A public health approach to well-being
It is fundamental to achieving the SHA’s objectives that health, health care and well-being should all be tackled from a population-based public health approach rather than an individually focused medical one. Because a public health overview is so important, the SHA believes that the Prime Minister should appoint a free standing Minister for Public Health to the Cabinet with specific responsibility for ensuring that all government policies are evaluated for their impact on health and well-being and on inequalities.
Action to reduce health inequalities goes way beyond health care. It covers the widest spectrum of life experiences that can be influenced by government. It requires joined-up thought and action by a whole range of government departments responsible, for example, for the economy, housing, education, the arts, the environment, leisure and transport. Each major government department should therefore have its own health champion, and each department’s contribution to public health should be audited annually. National, regional and local government should undertake health and health inequalities impact assessments of any major new policy that is proposed.
Only a senior politician with Cabinet status will be able successfully to tackle this agenda.
Democracy, accountability and participation
The government should enable citizens to participate in NHS governance through regional and local elections. Directly elected regional assemblies throughout the country should plan and commission specialised health care within their area, as happens already in Scotland and Wales, with directly elected Primary Care Organisations commissioning and delivering local services
An alternative model would involve strategic health authorities becoming directly elected with responsibility for commissioning local services being given to democratically accountable local authorities.
Whatever the model, local commitment and energy is vital to making real changes to people’s lives, and greater local autonomy is a precondition for this.
A healthier nation begins with healthier babies. It is known that poor health and nutrition in pregnancy cause health problems throughout the lives of the resulting children, yet so many young women are expected to subsist on benefit levels that are too low to support a healthy diet. There should be an immediate increase in benefit levels for pregnant women.
Free, healthy school meals should be universally available. Many children entitled to free school meals don’t take them because of the stigma. Children should be able to drink water throughout the day, and free school milk and fruit should be available to all. Budgeting and shopping for healthy food, and cooking it, should be a part of the National Curriculum.
The duty of care owed to children by schools should be extended to their diet. Young children should not be given the freedom to eat too much fat, salt and sugar just because the damage done to their health is not immediately apparent. There should be a total ban on advertising unhealthy food directed at children, and machines vending fizzy drinks and unhealthy foods should be removed immediately from all schools. Commercial schemes that encourage children to eat unhealthy food to obtain “benefits” for their schools must also be outlawed.
Regular sports, dance and other exercise must be re-introduced to the school timetable to tackle the increasing problem of childhood obesity, complemented by a full arts curriculum that enhances self-esteem and mental well-being. Parents should be actively discouraged from taking their children to school in cars, and each school should have a target to increase the number of children who walk or cycle, where it can be done safely, to school.
Learning to live healthy lives should have a place in the National Curriculum, where young people discuss their own and their community’s health. Sensitive issues must be tackled head on. The topics of drug, alcohol and tobacco abuse are avoided in many schools because they are controversial, yet children respond well to factual information on such matters. Education in sexual health and teenage pregnancy issues must also be compulsory and not left to the discretion of heads, school governors and parents.
Healthier lifestyle choices must become easier choices. Government faces a dilemma in striking the right balance between persuasion and prescription over individual lifestyles. However, the SHA believes that at the moment it errs too far on the side of persuasion.
For example, international evidence suggests that banning smoking in public and in the workplace can halve the incidence of smoking. Local authorities here should be encouraged to introduce bans, and pending the introduction of primary legislation there should be support for them to do what they can now through existing by-laws.
Individuals are often denied the information they need to make informed choices. Manufacturers do their best to confuse the public about health risks, and the government does too little to stop them. The food industry should be encouraged to reduce the amount of sugar and fat in prepared foodstuffs, and salt should be excluded altogether where practicable. The addition of salt to any food should be a matter of individual choice. All food and drink should be clearly marked with the percentage of salt, fat and sugar contained.
Policies on drugs, alcohol and smoking should concentrate on harm reduction and be based on sound evidence, not moral presumptions.
Poor diet and lack of exercise play a major part in the ill health of poor people. Access to exercise should be made easier, and people encouraged to reduce their intake of calories. The EU should not subsidise sugar or tobacco production. This gives a mixed message when government is exhorting people not to smoke and to reduce their consumption of sweet foods. The money should be invested instead in health promotion messages.
A healthy income
Most poor people would be able to live healthier lives if they had the means to do so. It is time for the UK to have a proper measure of the income level needed to avoid both absolute and relative poverty and ensure good health, satisfactory child development and social inclusion. This measure should determine benefit, pension and minimum wage levels, and it should inform the practices of debt collectors and the courts.
