Socialism and Health The journal of the Socialist Health Association Winter 2004/05
A glass half full? A public health white paper we can (almost) be proud of…. At last public health is on the front foot and the SHA has given a guarded welcome to the government’s White Paper – Choosing Health: making healthy choices easier. And it is good to note how many proposals in the SHA submissions to the Big Conversation and the Choosing Health consultation appear in one form or another in the White Paper. Previous government papers have acknowledged the need for action on public health but little real action has followed. This time, an implementation plan to complement the White Paper is expected imminently. Three principles underlie the White Paper’s proposals: People will be helped to “choose” good health (with special arrangements to promote healthy living for children); Services will match the reality of people’s life styles; Partnership work will engage the statutory, voluntary, business and community sectors. Priorities for action are identified, which include: Reducing the number of people who smoke; Tackling obesity and improving health and nutrition; Promoting exercise; Encouraging sensible drinking; Improving sexual health; Improving mental health.
Within these priorities, certain groups within the population are to be specifically targeted to improve health and reduce health inequalities. These are: Children; People with disabilities; People with long term conditions; Young people. A number of national initiatives are planned, including: Health Direct to provide accessible, confidential information on health choices; Healthy Start, to give vouchers to pregnant women to buy fresh fruit, vegetables, milk and infant formula; SMARTRISK to warn adolescents of the risk of accidental injury; Healthy Eating awards for private sector caterers; the Community Parental Support Project to promote changes in parental behaviour; developing the Healthy Schools initiative and extending it to nurseries; establishing Teenage Pregnancy Partnership Boards in areas with high teenage conception rates; piloting Communities for Health partnerships on locally chosen priorities for health and inequalities; the Health and Well-being Equity Audit to support joint planning between local authorities and PCTs;
introducing Spearhead PCTs – those with the 20% worst health and deprivation indicators;2. funding a Young People’s Development Programme to reduce substance misuse amongst vulnerable young people; increasing the effectiveness of the NHS Stop Smoking services.
By and large the SHA welcomes the government’s proposals but notes that the White Paper focuses predominantly on one domain of public health – people’s individual lifestyles. It doesn’t address the important underlying determinants of health - such 3. as income, educational attainment, housing and social networks - that lead to health inequalities. It is also weak on the prevention and health protection domain that adds so much to the public's health through effective immunisation and population screening. The parliamentary Health Select Committee has given notice that it will undertake a short inquiry into the Public Health White Paper. It is particularly interested in: Whether the proposals will enable the Government to achieve its public health goals; 4. Whether the proposals are appropriate, will be effective and whether they represent value for money; Whether the necessary public health 5. infrastructure and mechanisms exist to ensure that proposals will be implemented and goals achieved.
Putting the Department of Health in charge of achieving the government’s public health goals is not advisable. The SHA stresses the need instead for a cross-government Cabinet Minister for Public Health with the authority to require all government departments to work to improve public health. The Department of Health has the responsibility to improve health care. Improving health is the responsibility of all arms of government and the leadership must be in place to ensure that they all play their part. The role of local authorities must be greatly strengthened. Indeed they should perhaps have the lead responsibility to tackle health inequalities, so the proposal to use the national PSA targets and local area agreements more rigorously is welcome. The SHA also recommends the appointment of Joint Directors of Public Health working for both PCTs and local authorities. This would “join up” scarce public health capacity and provide leadership for the Local Strategic Partnerships that should be in the forefront of the attack on health inequalities. It is welcome that the NHS is to become an exemplar employer, but this duty should be extended to all statutory bodies. The ban on smoking in all enclosed public places should be unconditional. The current proposals will impact adversely on those least able to choose health – employees and customers in bars and pubs located in disadvantaged areas of the country.
The SHA will be submitting a memorandum to the Committee and asking to attend the inquiry. This will be to raise matters the SHA feels still need to be 6. It is unlikely that voluntary agreements with the addressed. food and drinks industries will succeed. The damaging consequences of fizzy drinks and 1. It is not appropriate to treat health as a processed foods, such as obesity and diabetes, consumer good. The more privileged in society are well known; as are the adverse consequences have easier and greater access to consumer of alcohol abuse that include violence, crime, goods. If health is to be a consumer good, then it drink driving and social disorder. The food and is likely that the health inequalities between drinks industries have had sufficient time in richer and poorer people will widen, albeit that which to improve their products and amend the overall health of the population may also their marketing strategies but have failed to do improve. The rich and healthy are known to so. adopt healthy lifestyles more quickly than more 7. Children need more protection and support disadvantaged populations, evidenced by the than are outlined in the white paper; for increasing gap in life expectancy between rich example, the proposal to roll out the Healthy and poor.
