The National Plan for Health 2000

1. Introduction
  1. The SHA was founded in the 1930s as the Socialist Medical Association to campaign for the introduction of a National Health Service. Following that initial success, it has continued in existence to focus debate on protecting and improving the NHS, and to campaign on issues of health and inequality. The SHA seeks to bring fundamental and enduring socialist values to the analysis and understanding of contemporary health politics.
  2. With the advent of a new Labour government it has been reviewing its role. It recognises that it may now seem out dated to some critics, and aligned to the forces of conservatism. This is, however, far from the case. While retaining its commitment to the enduring values of the NHS, the SHA wishes to be the “critical friend” of the Labour government. It will be welcoming and supportive of the government’s policies and achievements, while offering advice and views on those issues that require more attention.
  3. The SHA has over 1000 members. They are interested in and active at all levels of the NHS. They are doctors, dentists, nurses, and therapists, managers, lay members and non-executive directors, they come from the voluntary sector and the community health councils, and most importantly, they are service users. Most of them are trade unionists and members of the Labour Party. They constitute a wide-ranging and influential cadre of Party members within the NHS who know how it works on the ground
  4. Distribution of the internal questionnaire was patchy, and ordinary Party members have had little opportunity to contribute to the National Plan consultation. The SHA is seeking to fill this vacuum by offering the means for a continuous dialogue between the government and the Party on health and health care issues

2. Improving Health

  1. The key to achieving significant improvements in the health of the population will be through reducing inequalities in health by cutting the excess death rates and levels of chronic disability of those sections of the population with the worst health. This must be matched by modernising the operation of the NHS and the delivery of health and social care to achieve an efficient and effective service that is equally accessible to every person in the country
  2. Underlying the inequalities of health are inequalities in most or all aspects of life, of which the most pertinent measures are the differences between the richest and the poorest. Income inequality remains the single most important determinant of health inequalities, although the links to educational attainment, family breakdown, ethnicity and geography are also understood
  3. To reduce inequalities, income inequalities must be reduced by redistributive methods. Health inequalities internationally are greater where the greatest income inequality is found. Recent comparisons between cities in Canada and the USA have demonstrated that the typical mortality gradients described in the Acheson report for the UK are also observed in the USA, but are much less apparent in Canada. There, the combination of greater economic equity and publicly funded health and social welfare services have made an impact
  4. The disposition of disposable incomes in the UK is skewed to the right. Focusing solely on the proportionately small poor and socially excluded groups on the left hand side of the distribution, while important as a social goal, is insufficient to deal with overall inequality. Greater fairness and equity will improve the health of society as a whole, including the rich. There is evidence that growing inequalities in Britain, and particularly the legacies of Thatcherism, have been disadvantageous to the health and well being of all, including the affluent.
  5. The principles that underpin all the SHA’s detailed policies are equity, accountability, and quality. The government’s strategies to address poverty, particularly child poverty, are therefore applauded for their likely impact on health, as well as for many other reasons. However, the government should now extend these strategies to reduce relative poverty as well as absolute poverty for maximum health gain
  6. The challenge of reducing inequalities in health must be tackled under each of the five headings. In every case there are immediate actions that can be taken now, coupled with the need to build up hard evidence-based strategies for the longer term

3. Prevention

Primary prevention means tackling the wider determinants of health. The underlying causes of much ill health and premature death lie in unemployment and low income, occupational risks, poor housing and community environments, poor educational achievement and social isolation

  1. Resource allocations need to be positively weighted to support disadvantaged communities, as is happening through the Regional Development Agencies, Health Action Zones, Education Action Zones and Surestart schemes. However, all these schemes need to be centrally co-ordinated in a more explicit and systematic way so that they add up to a coherent and purposeful political agenda. There is risk in a bidding and lottery culture of allocation that those in deprived areas miss out once again – audiences at the Royal Opera House versus the population of Inner Manchester
  2. It is known that there are more barriers to be overcome for effective preventive measures in deprived communities, and resources must be allocated accordingly over a reasonable time. Where there are specific interventions that will prevent disease and reduce inequalities, then government must show leadership and the determination to introduce them. For example, if the expert committee on fluoridation reports that it is highly effective and safe, then it should be introduced as a water quality measure nationally, with minimum and maximum levels. Local determination would be an obstacle to achieving this as water companies are multi-national, with supply grids that do not respect local authority boundaries. This would be an example of effective determination for a government that is serious about reducing health inequalities
  3. Investment is needed in disseminating existing evidence about preventive and health promotion strategies that work for communities with the worst health chances. Significant investment in identifying and evaluating new possibilities, and in disseminating the results, is also required. There will be no magic formula – what is being sought are small increments in success across a broad field

