Socialism and Health, the magazine of the Socialist Health Association 2007 no 3
Gordon Brown’s leadership speech Inside this issue: Heeding History
A First Class National Health Service for Everyone
Should Patients be given choice?
Health policy Challenges
Patient and Public Experience
And let me say also that in the fourth richest country in the world it is simply wrong – wrong that any child should grow up in poverty. To address this poverty of income and to address also the poverty of aspirations by better parenting, better schools and more one-to-one support, I want to bring together all the forces of compassion – charities, voluntary sector, local councils so that at the heart of building a better Britain is the cause of ending child poverty. I've spent a lot of time in the last six weeks talking to patients and doctors, nurses and NHS staff. Let me say: every person I have met believes in the principles of our NHS – and like them I am proud that in this generation Britain will uphold an NHS free at the point of use, available to all on the basis of need, not ability to pay. But I know also from everything I have heard round the country, that we need to do better - and the NHS will be my immediate priority. We need to and will do better at ensuring access for patients at the hours that suit them; better at getting basics of food, hygiene and cleanliness right; better at helping people to manage their own health; better at ensuring patients are treated with dignity in the NHS; better at providing the wider range of services now needed by our growing elderly population, and while implementing our essential reforms, better at listening to and valuing our staff. And in the NHS we will also make progress by putting more power locally in the hands of patients and staff. So I propose that as we approach the 60th anniversary of the NHS we discuss a new settlement for a modern NHS free at the point of need – clear about where accountability lies – clear where Government should set overall objectives, clear where it should not interfere, and clear how independently local people should have their voice heard and acted upon in shaping the future of the NHS. And it is right that this party that created the NHS, that has always invested in the NHS, that has always believed in the NHS, will be the party that for the coming generation, renews the NHS.
HEEDING HISTORY Paul Walker, Chair In response to recent publicity I decided to look at the new health service plan for London, A Framework for Action. But I was disappointed. Not so much by the glossy presentation – even the English CMO’s annual report nowadays is as much gloss as substance; nor by the author’s recommendations which are sensible. No, I was disappointed that such a report needed to be written at all when all its main points have been made before, several times. In some ways it is a direct descendant of that long forgotten yet landmark document, the Dawson Report of 1920. This invented the concept of the health centre and envisaged an interactive hierarchy of healthcare provision from community to regional teaching centre. And over 25 years ago, to my certain knowledge, the four Thames regional health authorities were grappling with a radical rationalisation of health services in London and the Home counties, through the pan Thames regional strategic planning initiative. So I turned to the Framework’s list of references and discovered, unsurprisingly, that all are very recent. History began, seemingly, as recently as 1991. Which brings me to my point, that we seem to live in an age which ignores history. I did history at school but sensed that it was not a subject to be taken too seriously – certainly not as seriously as mathematics and the sciences. And it did not escape my notice that the only boys who studied it at A level were the less academic ones. I have no reason to believe that the situation is very different today though with the
flight from “hard” A level subjects one might have imagined that history would be resurgent. Even in academe, of its three traditional elements, teaching, research and scholarship, the latter, history by another name, is the one that seems to be least valued. Simon Sharma and David Starkey, among others, have done a lot to popularise a certain sort of history but have they succeeded in generating a proper respect for the historical perspective? I doubt it. And just to prove the relevance of history in the field of health one has only to turn to The Royal Sanitary Commission Report of 1869-1871, in which the Commission insisted that promoting and protecting the public health was dependent upon “the development of appropriate forms of health administration”. It looked forward to the day when “local government reform would constitute natural administrative divisions which would take responsibility for all local government functions including particularly health services.” It recommended that there should be, “In every place one Authority and only one for all sanitary purposes, with no intermediary body between the local government area and the Central Department”. The Central Department was seen not as a centralising administration but, on the contrary, as setting local life in motion and as an Authority to be referred to for “guidance and assistance by all Local Sanitary Authorities”. Are these not words that should guide our current approach to a new vision for public health and the NHS in England? History of course will not give us all the answers. There is no point in looking to Newton or Faraday for the answers to today’s conundrums in physics. But it will give answers and insights to many problems of today to those who are prepared to look. As a nation that has contributed more than its fair share of history over the last 300 years we should be particularly disposed to look. But our obsession with novelty like our obsession with youth puts us at risk of never learning from experience.