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3 Schools initiative to all schools should be brought forward and made mandatory for all schools as quickly as possible.
implementation as it did over the last 3 weeks of its incubation when it appears it changed a great deal, seemingly for the better.
But I have to confess to being thoroughly underimproving mental health and well-being. Mental whelmed by it. The general view seems to be that it represents an important step in the right direction. well-being is an important factor in health inequalities and chronic mental illness leads to But having been in the public health trade since poor quality of life. Local government and PCTs 1970 I have seen too many such steps, which in the have a key role in promoting well-being that is end have not amounted to very much. currently restricted by insufficient resources and I was disappointed that Whitehall still sees public capacity. health mainly in terms of lifestyle and personal responsibility, whereas we now know that the so 9. Some of the proposed innovations – such as Spearhead PCTs and health trainers - do not have called wider determinants, particularly income and a firm evidence base. Data show that there are education, play a crucial role. In Wales we now more poor and disadvantaged people outside have the health, social care and well-being agenda, the Spearhead PCT areas than within them and which recognises that everything impacts on public work based on spatial and geographical areas health and well-being and that local authorities are the major local drivers. The Welsh vision for public will not address the issue of inequality systematically or sufficiently. Health trainers are health is more fundamentally socialist than the English one as, it must be said, it always has been. simply not evidence based and this initiative risks wasting resources. It is also important to On a more positive note I welcome the recognition pilot such proposals to ensure that they can fulfil their aims and do not have unanticipated of the importance of community development and outcomes that widen rather than narrow health of the school as a key setting for health promotion. Extra resources for tackling sexually transmitted inequalities. infections will undoubtedly help as will the 10. Finally, the SHA believes that government must measures proposed in relation to smoking, alcohol do much more to raise the level of debate about and diet. But the whole document is too timid. Our quite how unhealthy UK society is, utilising a proposal that serious consideration be given to examining the case for legalising the supply and use range of marketing strategies. of drugs was, unsurprisingly, ignored; presumably Judith Blakeman it is just too hot to handle with a General Election in the offing.
8. There is little in the white paper about
Or half empty …… a view from the Chair
The government is overly concerned about accusations of nanny statism and too attached to a consumerist driven market model for lifestyle change. It is true that our consumer society Defender of the Public Health generates the wealth that is so important to health and well-being. But it is evident that some sectors of and Well-being big business are entirely careless of the impact of their activities on health and well-being. Some The big event of the autumn was, of course, the long would say that they comprise anti-health forces. awaited English Public Health White Paper to which This might be going too far, but what the faint SHA contributed through a very detailed response hearts see as the nanny state is better conceived as to the preceding consultation paper. In fact it is not the defender state – our only protection against so much a White Paper as White with Green edges commercial forces that are too powerful for us to and was too late to be included in the Queen’s tackle as individuals. Speech. So we will have to wait some time for Paul Walker implementation and there is the possibility that it will change as much between now and
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WHAT DO YOU THINK ABOUT THE WHITE PAPER? Let us know by writing to: The Editor Socialism & Health 50 Wesley Square London W11 1TS or by e-mail to: firstname.lastname@example.org
Growing from the Roots: PPIFs demand a national voice The SHA event Growing from the Roots: Patient and public involvement after CPPIH (the Commission for Patient and Public Involvement in Health, which will shortly be abolished) was held in London on Friday 3 December 2004. A significant number of members of local PPI Forums were present and the quality of the debate and discussion was high.
Malcolm Alexander, former director of the Association of CHCs of England and Wales (ACHCEW) and now chair of the London Ambulance Service PPI Forum, said that the issues centre around power and bureaucracy and developed his presentation around these themes. Sally Brearley, of Health Link and a local PPI Forum member, questioned the absence of any comment from CPPIH during the recent debate around the NHS Chief Executiveâ€™s annual report on the state of the NHS and contrasted this with the last national Casualty Watch by ACHCEW, when its Director was on national TV and its Vice Chair on local radio across the country. She said that if the push for the present arrangements return to the CHC style, this is not because of the influence of former CHC people but because PPI Forum members want to create something that is effective. To do this, they are learning from the past. Hilary Barnard is the chair of the Camden PCT PPI Forum and is an organisation consultant working in the areas of care, learning disability and mental health. He spoke of his perceptions, experiences and disappointments as a PPI Forum member and stressed the need to manage intervening pre- and post-CPPIH period effectively.