4. PARTNERSHIP

Health

  1. The SHA recognises that the NHS alone cannot improve the nation’s health, but requires the support of a range of partners. Therefore existing partnerships with local authorities, voluntary organisations and others need to be strengthened at every level. These will be facilitated if PCG/Ts and health authorities match one or more local authority boundaries. This will enable joint policy development, and reduce the emerging mismatch in England between NHS registered populations in primary care organisation and local authority resident populations
  2. Looking to the future, mechanisms are needed to ensure that local authorities and health authorities work effectively together to draw up and implement Health Improvement Programmes that will improve health and tackle health inequalities. The requirements are not sufficiently robust at this stage, and leave room for local authorities inimical to the government to do as little as possible to progress the government’s modernisation agenda. Performance review systems within the NHS and local government need to reinforce joint planning mechanisms such as Community Plans, Joint Investment Plans and Health Improvement Programmes
  3. In addition, the government should use its considerable skills to bring others on board for better health, including business, industry, leisure, food and catering, the press and other media. Areas such as combating exposure to tobacco smoke, alcohol availability and abuse, promoting the availability of healthier food, and alternatives to car travel immediately spring to mind, but there are limitless other possibilities. The SHA would welcome involvement, for example, with the trade unions and the co-operative and labour movement

Health and social care

  1. The SHA believes it is sensible to combine the delivery of health and social care, since recipients of these two forms of care do not recognise the boundaries. This would also help to abolish ‘cost shunting’ when local authorities move patients into health, where care is provided free at the point of use, whereas local authorities must means test service users and make up shortfalls through Council Tax. Local government’s role in HImPs offer one short term medium for engaging local democratically accountable organisations in the health agenda
  2. If the delivery of health and social care is combined, it will also be necessary to take cognisance of the size, range and complexity of the resulting organisation and the issues it will be dealing with. This would need to be broken down, and a balance struck between a national drive to improve the delivery of care, and the need for local flexibility to address local problems
  3. However, if social care moves to health, there will also be an additional democratic deficit to address. The democratic deficit at all levels of health care planning and provision is a serious blight on a service that the public otherwise holds in high esteem. It is therefore necessary to develop a model of representation of the public interest in the NHS that ensures that there is public ownership of the government’s modernisation proposals as set out in the National Plan
  4. At the moment, the only organisations with the statutory duty to represent the public interest in the NHS are Community Health Councils. However, care must be taken when considering the role of CHCs. If they are to be a substitute for democratic accountability, then their own membership structure will first require radical reform, and they will have to be properly resourced and independent of the NHS
  5. No new constitutional settlement for the NHS will work unless it reflects the will of the people. The government should therefore consult the public widely on the future structure and governance of the health services. This would be a natural progression from the government’s current consultation on the National Plan
  6. Issues that this consultation could address include:
    • the type of public body that the New NHS should be
    • how the relationship between the day to day running of the NHS and the Secretary of State’s responsibilities for overall policy direction and delivery will be defined
    • the shape and content of a new Patients’ Charter based on clear and easily enforceable rights
    • fairer and more efficient allocation of resources, both financial and human, to the provision of health care
  7. The SHA would welcome the opportunity to provide a thoughtful and detailed contribution to this debate, but does not wish to be too prescriptive in advance of that consultation
  8. In the meantime, and as long as NHS bodies are quangos, they must show evidence of serious involvement with local government and other local democratic structures and local communities, so that they have some means of delivering local accountability

5. PATIENT CARE

The inverse care law, which states that the availability of good medical care tends to vary with the need for it in the population served, is not a law of nature. It can and must be challenged

