This is our response to the Labour party consultation document Improving Health and Social Care.

The Socialist Health Association is keen to play its part in the Labour Party’s policy-making process and to make it a genuine and worthwhile exercise. To this end it has facilitated a number of meetings for Party members and arranged a series of six meetings across the country for SHA members. This submission has been produced as a result of these consultations with SHA members, who mostly work in the health service or are involved with the NHS as users.

The Socialist Health Association has, since its foundation in 1930 as the Socialist Medical Association, adopted a public health rather than a medical perspective, defended the principles of the NHS, and stressed the importance of democratic involvement and local accountability. The SHA is very pleased to see the determination with which the Government has defended and implemented these ideas. It would like to arrange a meeting with the Health Policy Commission to discuss how the SHA might improve the effectiveness of its contribution to the process.

There were difficulties with the first National Policy Forum exercise that caused some people to be cynical. It is important that all the organisations in the Labour Party have a genuine opportunity to debate relevant issues.

There are differences of opinion on some important matters that would be better discussed than glossed over. It was very demoralising to find that some policies advocated in the last general election in the health field bore little relationship to those produced by the policy forum process.

The SHA would also like some clarification about the relationship between the health policy documents agreed in Scotland and Wales and the document now being considered. The words ‘devolution’, ‘Scotland’ and ‘Wales’ do not appear in the consultation document.

Principles

The SHA is in general very impressed with the development of the government’s health policies over the past five years. Many of the most significant achievements have received insufficient recognition. The government should make more of its strategy to improve health and reduce inequalities, the National Service Frameworks for the major health conditions of heart disease, cancer, mental health and for vulnerable populations (children and older people), the creation of NICE and CHI, the NHS Plan and the commitment through the Wanless Report to year on year investment in the NHS. The SHA applauds the recent cross-cutting spending review and waits to see its proposals implemented.

Apart from any political credit to be gained, many of these initiatives will be more effective if they are more widely understood. For longer-term benefit, they need to continue to be resourced and to remain top level priorities. The SHA’s experience is that many of these initiatives are largely unknown, even to active Party members.

The SHA agrees that the NHS reflects values and not just a structure. The SHA sees it as a model for socialist services and socialist values, because it is based on need, not ability to pay, and because of its stress on equity and democratic accountability.

People are experts in their own health. The clinician/patient interaction should not be constructed as customer/provider but as a co-production based on a participatory democratic model. This is important when considering increasing choice. Rather than a market model, the government should develop a socialist model where people engage as citizens and users, where standards are achieved by leadership (National Service Frameworks), with local participatory democracy, by engaging users and carers, and by audit and inspection against standards.

It is counter-productive for the government constantly to be looking to the USA for ideas on how to improve the health service. The choice people want in most areas is not to sign on for primary care miles away, or go to schools out of catchment areas, but to be involved in ensuring that local services are good and responsive against explicit standards. This ensures that those less able to exercise choice are not left with a poorer service.

The SHA feels that there are some important general principles of social justice that the Party should adopt as central to its health policies:

1. A decent standard of living for all citizens, based on a realistic minimum wage and benefits system.
2. Equitable access to all public services for everyone.
3. Sufficient access to training and education in both vocational and non-vocational areas.
4. An undertaking that state agencies will not operate in such a way as to damage the health of the public.

These principles could become more widely known. Health is a complex area and it will never be easy to explain all that the government is doing to those not directly involved.

Public Health (Questions 1-6)

It is obvious that health care can absorb huge resources, but more medical intervention can make only a modest contribution to improvements in life expectancy or quality of life for the population as a whole. For example, only 30% of the variance in mortality can be explained by healthcare.

The NHS must not absorb all the resources that are needed to improve the health of the population. Public health is bigger than the just NHS, and includes other areas, such as housing, education and transport. Responsibility for public health should therefore rest with a minister who is both of Cabinet status and quite independent of the responsibility for healthcare.

Many of the important determinants of health are outside local control or influence. Every major Department should have a health champion. The contribution of each Department to health inequalities should be subject to audit. Regional Directors of Public Health should relate to regional government. Local Directors of Public Health should be joint appointments between local government and Primary Care Trusts (as some already are), and both bodies should each receive annual reports on the health of their populations.