The event was chaired by Martin Rathfelder, Development Director of the SHA and the speakers were Christine Hogg, formerly of the Department of A full report from this event can be found at Health's Transition Advisory Board Advisory http://www.sochealth.co.uk/confs/PPI.htm Board, Caroline Powell of Picker Institute Europe, Elizabeth Wincott, Chair of the Long Term Medical After the event, participants and others have drawn Conditions Alliance, Malcolm Alexander of the up and signed the following statement, which is to London Ambulance Service PPI Forum, Sally go to the Department of Health and to CPPIH in Brearley of Health Link and Hilary Barnard, Chair time for its next board meeting on 20 January. If you of the Camden PCT PPI Forum. wish to sign or otherwise endorse this statement, please contact Martin Rathfelder. Christine Hogg, who facilitated the Department of 1. Whatever organisation succeeds CPPIH Health's Transition Advisory Board that considered should be organised from the bottom up. arrangements around the abolition of community Any national or regional organisation shall health councils, gave an overview of the present be accountable to forums, not the other way situation and the consultation currently being run around. Forums should have control over by the Department on the future arrangements for their own budget and resources. Decision patient and public involvement in health when the making at all levels must be transparent. CPPIH is abolished. The Picker Institute Europe runs the Patients' Survey - Through the Patient's Eyes and Caroline Powell gave an outline of the findings from the surveys that set out what patients really want from their healthcare services.
2. The present consultation run by Opinion Leader Research neglects a number of important issues, which need to be decided.
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5 reflects and respects diverse experience coming together to create a national body. established as soon as possible so that they Martin Rathfelder and Judith Blakeman may meet and collectively have a voice in their own future organisation. In the longer term it is important for a national CPPIH and PPI: ignore the organisation to be established which is democratic and accountable and can speak chatter, acknowledge the facts for patients. A national association has much and get on with the politics to contribute to supporting an effective National Health Service to all communities Sharon Grant and Jennie Popay, Chair and Vice Chair of the Commission Patient & Public Involvement in in the UK and to good healthcare service Health, respond to the letter in the last edition of delivery at local level.
3. Forums need a national organisation to be
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4. Among the issues that need to be considered in future is the relationship between PPIFs and Overview and Scrutiny Committees. Forums should develop a partnership approach to their work involving other organisations with an interest in health. Forums should be encouraged to work together and with Scrutiny committees.
There is much chatter on the left about the recently announced abolition of the Commission for Patient and Public Involvement in Health after a mere 18 months of life. So what are the facts?
In the face of a government determined to abolish CHCs, the Commission was a hard won victory for all those who believe that there must be an independent voice for patients and the public in 5. Any centre of excellence which is established health decision-making, both locally and nationally. could be directed by and accountable to the The combination of a national, local and regional proposed National Association of Forums. presence with rights and responsibilities enshrined in legislation had the potential to counter the 6. We have grave doubts as to whether the enduring barriers that have over decades prevented NHS Appointments Commission is a the development of authentic and effective suitable organisation, as it presently involvement of lay people in the public sector. operates, to recruit members to forums who Prominent amongst these are the powerful vested are sufficiently diverse to reflect the interests of managers and professionals and an populations they serve. It is crucial for organisational culture characterised by risk aversion Forums to be representative of a diversity of and defence of the status quo. people from different backgrounds, particularly under-represented groups. The Commission was charged with setting up Forums should be enabled to assist in independent Forums of local people for each of recruitment in order to tackle this problem England’s 572 NHS Trusts, and representing their effectively. views at a national level. We were required to do this to a demanding timetable – within 11 months of 7. We request CPPIH or the Department of start up – and on a budget that was widely Health to fund a national conference to acknowledged to be inadequate to support the which all PPIFs are invited to send delegates many ministerial promises made in the heated without delay. If CPPIH is not prepared to debates surrounding the Commission’s founding do this we propose to organise one legislation. ourselves. This conference shall consider these issues together with any other matters Despite all the difficulties, including Minister’s pertaining to the future organisation of demand that we bring forward the establishment of Forums and patient representation in the the forums by four months, with their initial 5,000 NHS. The event should belong to Forums plus members, we did set up the new system by from the start. The event needs to be December 2003. The logistics were challenging to organised in a transparent way, which say the least, with hundreds of Commission staff across the regions, and contracts to provide the
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6 essential support for the Forums, put in place in record time.