  1. The amount, quality, accessibility, appropriateness and affordability of health care available for those with the worst health must be improved. Proposals for improved health care must address the current problems of unequal access to health care. This will require additional resources and training for all health services in deprived areas. A particular and urgent priority is to accelerate the development of well-resourced, multi-disciplinary primary health care teams. These will have salaried GPs with links to centres of excellence. This seems the only option if the primary care deserts found in some urban and rural areas are ever to be transformed
  2. Professionals working in deprived communities have a more difficult task. This must be recognised, and remuneration and resources modified according to need. The risk of a league table and Ofsted approach that is not sensitive to these issues will alienate professionals working alongside these more disadvantaged communities
  3. At the practical side of access, there is general public concern at the difficulties and delays in securing appointments at GP surgeries as well as unacceptable waits to receive hospital referrals, diagnostic procedures, receiving reports and test results, and operations
  4. Achieving equal access is particularly difficult for many vulnerable people, such as the elderly, people with physical and learning disabilities, members of ethnic minority communities, especially those whose first language is not English, users of mental health services, and substance abusers. In addition, many people who should be accessing health care are unwilling or unable to do so at the moment
  5. Steps to address unequal access to health care services could include:
    • removing or substantially reducing patient charges
    • providing specialist facilities in primary care settings to enable more care to be provided within the community
    • increased use of nurses and nurse practitioners in primary care
    • increased use of salaried GPs and GDPs, and the phasing out of independent contractual status
    • re-establishing NHS dentistry based on lists of patients, with salaried dentists responsible for General Dental Services
    • changes to the consultants’ contract to ensure that they are fully committed to the NHS by rewarding full time NHS consultants, and making all consultants’ job plans subject to explicit annual review and monitoring
    • mandatory ethnic and language monitoring accompanied by the effective use of interpreters and advocates for vulnerable patients
  6. The SHA’s continued opposition to patient charges reflects its commitment to the anti-poverty agenda. Nevertheless, the SHA applauds government initiatives that have already been taken to improve access to health care, such as NHS Direct
  7. Another crucial step to improve access will be by empowering patients to become equal partners in planning their own health care packages. The socialist model is to think of health professionals and patients as being co-producers of health, not as consumers and suppliers in a market framework
  8. An alternative role that could be considered for Community Health Councils is to embed them firmly on the patient side of the NHS/patient partnership. They could be given two clear and specific responsibilities. One would be, independently and from the patient perspective, to monitor the delivery of services, with a remit covering both primary and secondary care and any private provider used for health care for NHS patients. CHCs should anyway have the right to inspect all private premises in advance of them being used for NHS care
  9. Their other responsibility would be to act as patient advocates, with a clear remit within a modernised, responsive and effective NHS complaints procedure. As stated above, however, the CHCs would need proper resources and independent status to fulfil these roles effectively
  10. The private sector must also be better regulated, especially hospital services that are currently part of nursing home registration guidance. Private sector activity on all NHS patients must be properly recorded as part of the NHS Information System so that there is a better picture of need, demand and supply. This is especially important in areas where a very significant proportion of elective surgery is undertaken in the private sector

6. PERFORMANCE

Health

  1. Clearly, improvements in measures of health as the ultimate performance indicators are necessary, but it must be recognised that these will take time to achieve, and anyway may be less influenced by NHS activities than by economic and social factors. More realistic and achievable performance measures, including process targets, must be used as interim outcomes for the NHS. Nevertheless, national targets to reduce inequalities will help reinforce national government’s commitment and enable it to be seen in a more holistic way by relevant parties
  2. The Cabinet and all government departments, including the Department of Health and the NHS, must undertake health impact assessments of their policy options before they agree and implement priorities, and must work with other agencies on health improvement assessments of their policies. This should apply at every level – national , regional and local – and should focus on how each policy impacts on those with the worst health. The public health agenda must be heard at Cabinet level, with national accountability for the health of the population being through the Prime Minister
  3. NHS structures and Department of Health structures must assess the impact on the local and larger environment of policies adopted, and give the lead on green approaches to building use, power, transport, waste disposal and other environmental issues. The government must also sharpen the division between planning and commissioning, and put greater emphasis on the need to improve the planning side of the process – coherence and consistency versus overburdening the NHS with fragmented budding processes

Health Care

  1. The NHS must move from the position where performance management is about identifying scapegoats when things go wrong to a situation where it is used primarily to improve the delivery of care. The introduction of clinical governance, and the establishment of NICE and CHI have gone some way to address issues of quality. However, public confidence in the Labour government’s ability to manage and run the NHS effectively will not be restored until it can demonstrate its intention to deal rigorously and robustly with all the issues around quality and clinical governance. Organisations with a memory consultation document make an excellent start to linking clinical with corporate governance and the development of learning organisations
  2. Performance monitoring should also be aligned with risk management because of Shipman, the Bristol cases, cancer screening failures, the laxity of GMC procedures in dealing with doctors associated with defective care, and other concerns now being brought to the public’s attention almost on a daily basis. Patients want assurances that the care they receive is not only appropriate, but does not expose them to dangers and difficulties
  3. Although the public lacks the competence to judge the adequacy of medical care, it is well placed to draw attention to adverse clinical incidents. The main medium required is an effective and responsive complaints procedure, and immediate steps must be taken to reform and strengthen the existing procedure