Many local health services have a poor record of engaging with deprived communities. Too often poor people receive poor services from unenthusiastic professionals who live elsewhere and do not engage with those communities.
The government must maintain its commitment to reduce health inequalities over the long term. Some key determinants of ill health, such as poor educational attainment, income inequality, and child and family poverty are seldom mentioned in a health context, and these must be addressed more robustly. The resource allocation formula should take better account of economic and social disadvantage to produce a more equitable distribution of the nation’s resources. The many excellent local initiatives to tackle poverty and deprivation must be accompanied by robust monitoring systems that can measure progress made in developing healthier communities.
The current political focus on hospitals makes no sense, even in health care terms. Whilst medical interventions contribute increasingly to life expectancy and the quality of life in developed countries like the UK there are still great gains in health to be made through healthier lifestyles and primary care. All local directors of public health should therefore be joint NHS and local government appointments, and local government should share with primary care trusts the statutory responsibility to reduce health inequalities.
Targets for improving the health of populations should take priority over targets for treatments, waiting lists and operations and they should be integral to the role of all senior managers in local and regional government as well as in the NHS.
People are experts in their own health. The clinician/patient interaction should not be defined as a customer/provider relationship but as a co-production of equal partners.
The new statutory rights for patients and users in the Health & Social Care Act 2001 and the Race Relations (Amendment) Act to influence the planning and delivery of health care are welcome as a potentially powerful means of achieving the patient-centred health service envisaged in The NHS Plan. However, the mechanisms of this influence, such as local authority overview and scrutiny and patient and public involvement forums, must be properly resourced.
A healthier workforce
The NHS must engage with its staff, develop their vision and utilise their unique experience of delivering health and social care. Money on its own will not raise the morale of health workers, but neither is there any sense in contracting out support services to an underpaid workforce. Securing the lowest tender price at the cost of impoverished workers should be recognised as the poor long-term bargain that it is.
The NHS could also focus much more on recruiting and training staff from deprived communities, and paying realistic wages.
Seamless health and social care services
Social care cannot be considered separately from health care, and greater co-operation between the NHS and social services is essential. Lip service is paid to the idea of a whole systems approach, but there is no evidence yet that this is delivering significant change. Much more needs to be done, although the development of care trusts and children’s trusts must not be at the expense of democratic accountability.
More resources are needed to keep people in their own homes. Personal care contributes greatly to keeping people out of hospital, yet the role of carers is neglected. They also need proper support and resources.
Services in the community are rationed in a way that would be unacceptable in acute health services. It is as much a priority to ensure, for example, that people with disabilities can function fully in the community as it is to ensure that they do not have to wait too long for an operation.
The poor image of social workers has become acute, and there should be regular campaigns to counter the low morale of social workers and the negative and unfair media coverage they often receive.
There should be an urgent review of charging policies, including the recommendations of the Royal Commission on Long Term Care, the perverse incentive of intermediate and domiciliary care charges that drive people into residential accommodation rather than remaining in their own homes, and dental, optical and prescription charges. Pending fundamental change, the government should introduce an immediate flat fee for a whole prescription.
Mental health – the Cinderella service
Mental health services remain under-developed and of low priority. Mental health policy appears to be in the grip of the law and order lobby, whose policies are misguided, counter productive and damaging to service users.
The government’s decision to delay publication of the new Mental Health Bill is a welcome sign that it has heard the overwhelming opposition to previous proposals. The SHA looks forward to a new draft Bill incorporating the constructive suggestions made by so many mental health organisations. In particular, the SHA believes that mental health care services should be the place where the government first implements its commitment to provide a wider range of choice for patients.
The Labour Party’s policy making process
There are differences of opinion within the Labour Party on some important matters that would be better discussed than buried. Some health policies advocated in manifesto for the last general election bore little relationship to those that came through the national policy forum process, and the government has implemented other controversial policies without discussion within the Party. The SHA therefore advocates a reform of the national policy forum process to give Party members real opportunities to influence government.
There is an increasing divergence between the health and health care policies in England and those in Scotland and Wales. The SHA supports this trend on the basis that pluralism promotes innovation; and would like to see formal arrangements established so that all home countries can learn from the experience of the others.
A holistic approach to health and well-being
The SHA believes that everything that government, industry, communities and individuals do impacts on health and well-being. And that promoting health and well-being must be an objective – not always necessarily the prime objective – of all organised activity.