The SHA would also like both national and local government to produce a public health impact assessment statement when any new policy is introduced.

Targets for improving the health of the population are more important than targets for performing more treatment and operations. They need to be among the lists of things that must be done by senior managers. If there are to be league tables, let them show the Primary Care Trusts and local authorities that have implemented policies that will reduce infant mortality inequalities and increase life expectancy the most. If these things are difficult to measure directly, let them be judged by factors demonstrated to affect those central outcomes, such as smoking in pregnancy, low birth weight, and multiple births. An excessive political focus on hospitals makes no sense, even in healthcare terms. It is in primary care that the biggest gains in health can be made.

Healthier lifestyles

Healthier lifestyle choices must become easier choices. At present many factors – mostly commercially driven – conspire to make unhealthy choices easier. There should be an emphasis on the importance of well-being, and positive healthy values must be brought into play in relation to recreation, leisure and sport. There should be much firmer control of advertising directed at children.

The SHA would like the Health Improvement and Modernisation Programme in partnership with local government to be revived and extended. Targets are less important than the development of effective mechanisms to achieve them. The SHA welcomes the emphasis on community regeneration and the development of Local Strategic Partnerships, although there may be a significant wait before any real change happens.

The NHS and other official bodies should use their purchasing power and position as major employers and contractors in conjunction with local regeneration initiatives to ensure that those involved with it are affected beneficially. Securing the lowest tender price at the cost of an impoverished contracted workforce should be recognised as the poor bargain that it is in the long run.

Drugs

Policies on drugs, alcohol and smoking should concentrate on harm reduction and should be based on sound evidence, not moral presumptions. The war on drugs is not effective. Prohibition didn’t work in the USA and it doesn’t work here. Effort needs to be proportionate to the harm done by each drug, of which alcohol and tobacco are far and away the most important. There should be a tailored strategic approach to each drug.

Alcohol is always underestimated in its mixed and damaging effects, which include accidents, domestic violence and crime, as well as health problems such as liver disease, cancer and hypertension. The SHA is very disappointed that no strategy has yet appeared for dealing with alcohol.

Those who abuse drugs, alcohol or tobacco should have ready and assured access to appropriate services, including those for their other needs. These services are not at present sufficiently resourced. The government should consider a much more extensive programme of vaccination against hepatitis. Pharmacy premises may need improving if they are to be used to provide advice or medical facilities confidentially.

These issues need to be tackled honestly in schools, because most of the damage is done before children reach the age of 16. Schools avoid talking about these things because they are controversial. However, there is plenty of evidence that children respond well to factual information in these areas if they are given it, but they need the information much earlier than it is provided now.

Teenage pregnancy needs to be tackled in the same way. These essential areas cannot be left to the discretion of heads and school governors. Parents should not be permitted to remove their children from this important part of education.

The UK government should not condone the continued use of the Common Agricultural Policy to encourage the growing of tobacco and at the same time tell children that it is bad for them. Messages in respect of drugs of all sorts need to be clear, factual and unambiguous.

Schools are not islands in themselves. Health promotion campaigns in schools alone are ineffective. Home and community influences must also be acknowledged, as well as the media – films, television and pop culture. Tobacco control should extend to banning advertising and product placement in films and TV. The age at which young people can buy cigarettes should be raised to 18, and the penalties on shops that sell to the under-18s should be more punitive.

Schools should be seen as community assets and be available for dual use, and they should funded to take account of this.

Serving local communities

Local health services have a poor record in engaging with deprived communities. Too often they receive poor services, provided by unenthusiastic professionals who live far away in less deprived areas. Health services must work to develop local communities, and the public health role of nurses, midwives, health visitors and doctors should be enhanced.

Schools also have important potential in this area. There is a place for health in the National Curriculum and more efforts should be made to engage young people in debate about the future of their communities. Children who are excluded from school, often from very deprived families, should nevertheless receive a proper education.