healthcare and public health issues and allow their collective voices to be heard at local, regional and national levels. Like other organisations with a It is not true to say that the Commission spent too healthcare and public health remit the new PPI much on central administration. Our budget in our system has to develop mechanisms to ensure that first year was ostensibly £33 million. However, £8 the wider public health concerns do not become million was retained by the Department of Health marginalised by the role in monitoring healthcare. to support the Community Health Councils in their The Commission was intending to support the last year and a further £3.2 million to manage the establishment of a broad ‘Our Health’ network new complaints advocacy service leaving a budget within local areas. This would have given the Forums a popular base from which to recruit and of £21.8 million to set a new organisation from with which to engage and a means for maintaining scratch. a focus on the social determinants of health. One of the major challenges facing the new Commission was to decide how to provide support Perhaps the most important but difficult challenge we have faced is how to shape and influence the for the 572 Forums required by the legislation within the budget available in our first year. In our culture of our new organisation – for culture is not something that can be ‘established’ in the direct way view the Forum Support Organisations were an that is possible with other aspects of organisational innovative and courageous response to budget constraints which aimed to link the new structure form. Even in relatively straightforward organisations, the cultural context and its into the wealth of experience and expertise of involvement and engagement built up over many relationship to other aspects of an organisation will be complex. In CPPIH this complexity is arguably years in the voluntary and community sectors. unparalleled in the public sector. As an Over half of our first year budget - £12 million - was organisation we are a combination of paid employees and volunteers working alongside a rich spent on setting up these forum support diversity of community and voluntary groups organisations – many of them located in local delivering support to the Forums. The Forum voluntary groups - and recruiting 400+ staff to provide support to the fledgling forums. £2 million Support Organisations have their own cultures and as they develop, so too will the local Forums. The was used for the campaign to recruit forum newly appointed staff within the national and members, which involved a genuine attempt to bring in people who had little if any previous regional offices also came from very diverse experience of involvement in the public sector. backgrounds in terms of the organisational cultures Establishing and running the central and regional they were used to operating in. offices cost around £8 million in our first year. In our experience of public life the composition of We have not yet completed a second year so we CPPIH’s board is also exceptional with the strong can’t yet report fully on how the distribution of presence of people with considerable experience of expenditure between local, regional and central active involvement as patients and lay people in elements of our structure has changed. However, health decision making. They bring a rich cultural once we realised that our annual budget would not heritage as well as a passion to their work. And last be significantly increased – as we had hoped – we of all CPPIH is accountable to the Department of made strenuous and successful attempts to increase Health – a formidable cultural presence in our short the proportion of the budget going directly to the life! It is far too early to describe the cultural fabric Forums. We were and remain unapologetic about of CPPIH with any degree of precision or accuracy. our decision to continue to support a significant As we have worked to put in place systems for regional and national presence as we believe that governance, accountability and delivery in this this is essential for effective involvement and complex and dynamic environment many cultural engagement of people in health related decisionand political forces will have been operating – some making. more controlling some more enabling. How the balance between such tendencies would have A second challenge for CPPIH was to design a evolved as the organisation matured we will never system that would enable Forums to focus on know.