7. PROFESSIONS

Health Care

  1. The SHA welcomes the consultation paper on workforce planning and in particular its analysis of the problems with the current system. However, it also recognises that there will be difficulties in getting the changes implemented
  2. One major challenge will be in ensuring that the workforce is properly remunerated, motivated and allocated. The remit of the proposed National Workforce Development Board will need to encompass all the factors relating to the NHS workforce, including strategies on pay and access to affordable accommodation, particularly in large conurbations
  3. The respective responsibilities of health authorities and NHS trusts for workforce planning are not clear, and other things on the workforce agenda need greater precision. For example, a revised structure on its own will not produce more effective workforce planning. It needs to be placed within an overall strategy for organising and running the NHS that includes identifying the best organisational structure for delivering it
  4. A human resources strategy that best serves the business strategy is also needed, with an organisational structure matching authority to responsibility. It must also be explained more clearly why health authorities should lead on workforce planning, and what power they will have to influence critical factors, such as the number of students and trainees. The proposals give health authorities the responsibility for workforce planning, but little capacity and authority to carry it out effectively. For example, the boundaries for the proposed workforce confederations and health authorities would need to be aligned. Skills in workforce planning would also need to be strengthened throughout the NHS, and in particular within the trusts and the English regions
  5. The proposed care group boards related to National Service Frameworks will have to ensure that too much focus on specific diseases does not lead to a fragmented approach to workforce planning that overlooks patients falling into more than one care group. For example, trauma patients with injury to many organs, elderly people with heart problems, chest disease and a malignancy, and people with learning difficulties who need treatment for psychiatric or physical problems
  6. This paper has already referred to the urgent need for general practitioners to have attractive options for salaried employment in deprived areas. Over time this should become the norm everywhere. The government must also work towards the position where all consultants have normal contracts of employment with clauses that preclude conflicts of interest, such as may arise when private practice benefits from long NHS waiting lists
  7. Retention of staff who have worked for over 20 years in the NHS is an important issue, as the number of older GPs and consultants taking early retirement creates shortages. NHS employment policies on prolonged study leave and sabbaticals would refresh those people who still have a useful contribution to make. Occupational support for all NHS workers, including ancillary staff, is an important input

  • Health

    1. Although government policies depend heavily on services and policies being governed by public health considerations, it is not clear how this will be achieved. Management structures at regional, health authority and PCG/T level must include senior public health professionals including doctors, public health nurses, and other public health specialists such as health promoters and public health dentists, with powers to give direct advice to boards and other agencies, and a duty to report to the public
    2. Public health professionals must be given the time and continuing education to work strategically and across agencies, as well as to contribute to current health policies and their evaluation. Different populations at neighbourhood and PCG/T level, health authority and regional level, and national and international level have different public health issues. The concept of epidemiological stability and population levels means relevant public health support is needed at all those levels

8. FINANCE

  1. The National Plan will be unable to deliver any improvements unless the financial underpinning of the NHS is correct. The SHA is therefore adding a section on Finance to its presentation
  2. The SHA recognises that the government is moving in the right direction on funding. The new money is a massive transformation, but should be set to reach a target of 8% of GDP, to bring the UK in line with the best of the European Union countries. The benefits of the new money will also take time to become apparent, because of massive deficits and backlogs
  3. However, the challenge of capital funding must also be tackled. Funding of all major capital replacement and developments should be reinstated as an essential part of its year on year resourcing through the public purse. The fabric of the service should be maintained and modernised on a consistent basis, with the improving assets retained in public hands. This would avoid the use of PFI schemes. PFI schemes mortgage the future through higher revenue costs, and usually involve a reduction in the number of acute beds, which would militate against the achievement of the 85% occupancy target of the National Beds Inquiry
  4. Annual efficiency savings should not be required as a matter of course, given their often deleterious effects on the level and quality of service delivery. A standard costing system should also be introduced to ensure a level playing field between trusts and transparent financial accountability when trusts and health authorities are being held to account

9. CONCLUSIONS

  1. The SHA welcomes this wide ranging consultation on the National Plan and the opportunity it gives every citizen to participate in planning a National Health Service for the 21st Century. It believes that the National Plan must be an aspirational and inspirational Plan that describes a healthier and fairer society. However the SHA also hopes that this is just the start of the dialogue, and looks forward to joining future debates directed at improving the nation’s health and the delivery of health care services through the development of a genuinely patient-focused NHS
  2. Every citizen has a right to be served by an efficient, effective and accountable health service, and this will only be delivered by a Labour government