Services for victims of domestic violence also need considerable development. And the importance of work as a determinant of health must not be overlooked. Although the number of people killed and injured directly at work has fallen considerably, there is a great deal of evidence about the importance of autonomy at work as an influence on health and mental well being.

Poverty

Poverty and disadvantage are the principal causes of poor health. The need now is to tackle poverty (including the impoverishment of educational disadvantage) systematically and over time. The attack on child poverty is very welcome, but the policy pressures across central and local government must be kept up to ensure that measures to reduce inequalities succeed. This is not a quick fix, and will need a sustained political commitment over many years.

Some key measures are absent, not so much of the outcomes, for example, life expectancy and infant mortality, but of the determinants, such as poor educational attainment, income inequality, and child and family poverty. Too often the drive for new initiatives gets in the way of sustained follow through on these key political and structural problems.

One key mechanism for local authorities and primary care trusts, as the population based bodies responsible for reducing inequality, is for a resource allocation formula that properly reflects not just market forces but also economic and social disadvantage. National and local government should assess policies in terms of the contribution they make to these issues. The many excellent local initiatives to tackle poverty and deprivation need to be accompanied by a more robust national redistribution of resources to reduce inequality. Income distribution monitoring systems should be established to monitor progress in reducing inequalities.

In many ways, the plight of people who are poor in otherwise wealthy areas is even more desperate than that of people in communities where deprivation is widespread. Most poor people know perfectly well what they must do to keep themselves healthy, but they lack the means to do so. Government initiatives in smoking cessation are to be applauded, and should be complemented with policies to tackle obesity and other diseases of poverty.

It is time for the UK to have a proper measure of income adequacy to demonstrate the government’s commitment to overcoming poverty. The government should fund research into the levels of minimum income needed to avoid poverty in both absolute and relative terms; and it should set up a working party to devise publicly acceptable measures that will ensure good health, social inclusion and satisfactory levels of child development for all. This information should be used to set benefit, pension and minimum wage levels. It should inform the practices of debt collectors and the courts. Policies that reduce income inequality and redistribute wealth are needed. Reducing poverty alone is not a sufficient goal.

The new primary care trusts, now the main commissioning and delivery units of the NHS in every area, must have the capacity to address the wider public health agenda around inequalities, health improvement, and partnership with local authorities, service users and their carers. Given shortages in key skill areas, such as health visitors, public health specialists, health promotion, and the emphasis that a clinically-led organisation may inevitably place upon health services, these wider concerns need to be addressed effectively. There is much that can be done to encourage positive involvement in the development of public policy and a healthy lifestyle.

Services for asylum seekers and refugees are much worse than those for the rest of the population. Asylum seekers in receipt of government funding should be entitled to the same health and welfare benefits as people on Income Support, especially free prescriptions and milk for small children, and for pregnant and nursing mothers.

Food

Poor diet plays a major part in the ill health of poor people. Initiatives to improve the consumption of fruit and vegetables in school are welcome, but there must be a far wider emphasis on tackling the poor nutrition that causes illness and premature death.

The epidemic of obesity, associated with poverty, that contributes to the development of diabetes and heart disease must be tackled. People must be encouraged to increase their physical activity and reduce their intake of calories. There is no other way to address obesity.

Many children in deprived areas never sit down with their family and eat a cooked meal. The introduction of choice into school meals has not been a success. It is not appropriate to allow young children to choose their own diet, faced as they are with an immense barrage of advertised junk food and very little alternative information. Sitting down and eating together regularly is an important part of education, and free school meals should be universally available. This could play an important part in ending child poverty. At present a high proportion of children entitled to free school meals do not take them because of the associated stigma. Children should be encouraged to drink water freely throughout the day. There is good evidence about the harm done by restricting the intake of water. School milk – which is subsidised by the European Union – should be available in all schools. Commercial schemes that encourage children to eat crisps and other unhealthy food in order to get benefits for their schools should be ended. Advertising unhealthy food to children should not be permitted. Children must be taught about healthy food and how to cook it. Food technology as taught in schools treats cooking as an industrial process. Cooking is an important skill in its own right and cannot be assumed to be learned in the home.