Labour Party Conference Report Martin Rathfelder Director
My experience of the Labour Party Conference this year was very different from the last one. In 2007 we had a very bust programme of fringe events and I spent most of my time doing the washing up. This year our only fringe meeting fell apart during the summer as a result of the ministerial reshuffle, so I had much more time to participate. For the first time in many years we had a delegation with two doctors, Brian Fisher and Jane Roberts. We booked a small hotel and filled it with SHA members and their friends and relations—and pets. This gave us an opportunity to meet over breakfast, and these sessions, which went on until nearly lunchtime were really the most stimulating part of the whole thing. Over the years the Conference has become more and more like a rally. Measuring the length of the standing ovations to the leadership has become as important as voting. The real audience is not the delegates in the hall but the television viewers.. Of course the rally performs an important function both to inspire the members and to impress the viewers, but it doesn't contribute much to the formulation of policy, which was originally the point of the whole conference. There are debates about policy, but it is difficult to get much real engagement in a ninety minute session on health with an audience of more than a thousand which has to in-
clude a speech or two from a Minister making announcements designed to grab the day's headlines. We also have policy seminars, but they too are a bit unfocussed. In health we normally have our six ministers answering questions from an audience of about 100. Typically in a ninety minute session 20 people will ask questions about 15 different policy areas. The knowledge of delegates varies widely, as might be expected. At the same time as these rather unproductive discussions are happening inside the conference we have an immense programme of fringe meetings – hundreds of them – with enormous numbers of extremely eminent speakers. Ministers dash around trying to fit four or five meetings into what is supposed to be their lunch break and trying to avoid upsetting anyone by failing to appear. The health industry have taken to organising a Health Hotel at each of the party conferences which is practically a self contained event of its own.. In parallel with the official fringe meetings which are open to delegates and the public there is an extensive programme of seminars on an invitation only ba-
Dr Brian Fisher at the podium sis, which often generate quite interesting discussion and get rather more time and attention from ministers. One of the few decisions actually made by the conference was to alter the procedure for contemporary resolutions. This was the last vestige of the old way of doing things— haggling of the words of the resolution in a composting session. In future we will only submit “Issues”. That will reduce the possibility of frightening the viewers by disagreement. As far as raising the profile of the Association we had a successful conference. Brian (pictured) made a good speech in the health debate about patient involvement which went down well. and resulted in an invitation to meet Alan Johnson to talk about it.
