suitable balance of services between community health and hospital care?

Changes in expectations

Before the NHS was set up, people feared they could not afford to pay for health care. The NHS banished that fear. Fifty years ago the public were promised free health care available to all according to their need and not their ability to pay. By meeting that expectation the NHS has continued to maintain public confidence. But people’s expectations have increased over the years. People now expect an accessible, prompt, quality service and if they are not happy they expect their complaints to be handled efficiently.

As public expectations have risen, so too have demands on the health service. Demands are not necessarily threats. Women taking greater control over childbirth and diabetic patients taking greater control over their own treatment are opportunities. Patients’ expectations are used to lever up standards of care and responsiveness of services. The NHS has begun to stop seeing patients as passive recipients of treatment, and has started seeing them as partners in their own care – providing people with good-quality information and working with them to use it to their best advantage.

More effective patient and public involvement leads to more effective, better-quality treatment, better-quality services and better-quality management. But with increased rights for patients, must come increased responsibilities for the public – to use services properly, with respect for staff and other patients, and to look after one’s own and one’s family’s health.

Labour’s Health Policy Commission invites views and comments on how public confidence in the NHS can be maintained by balancing people’s expectations with what people are prepared to pay in taxes.

Key questions:

Most people’s contact with the NHS is through their local health centre or family doctor – how can these services be improved for patients?

Do the expectations of older people differ from those of other health service users?

To what extent do people expect to be involved as citizens in the planning of local services?

Labour’s Health Policy Commission welcomes views and ideas on how the NHS can make technological advances work for patients.

Key questions:

Information technology has the potential to bring the NHS closer to people’s homes – to what extent do people want the sort of innovations described above?

To what extent do people and their families want to be involved in decisions about their own treatment?

How might the use of information technology and telecommunications be used to help people take more control over their own health?

What is an appropriate relationship between the NHS and the organisations that develop new treatments and new technologies?