The government has a role in regulating the market, especially in the enforcing the labelling of food and drink. At present this is ineffective in communicating a clear message to consumers. The food industry, especially junk food producers and retailers, are part of the anti-health forces and need to be regulated and challenged. Alcoholic drink carries little useful information, even about potency. All food, especially unhealthy food, should carry simple, clear labels about the proportion of fat, sugar, salt and fibre, using words alongside percentages with simple messages such as “high in salt” or “low in sugar”. Information about cooked food in restaurants and take-aways should be available, especially where the food is a standard pre-packaged item. These can be related to dietary advice. Consumers have no means of knowing what levels of sodium or carbohydrate are healthy or unhealthy. Misleading labels – such as “80% fat free” – should be banned. Advertising of unhealthy foods to children should be stopped by, for example, regulating advertising during children’s television. Making health claims based on the addition of vitamins to fundamentally unhealthy concoctions of processed fat and sugar should not be allowed. The Common Agricultural Policy subsidy of sugar production should cease.

There is evidence that poor health and nutrition of pregnant women causes health problems for their babies throughout their life. Young single pregnant 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, and policies put in place to assist them to consume healthy food.

Local health improvement and community plans should monitor and address food inequalities.

Dentistry

Inequalities in dental health are even more marked.

It is imperative that the government ensures fluoridation of the water supply at the earliest opportunity. Fluoride is a natural mineral, not a mass treatment, and a very effective way to reduce dental health inequalities and preserve teeth into old age. People in the West Midlands have benefited from this for the last 30 years. If the 50 largest cities in the USA can manage this intervention it is difficult to see why the UK cannot.

The SHA also recommends a move away from the system of paying dentists according to the number of teeth they fill.

Health Services (Questions 7-14)

Funding for both the NHS and local authorities should be distributed across the country according to need rather than historic spend. It is quite apparent that the weighting according to need at present is insufficient.

Social services

Social care cannot be considered separately from health care. Greater co-operation between the NHS and local authority social services departments is essential, since this can only lead to a better and more efficient service to the public. Much needs to be done before the service could be described as seamless. However, the development of a seamless service through social care trusts or other formal partnership arrangements must not be at the expense of democratic accountability through the local electoral process. Social care should be paid for out of central taxation.

The poor image of social workers has become acute, and the government does not appear to be addressing this. The first national advertising campaign promoting a positive image of social workers seems to have had little impact. There should be regular campaigns to counter the low morale of social workers and the negative and frequently unfair media coverage they receive.

Social and personal care, together with community health services, contribute greatly to keeping people out of hospital by supporting them in their own homes. However, lip service only is paid to carers. They also need to be properly resourced.

Services in the community are rationed in a way that would be seen as outrageous in acute health services. It is just as much a priority to ensure, for example, that people with disabilities are able to get in and out of their homes as it is to ensure that they do not have to wait for an operation.

Much lip service is paid to the idea of a whole systems approach, but there is no evidence that substantial changes in approach are being delivered. Far from being seamless, services are full of darning and are frayed at the edges. Many more resources should be allocated to services that keep people in their own homes, and in the absence of a great increase in available funding, this means reducing resources for hospitals.

Choice

The importance of patient choice can be overstated. Most patients neither have nor want choice most of the time.

What are these choices? In a league table, who chooses anything other than number one? In the areas where informed choice is a real option, such as choice of GP, patients need more information as well as more capacity before they can exercise choice. In some care areas, such as midwifery and mental health, it is important to develop fewer medical options. Informed patients are already demanding this. At present it appears that some consultants are thwarting the development of alternative care options.

If choice is to be developed, far more detailed information at every level of care must be there than is yet available. And choice demands excess capacity. The NHS is some way away from being able to provide even sufficient capacity, so it seems unlikely that this excess capacity will be available in the near future.

Regulation

The establishment of a framework for clinical governance is an important achievement and is very welcome. However, the reduction of dramatic risk should not be emphasised at the expense of more significant insidious risks. No human activity is without risk, and there is no point creating expectations of an NHS that operates without any mishaps.

The regulatory framework for the health professions must become easier to understand. The creation of one organisation to regulate health and social care, both public and private, is welcome. It should involve patients, carers and lay people extensively in its work.