A First Class National Health Service for Everyone Dr. David Joselin, Budleigh Salterton email: email@example.com
Gordon Brown’s intention is to provide a personal health service for everyone. How might a personal health service differ from the current NHS? In a first class National Health Service there would be no waiting lists. Consultants would be on 24 hour call at Casualty Departments, they would be far more available to patients than they are at present and they would lead from the front in hospital emergencies. Outpatient waiting times would be one or two days, and surgical waiting times would be no more than two weeks. New patients would have 60 minutes with consultants and 15 minutes with general practitioners. There would be genuine continuity of care and patients would have their own general practitioners when they went to hospital. There would be no shortage of hospitals, and rich and poor would have equal access to first class medicine. Everyone would have immediate access to laboratory tests and scans. Everything would be free at the time of use. All this is commonplace abroad but it has never happened in Britain because the NHS is riddled with restrictive practices. In particular, restrictive practices restrict the number of consultants to such a small proportion of the medical profession that the National Health Service can never develop into a first class system. Why restrict the number of consultants? Money of course – it is all about supply and demand and relative scarcity. The scarcity of consultants in the NHS raises the demand for consultants in the private sector, and private practice means serious money for NHS consultants, very serious money indeed. Thanks to the National Health Service Act of 1948, consultants not only have a monopoly of scarce positions in the NHS, they have a monopoly of scarce positions in private practice as well. The Royal Colleges have allowed the training of consultants to be dragged-out far longer than is necessary, slowly over twelve or more years. But in America, Canada and some European countries, specialists are trained intensively in only six to eight years, so that the normal age for consultants to be appointed is 30-32. These countries thus have far more consultants than the UK, and in consequence, American ‘consultant’ surgeons average about 2,500 patients each, Canadians nearly 4,000, and British
consultant surgeons over 10,000 NHS patients, as well large numbers of private patients. This is an impossible workload. Long NHS waiting lists are therefore inevitable. The NHS needs a huge increase in consultants, especially in surgery, and it could increase the proportion of consultants in the medical profession from 25% to 40 - 50% if it wanted to, as abroad. Furthermore, it already has a large surplus of thousands of specialists, especially surgeons, doctors who would already be consultants in other countries. Indeed, the surplus is so large in some popular specialities that the NHS throws nearly half of them away, and it has been government policy to do so for the last 60 years. This is because in 1948 Aneurin Bevan, the first post-war Minister for Health, was forced to allow NHS consultants to keep their private practices. No man can serve two masters, and in my opinion, private practice remains a major cause of long NHS waiting lists. Bevan had to staff the National Health Service with hospital doctors, and he had to choose from the two pre-war systems. The Municipal Hospital system was deeply unpopular with the consultants. The Voluntary Hospital system was unpopular with the junior hospital doctors because there were so few consultant posts. Aneurin Bevan had no alternative but to choose the Voluntary system, because the consultants insisted on it. In 1948 the 30 undergraduate Teaching Hospitals had hierarchies of ‘junior’ hospital doctors. Consultants headed huge teams of senior registrars, registrars, senior house officers, housemen and medical students. Teaching hospital consultants spent most of the week in the private sector while their junior doctors did the routine work of the hospitals. Juniors admitted the patients, juniors did many of the operations, juniors managed the casualties and juniors staffed the wards. Junior doctors - very large numbers of juniors - were essential for teaching hospital consultants to be left undisturbed in their private practices. There were also 1,034 Non-Teaching
A First Class National Health Service for Everyone (cont) Voluntary Hospitals with few junior doctors. When the consultants rejected Bevan’s National Health Service he had to convert them to his way of thinking. Famously he promised to “stuff the consultants’ mouths with gold.” Less famously, he promised teachingstyle teams to every one who would join him. There is an apocryphal story that he was warned. When he was told that there could never be enough juniors to go around he is said to have replied “Very well. In that case I will import 14,000 foreign doctors and make the scheme work.” But he had been misinformed about the staffing of the voluntary system. In 2007, despite 30,000 foreign doctors in England alone, a severe shortage of consultants still remains. Now, nearly 60 years later ‘junior’ hospital doctors make up over 40% of all the doctors in the NHS. Allowing 30% for the general practitioners, little more than 25% are left to be consultants. But as I saw in Canada, juniors need only make up 11% of a medical profession, allowing more than 40% to reach consultant status at a much earlier age. American figures tell a similar story. Man for man, NHS consultants are heavily overprotected compared to their overseas equivalents. Productivity in NHS hospitals is ruinously low. To take the Canadian example a step further - Canada needs fewer junior doctors than any other country because