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7 the reduction of health inequalities still figures in It is of course the outcome of all this activity that is the Department’s ‘vision’. However, given that ‘Our Health’ will not now be developed, it remains important. Only a fool would suggest that the empowerment of patients and the public could be to be seen whether the new arrangements will cause achieved in 18 months. The exclusion of their voice the public health role of PPI Forums to wither on the vine or to grow and mature in the context of the is a consequence of centuries old processes and new White Paper. hierarchies, now firmly embedded in the public sector and which have been remarkably resistant to change. They will take time, energy, ingenuity and In the meantime the commitment of the CPPIH considerable political commitment to reverse. The Board and staff is to maintain continuity of support Commission has made enormous efforts to include for the Forums over the transitional period and to traditionally excluded groups in forum membership seek to ensure that the new arrangements for the but much still needs to be done to ensure that the appointment and training of Forum members; for Forums reflect the diversity of the communities theyproviding support for Forums; and for the serve. Additionally, it was always going to take management of their ‘performance’ retain the time for Forums to get to grips with exercising their principles of independence, authenticity and new powers and continued thought must be given diversity that are fundamental to the new system of to the way in which they can be best supported to PPI. We believe that it is also vital that the new do this. The signs are promising, as the Forums arrangements recognise and support the voluntary begin to get down to their work. Now that the set nature of PPI and allow the Forums to develop their up months are over, some 85% of Forums tell us own interpretation of good governance, rather than they are pleased with the support they are imposing from above a more traditional receiving. bureaucratic model. Finally, we believe that it is imperative that the new structures provide an There is much to play for in the months ahead as effective and independent means for the Forums to the government and their civil servants decide on get their collective voice heard at a national level. the organisational forms to be put in place for There will always be those who will claim that the delivering many, if not all, of the functions CPPIH Commission has failed in its task – although it is was set up to fulfil. Some understanding of the clear that many of these critics simply fail to factors that led to our abolition and of the complex understand the complexity of the task we were issues the new organisation has been grappling charged with. Our main regret is that the Board with may help here. But this will only come from and staff of CPPIH are not now going to have the careful reflection and analysis, not from the ill opportunity to try to deliver our vision for PPI – informed, sometimes vindictive and often self and it was an ambitious one. To some extent it was serving commentary emanating from some ever thus in public life! Despite the uncertainty and quarters. The demise of CPPIH is a victory for no the regrets, one thing is certain. Assuming that we one – save perhaps for those who pooh-pooh the are allowed to - and despite some personal notion of accountability in health and health misgiving about the alternatives being proposed – services. we will stay the course to do whatever we can to ensure that the new arrangements are consistent with the development of a more authentic and The Forums are to remain, we are told, but as yet sustainable system of PPI in both healthcare and the infrastructure for their support is unclear. At public health into the future. our insistence, the Department of Health is currently conducting a consultation exercise with Forums and key stakeholders with a view to determining the shape of PPI in the future. It is to be Great minds think alike? hoped that many Forum members will have their say. The Department has also produced a position The Local Government Association, the NHS paper setting out their expectations of the future Confederation and the UK Public Health role of Forums and the ‘givens’ in the new Association have recently published a paper arrangements. From a public health perspective it Releasing the potential for the public's health – that was good to see that the wider role of Forums in supports the SHA’s longstanding contention that contributing to population health improvement and
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8 there should be a Secretary of State for Public Health in the Cabinet. This Cabinet minister would have cross-departmental responsibility and the Chief Medical Officer would be jointly accountable for health matters to the Public Health Minister and the Department of Health. Primary care trusts and local authorities should also have a strengthened role and responsibility for public health, so all should have co-terminous boundaries.
cessation services, monitor blood glucose levels, help people to manage common complaints and generally promote healthy lifestyles. They will be able to work with GPs on repeat prescriptions by reducing the number of times the patient will have to return to the GP. Patients will get just the one prescription for up to a year, and the pharmacist will be able to dispense it in instalments. Pharmacists often point out that they are an underused resource in the NHS. The new contract, The three bodies argue the need for a radical change if approved, will help them to work more closely in the way public health in the UK is addressed and with primary care professionals and, with the promoted. They believe that government should support of their PCT, provide better services to local move away from its focus on hospital treatment to a residents. broader approach that tackles the root causes of ill- A new approach to monitoring health, including poverty, housing, diet and social healthcare inequalities. Because local councils play a key role in many areas affecting public health, such as The Healthcare Commission wants comments on education, sustainable development, housing and how it should assess healthcare in both the NHS transport, they are urging government to give local and the independent sector after 2005. authorities and local communities more control over public health issues, with sufficient resources The Commission has published a consultation to drive health improvement in a way that best suits document setting out one proposed approach that it local needs. The report reiterates the facts that only hopes will monitor the things that matter to 25% of the variation in health is due to the quality of patients, the public, clinicians and managers. The healthcare services, the other variations being 50% emphasis is on improved outcomes within the due to socio-economic differences, 15% to biological context of the new targets and standards for inheritance and 10% to environmental factors. healthcare set by government. It is encouraging to note that the Local Government Association in particular endorses the SHA’s stance on public health. Perhaps in time it will also take that extra leap and recognise that democratically elected primary care trust boards that work in partnership with democratically elected local authorities is the best way to tackle health inequalities within local communities.