Professional standards should be expressed clearly and simply so that ordinary people can detect when they are not being met. Both the standards to be met and monitoring reports should be publicly available. Users should lead the evaluation of service delivery in both health and social care. Managers should have a key role in developing the involvement of users and carers.

The move towards national performance figures is welcome, as it will bring to the public some indication of how effective services are. It should be recognised, however, that the collection and measurement of service delivery data has increased bureaucracy within social services departments. It is to be hoped that performance indicators are no longer subject to regular change, in order to maintain stable and consistent measurements.

Private Finance Initiatives

Public money must be available for capital investment whenever it can be shown to be more cost effective than PFI alternatives.

There is no reason why public borrowing is inappropriate to fund capital schemes. PFI is presented as the only way forward, when arguments fail utterly to convince that there is anything to be gained from PFI in the NHS that cannot be obtained more cost effectively by traditional funding.

Where PFI schemes are seen as the answer, the government should publish the criteria, explaining clearly why this is the best option. The criteria should focus on the following questions, which should be answered satisfactorily before any more PFI schemes are agreed:

• What time frames are built into the planning and tendering phase of PFI schemes?
• Will PFI schemes come in more on time and closer to budget than those that are conventionally financed?
• Over the length of the contract, are PFI schemes cheaper to run, and do they provide better value for money?
• Do PFI schemes offer greater or lesser flexibility in service provision?
• In what circumstances do PFI schemes improve the quality of care?
• Can PFI schemes demonstrate accountability to the local population?
• Will the land and building become private property some time in the future?
• Is there a genuine transfer of risk to the private sector that justifies introducing the profit element?

There is a great danger implicit in concentrating too many expensive and not very effective services in shiny new hospitals and neglecting primary care, which is much more cost effective. It is dishonest to present hospitals as the solution to the health needs of the population.

Primary care trusts must be encouraged and enabled to move the pattern of service delivery away from hospitals by improving primary care and community services. PFI arrangements that prevent this transfer should be avoided. Services should be provided at home if possible, and in hospital only when absolutely necessary. However many hospitals are built, people will still die in the end.

Contracting

People do not want anyone to make a profit out of their illnesses.

No one should have any incentive to prolong anyone’s stay in hospital, nor to subject any patient to treatment that is unnecessary. So where is the sense in employing private contractors to do for the NHS what can be done better by in-house NHS staff? Competitive tendering hived off cleaning, catering, laundry and other support services. The result was filthy hospitals, poor quality food, more hospital acquired infections, and an inability to control these essential services.

Contractors make profits by reducing the terms and conditions of the lowest paid staff, many of whom are black or female, whose own health suffers as a result. If the government is introducing contractors because NHS terms and conditions of employment are not sufficiently flexible, then it is those terms and conditions that should be renegotiated.

The SHA does not support the use of the private sector in the UK to reduce waiting lists unless there is some very compelling local need, since it is undertaken by the same surgeons and staff who undertake this work in the NHS sector. It is precisely those surgeons working in both the public and private sectors who have an interest in keeping NHS waiting lists long.

The SHA has considerable doubts about the standards of safety and effectiveness in private medicine. The SHA does not object to bringing staff in from Europe, nor to sending patients abroad for treatment, but if money is available for such exercises, it might be better used to enlarge long term capacity within the UK. Experience shows that it is often not a shortage of clinical staff that limits capacity, but the operational problems within a health economy that need to be addressed.

The Mixed Economy

If it is thought desirable to develop a mixed economy in healthcare provision, then there are many interesting initiatives in the voluntary and not-for-profit sector that can be developed.

However, terms and conditions of employment in some of these organisations are poor, and this affects the quality of the service they can provide. If contracts with these organisations are priced such that it is impossible to fund a decent pension scheme, for example, then staff are unlikely to stay in the long term. However, voluntary and not-for-profit organisations can often be more responsive than the NHS both to the needs of patients and to the local community. There should therefore be a greater focus on organisations that provide health care and employ local people, but these bodies must also be open and accountable.