their general practitioners have evolved into a form of hospital doctor known as ‘Hospitalists’ or ‘Attending Physicians’. As Attending Physicians they make up 44% of the Canadian medical profession, and they manage their own patients in Canada’s highly efficient district hospitals. But Britain’s Royal Colleges have traditionally blocked general practitioners (and their apothecary predecessors) from major hospitals for centuries. In 1948 family doctors were finally banished to the community, denying them the diagnostic and treatment facilities they needed to compete with consultants for private patients. I watched for years as NHS-trained general practitioners, working as highly skilled Attending Physicians, admitted and treated patients in three Canadian district hospitals. They manned the hospital wards, the Accident and Emergency departments expertly. They delivered their own patients in obstetric units safely and professionally. Even more importantly, they assisted surgeons at operations and physicians at the bedside, enabling them to exercise a genuinely informed choice of consultants in referrals. As Attending Physicians they provided an absolutely seamless service. “Why can’t the NHS be like this,” British patients would ask? Do general practitioners have the time to do this in Britain? Of course they do. It may surprise readers to be told this, but general practitioners
send to hospital wards an average of two or three patients a week in medicine, and one or two patients a week in surgery. They have already examined and diagnosed them, and for general practitioners to replace junior doctors would mean only a small amount of extra work, but it would enable the National Health Service to develop into one of the best and most civilised healthcare systems on earth. Six years of intensive postgraduate training as abroad would soon produce a substantial increase in the number of NHS consultants, and the increase would enable them to be far more available to patients than they are at present. There would be enough consultants for them to be at the forefront of hospital emergencies. Outpatient waiting lists would disappear. Surgical waiting times, as I saw myself, would be much shorter. Restrictive practices, designed around the private sector, prevent the NHS from realising its potential. After 60 years of relative failure it is time for a radical solution. General practitioners should be allowed to manage their own patients alongside consultants in district hospitals as well as in the community. The replacement of junior hospital doctors by general practitioners would not by itself lead to equality of access in healthcare, but it would be a civilising step on the road to doing so.
Medact —one of the organisations to which we are affiliated Medact is a UK organisation of health professionals, with over 1,200 members, seeking to promote the right to health and peaceful existence worldwide by such means as: • Campaigning for the abolition of nuclear weapons and other weapons of mass destruction.
Seeking to understand the causes of violent conflict and working towards its prevention.
Advocating changes to those economic policies which harm the health of individuals and communities.
Promoting environmental policies which contribute to global health.
Activities last year included opposition to Trident renewal, including a joint report with Greenpeace: “Britain’s New Nuclear Weapons, Illegal, Indiscriminate and Catastrophic for Health”; a submission to the House of Commons Defence Committee; a visit by former Co-President of the International Physicians for the Prevention of Nuclear War and member of the Russian Duma Dr Sergey Kolesnikov to the AllParty Group on Non-proliferation and Global Security and officials from the FCO and MoD. Medact organised a health professionals day at the Faslane nuclear submarine base as part of the Faslane 365 campaign. It is a founder member of the WMD Awareness group (www.comeclean.org.uk). Medact has produced two updates to its reports on health and health services in Iraq which were written pre and post the 2003 invasion; Medact has also collaborated with Landmine Action to
initiate a Register of Explosive violence, analysing media reports on incidents involving explosions. As part of the Crisis Action coalition, Medact contributed to the campaign against any military action against Iran and the publication “Time to Talk”, and was part of the ‘Ceasefire Now’ campaign during the Israeli / Lebanon conflict. It is a member of the Peace and Security Liaison Group. Medact is on the Steering Committee of the Global Health Watch, (www.ghwatch.org/ ) and is preparing for the second edition to be published in 2008; with the British Medical Association and the UN Special Rapporteur on the Right to Health Medact contributed to a report on ‘Improving health in the developing world: what can national medical associations do?’ Medact hosts the meetings of the People’s Health Movement UK group, and is coordinating a submission to the Committee for Economic Social and Cultural Rights. The third Elisabeth James Memorial Lecture was on “Notions of mental health as a western cultural export: a critique’’. Working closely with the British Medical Journal Carbon Council Medact promotes contraction and convergence as the model to address climate change in a sustainable way, and raises awareness of the health impact of climate change and how health professionals should respond. Medact has been involved in Campaign against Climate Change and Stop Climate Chaos events and in the publications of the Working Group on Climate Change and Development. Medact organised a conference on the true health and environmental consequences of Chernobyl, which included speakers from the Ukraine, Belarus and