Pharmacists to develop their healthcare remit Pharmacists are being encouraged to vote “yes” for a new contract that will enable them to extent the range of services they offer to their communities. Under the new contract they would no longer be rewarded for the amount of medicines they dispense but for the range and quality of their services. If the new contract is accepted, the new arrangements will start in April 2005. This means that pharmacists will then be able to check people’s blood pressure, offer smoking
Do you believe that healthcare organisations are getting things right? How should they develop and improve in the coming years? How can the Commission inspect healthcare providers effectively but without unnecessary disruption? How should the Commission co-ordinate its work with the other bodies that inspect and regulate the NHS? If you wish to join in this discussion, the consultation document is at: http://consultation.healthcarecommission.org.uk/ download/Exec%20summary.pdf
Moves towards fully-funded NHS care The problems faced by disabled and elderly people in getting NHS funding for long term care are highlighted in a new report from the Health Service Ombudsman, Ann Abraham, that was published on 16 December. This is the long term package of care that is arranged and funded solely by the NHS for people who need it because of disability, accident or illness, which is provided in a care home, the patient’s own home or in hospital. The report is
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9 based on evidence gathered from almost 4,000 complaints received since the publication of a first report on the subject in February 2003.
local level to help patients get the funding to which they are entitled. Other recommendations include developing accredited assessment tools and good practice guidance; supporting training and The Ombudsman believes that, from the patient’s development to expand local capacity so that cases point of view, applying for funding for long term are assessed and decided properly and promptly; care has been a lengthy and sometimes hit and miss and improving record keeping and documentation. Age Concern has called for clear assurances that process, causing real hardship for a number of there will be a full consultation and that the system disabled and elderly people and their carers. She will be improved as a matter of urgency to stop wishes to be assured that no-one has been wrongfully denied NHS funding for long term care older people being penalised by a failing care and that the lessons learned from the current review funding system. of cases are used to make sure that open and fair procedures are put in place across the country.
Letter to the Editor
In anticipation of the Ombudsman’s report, the Department of Health has said that it is to develop a Michael Howard and the Tory party have had a brilliant nationally consistent approach to assessment for idea for the NHS. They will get rid of the civil service fully funded NHS continuing care. The Health managers (pejoratively called "bureaucrats") and have Minister, Stephen Ladyman, said that his the NHS run by the doctors and nurses, and also get rid Department will work with the Strategic Health of targets for waiting times etc., etc. So doctors and Authorities. Learning from good practice and the nurses can spend their time at meetings instead of with findings of an independent review, they will patients and the waiting times will escalate. This of produce a national approach to improve course will favour their friends in the private sector who consistency and make the process easier to will stand to benefit and are currently feeling the pinch understand for practitioners and patients alike as waiting times are dramatically reducing under the government's targets. I hope people will understand the The Ombudsman’s report makes six key import of their policy. recommendations that point to the need for national minimum eligibility criteria; a national set of Derek Marcus Potters Bar assessment tools; and the right skills and capacity at
Central Council Central Council meets next on Saturday 19 March at Wesley’s Chapel, City Road, London EC1 (nearest station is Old Street, exit no. 4), commencing at 12 noon. Doug Naysmith MP will lead a discussion on the SHA and the forthcoming General Election. All SHA members are welcome to attend.
SHA BRANCH CONTACTS Greater London: Greater Manchester: North East: Scotland: Wales: West of England: West Midlands: 0
Huw Davies Martin Rathfelder Rita Stringfellow Ali Syed Anthea Symonds Paul Walker John Charlton
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Contact the SHA Do you have a point of view? The pages of Socialism & Health are open to everyone. All letters and articles will be considered for publication. And the SHA welcomes any other expertise or help you can offer to ensure that the SHA remains a dynamic and respected campaigning pressure group in the 21st Century.
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Socialist Health Association E-mail: email@example.com Website: www:sochealth.co.uk Editor: Judith Blakeman The views expressed in this journal are not necessarily those of the SHA