The proposed foundation hospitals appear to have many features akin to pre-NHS voluntary hospitals, and can potentially fragment services and recreate the discredited internal market. The freedoms proposed for them will damage nearby NHS institutions. It is difficult to see how they can be democratically accountable to their local population, and if they are answerable neither to the local population nor to the Secretary of State then they will effectively have been removed from the NHS.

The SHA does not want to see the introduction of local pay bargaining, nor any other mechanism that will increase inequalities in healthcare. The SHA would like to see proper regulation of the nursing and other agencies that make immense profits out of NHS and social care staff shortages.

NHS Direct has great potential and should be linked to patient held electronic records. Serious investment in information technology will enable NHS Direct to become the front line of the whole health service. But the government must ensure that the money is spent on the technology and training, and not set targets that so ambitious that they cannot be delivered. With broadband connections, a great deal of monitoring currently done in hospital could be done at home.

Staffing

Good staff management depends on engaging with staff, developing their vision and experience of health and social care, and providing them with the necessary resources. Current staff turnover rates demonstrate that this has yet to be achieved.

The SHA welcomes greater involvement by service users in the planning and delivery services. Current examples of good practice include consulting service users on the design and adaptation of buildings, involving service users and carers in recruiting and interviewing health and social care managers and professionals, and in staff training.

The importance of teamwork and flexibility cannot be over-emphasised. Money on its own is not going to raise the morale of health professionals. They are suffering from overwork and too much change. They do not feel valued, especially by politicians. They complain that they spend too much time on pointless bureaucracy, and too little time on those elements of their work that actually make a difference for patients. They feel that the NHS has become dehumanised. That is why so many of them want to leave.

What is needed is more multi-professional education and training. The professional hierarchy is a real obstacle to flexibility and modernisation. There is a lot of scope for other staff to do more, and relieve the burden on doctors.

Doctors need to be persuaded in some cases to let other staff operate more autonomously. Patients will never learn to trust the judgment of a physiotherapist, for example, if s/he always has to ask the doctor to authorise any change in approach

Professional staff also need adequate administrative support. There is no point in putting them through ten years of expensive training and then expecting them to do their own photocopying, or share a secretary and a small office with six others. If there isn’t a ward clerk then the nursing staff have to do the administrative work. The drive to reduce the number of administrative staff is counterproductive.

The NHS should be using refugee doctors who are already here, not enticing doctors from poor countries who don’t have enough to serve their own population. There is a need for training and validation systems that are flexible enough to use their talents. Medical students who arrive from the Third World as refugees before they have qualified are given no credit if they want to continue their studies. Employing people who have relevant language and experience would be a great asset in city areas with large refugee populations and skill shortages.

Issues around institutional racism must be tackled immediately. There should be a concerted and continuous drive to recruit staff from deprived areas, and from black and minority ethnic communities. Large teaching hospitals are often sited in deprived inner city areas and have many minority ethnic patients and support workers, but very few qualified professional staff drawn from the local population.

The provision of starter homes and cheap accommodation is unlikely to have a significant impact on the shortage of skilled labour in London. Housing subsidies and weighted salaries will be counterproductive because they will feed housing market inflation. The real solution is to increase the supply of housing, especially for rent. It may also be necessary to consider providing some elective health care for the capital in areas where unemployment is higher and labour cheaper.

National pay bargaining should be retained, and it would not be desirable to provide further subsidies to the South East.

Reorganisations

Ministers underestimate the disruption caused by structural change, and should announce as a policy that there will be no more significant changes for at least five years.

When reorganisations are proposed, they should be tested first to demonstrate that they will deliver real benefits. Too often ministers give the impression that they want to be seen to be doing something. Initiatives such as foundation hospitals are announced peremptorily and without detailed explanation. If the staff required to introduce these changes cannot perceive the benefits of the change, they are unlikely to be motivated to make them work.

There is now considerable evidence that attempts to drive an organisation by setting multiple targets are not effective in a complex organisation like the NHS. To achieve real improvements, some organisational stability is required. Organisational change in itself has no electoral effect. Even active Labour Party members have yet to absorb the impact of five years of organisational change in the NHS.

Authorities and trusts protest, with some justification, that so much of their budget is earmarked that they are prevented from addressing local issues. The government must address the tensions between local autonomy and national imperatives, and the problem when large sums are announced at the centre that do not reach the front line. Significantly increased funding and new targets have been announced, but much of the money has been ploughed back into overspends.

If decision-making really is to be decentralised, then local communities must be permitted to make their own decisions about their own local priorities. There should be fewer national targets, with greater local discretion as to how they are to be achieved.

It is also vital that long-term preventive work is not crowded out by too many immediate imperatives.

Accountability and Democracy

There is little local democracy within the NHS, and the potential of overview and scrutiny committees and the role of the Patients’ Forums must be developed. Neither initiative can fulfil its potential within the limits of the resources currently proposed.

Every local scrutiny committee must have the right to call to account any part of the NHS that provides services to its population and any private contractor that is commissioned to provide services for local NHS patients. This right must extend to private contractors such as GPs, general dental practitioners and pharmacists.

The experience of patients who live far away from, for example, a tertiary service provider, may be entirely different from that of those living nearby. Local scrutiny committees must be allowed and encouraged to inspect services from the perspective of all patients if they are not to be dominated by the interests of local providers and users.

The provision of advocacy services and assistance with the NHS complaints procedure must be effective, independent and adequately resourced. These services should also be available to patients who do not wish to use the formal complaints procedure. Providers of independent advocacy and assistance should be integrated within the local Community Legal Services Partnership.

The role of non-executives on trusts, health authorities, and other health service quangos is not clear. Many NEDs are Party members and more use could be made of them, especially with the new proposals for training. It is also important to provide greater support and to improve the current selection process to achieve the necessary diversity of public representatives.

In the longer term, both health and social care should be under the democratic control of regional government. That would permit the abolition of health authorities, as has happened in Wales.

Acute and primary care trusts can never be accountable to their local populations unless information about their operation is easily available to everyone. At present many do not even have a simple website advertising their achievements, their board meetings and their public and user involvement opportunities. The Internet is a very cost effective way of producing information in an accessible form, and this should be a priority for all trusts.

A break should be placed on the amalgamation of acute and primary care trusts. Many of them are already too large to relate to local communities.

Negotiation and debate around trust funding and service priorities – the Service and Financial Framework (SaFF) process – should be open and public. At present much of this is undertaken behind closed doors and is not in accordance with the principles of open government.

Many psychiatric services are still very poor. There are many mental health issues beyond those around risk that need addressing. The government seems currently to have united every organisation in the mental health field in opposition to the Mental Health Bill, and must pay greater attention to the responses it has received. 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.

Charging

The SHA would like to see a major debate about charging policies. This should encompass not just the recommendations of the Royal Commission on Long Term Care, but the wider health and social care distinction in respect of intermediate care, and also domiciliary care charges and the perverse incentives they can produce.

The Wanless Report demonstrated that charging at the point of need as a method of financing healthcare is most unsatisfactory. Dental, optical and prescription charges are a normal part of most working people’s dealings with the NHS, and can be a significant part of a week’s disposable income of those on low pay.

The SHA recommends serious reconsideration of the current practice of additional charges for second and subsequent prescribed items. Moving to a flat fee for a whole prescription would reduce the cost of the associated bureaucracy. Charging for dental and optical tests is misguided and counterproductive. There are also issues around the provision of better but more expensive aids for people with disabilities, such as digital hearing aids.

The way forward

It is time for the both Labour Party and the Labour government to reconsider the notion that the only help that can be provided by the NHS is what was available to the population in 1948. It should not be done this way just because it was always done this way.

Submission to Britain in the World

1. Simple public health measures will make immense differences to many people in the poorest countries. Probably the most single effective measure is the provision of clean piped water. Efforts should be directed in this way rather than in the provision of expensive medical solutions which can only assist small numbers of people.

2. Aid should be delivered locally on a small scale where possible. Encouraging links between local community groups in this country and local groups in recipient communities will reduce the possibility of corruption and encourage political and human awareness.

3. Vaccination against malaria and AIDS is potentially of enormous significance and should be pursued vigorously.

4. Recruiting staff for the NHS from poor countries does nothing to help their health systems unless what is arranged includes returning staff trained with new skills.

5. British rules on the recognition of overseas medical qualification appear to have strong racist elements and are in urgent need of review.

6. Refugee doctors and health professionals should be given financial and practical assistance to help them practice in this country and when possible to return to their countries of origin.

7. Subsidisation of food production in the European Union makes no economic sense and damages the economies of less developed countries. It should be stopped.

Submission to A Modern Welfare State

1. Work is the best form of welfare, but not everyone is able to work. It is time the Government addressed some of the problems in the benefit system for those who cannot work.

2. The decision making system in relation for incapacity for work and assessment of disabilities is badly administered. Information about the medical situation of claimants too often does not reach those who are making decisions about their benefits. Claimants appear to be expected to pay their doctor a fee to supply information about them which has been gathered in the course of the doctors work for the NHS.

3. The benefit system is riddled with age discrimination. On reaching the age of 60 a person on means tested benefit is awarded £98.15 just for being alive where the week before they apparently needed only £53.95 to live on and were required to actively seek employment in order to be permitted to qualify for it. People under the age of 25 only need £42.70 a week. That is not enough to live a healthy life. However we pay an allowance to people who cannot walk if they are under 65 but anyone over the age of 65 is no longer expected to be able to walk.

4. Benefits for pregnant unemployed women are set at a level below that necessary for health. There is good evidence that poor diet in pregnancy contributes to poor health and premature death for the whole of a baby’s life. There should be an extra premium for pregnant women in the means tested system.

5. The Social Fund was attacked by labour in opposition but has been left largely unchanged. The poorest people are left in the hands of loan sharks and have to pay more for basic necessities like gas and electricity than rich people.

6. Debt enforcement procedures and the criminal justice system in relation to TV licences and parking fines make a significant contribution to the impoverishment of the most excluded sections of the community. It is time for the UK to have a proper measure of income adequacy to demonstrate the Government’s commitment to overcoming poverty. The Government should fund research into the levels of minimum income needed to avoid poverty in both absolute and relative terms; and should set up a working party to devise publicly acceptable measures of such levels in order to ensure good health, social inclusion and satisfactory levels of child development for all citizens. This information should be used to set benefit, pension and minimum wage levels. It should inform the practices of debt collectors and the courts.

7. Many services for poor people are delivered in appalling fashion and this contributes as much to the disadvantage suffered by poor people as does their lack of income. Thousands of poor and voiceless people are still suffering from the collapse of the administrative systems in Housing Benefit and Immigration. In each case the collapse has been caused by an obsession with abuse and fraud. There is no evidence that abuse is more common among the poor than among the wealthy. If the campaign against social security fraud is to continue it should be accompanied by posters urging the population to report their friends and neighbours for evading Income Tax, Inheritance Tax and VAT and for defrauding pension funds.

8. We question the usefulness of imprisonment for arrears of council tax, fines for absence of TV licence, parking meter offences, CSA maintenance and fines for all offences that do not carry a custodial sentence. Bailiffs should not be used until the courts have assessed the debtors means. Different parts of central and local government should share information about poor and vulnerable people.

9. The administration of benefits for asylum seekers is scandalously inefficient. It must be reviewed immediately.

10. The system of exemption from charging from prescriptions, glasses and other NHS services makes no sense. The administration of many of these systems, particularly that in respect of fares to hospital, is lamentable. It should be thoroughly reformed.

11. Further immigration is essential to sustain our economy. Immigrants should be welcomed. This island is largely populated by economic migrants. It is hard to see why such a designation should become a form of abuse.

Submission to Democracy and Citizenship

1. When Regional assemblies are established Strategic Health Authorities should be answerable to them.

2. The absence of any significant elected element in the governance of the health service is a significant weakness in our democratic structure which needs remedying.

3. Public health responsibilities should be transferred from the NHS to local government.

4. Commercial considerations should not be used to reduce public information about the handling of public money.

5. The commitment to involve patients, carers and citizens in the running of the NHS is very welcome but will take enormous effort to achieve