Russia and launched The Other Chernobyl Report (the TORCH report), and has lobbied decision makers on the limitations and dangers of using nuclear power as part of the response to global warming, based on its submission to the House of Commons Environmental Audit Committee. The Refugee Health Network is a powerful advocacy group for the right to access to health care for asylum seekers and a practical network providing information and contacts for practitioners; it made a submission to the Joint Committee on Human Rights and assisted the Department of Health to develop their website in this area. Medact’s Reaching Out Project promotes the reproductive health and well being of marginalised and minority women in UK, developing materials to improve awareness and understanding of services. Medact has collaborated in the development of web-based peace medicine educational materials as part of a European-wide project, and with Skillshare International on promoting global health in the regular medical curriculum. Medact has a close working relationship with Medsin - the national medical student organisation, and AlmaMata - a group of young doctors promoting global health. Medact will continue to work closely with other NGOs, with campaigning and professional organisations, and to consult with government, in order to promote health globally. Medact welcomes the support, input and collaboration of other organisations.
For more information please visit our website – www.medact.org
Should patients be given choice in healthcare?
Patients like to be offered choice about their healthcare. However, in an article in the Health Service Journal, Martin Roland and Marianna Fotaki question whether increasing patient choice in the NHS will produce all the benefits that the government hopes for. In a review of the literature, the authors found that there is little consistent evidence that choice will increase quality of care, or improve overall efficiency of the health service. And increasing choice may make health inequalities worse. This is because educated patients are better placed to make use of choices offered. There are ways of dealing with the last problem, e.g. providing advisers to help less articulate patients make choices, as happened in the London Patient Choice Pilots. Patients mainly want choice when local services are poor, or there are very long waiting lists. They were certainly keen to choose different hospitals in the London Patient Choice Pilots in 2004, but the very long waiting lists which existed then no longer exist in the NHS. Its not clear that patients want choice if they have good local services.
Ethnic Monitoring From Health Service Journal Middle managers have hit out at inadequate incentives to collect information on ethnicity that could help tackle health inequalities. The call came as the chairman of the British Medical Association's GPs committee estimated 70 per cent of GPs 'didn't care much' about collecting the information. It follows pledges by the prime minister and the health secretary to put health inequalities at the top of the political agenda. At a seminar for the Race for Health programme, primary care trust representatives criticised the fact that GPs get just one quality and outcomes framework point for collecting the ethnicity data of new registrants. One delegate said this meant there 'was no incentive for anyone to do anything'. BMA GPs committee chairman Dr Laurence Buckman said the QOF point equated to just £128 a year. He estimated that, while about 20 per cent of GPs supported ethnicity data collection, including himself, 70 per cent 'didn't care much' and about 10 per cent 'really didn't like it'.
The choice that patients want most, and are not getting, is the opportunity to disThe global impact of income inequality on health by age: an observational cuss individual treatment options study with their doctor. This is someD. Dorling, R. Mitchell, J. Pearce BMJ 2007;335:873 (27 October), thing that British doctors, in the Objectives: To explore whether the apparent impact of income inequality on main, aren’t very good at. health, which has been shown for wealthier nations, is replicated worldwide, and whether the impact varies by age.
Professor Roland said: “What patients want most is to be able to Setting: 126 countries of the world for which complete data on income inequaltalk through treatment options ity and mortality by age and sex were available around the year 2002 (including 94.4% of world human population). Data on mortality were from the World with their doctors, and they often Health Organization and income data were taken from the annual reports of the don’t get the opportunity to do United Nations Development Programme. Main outcome measures: Mortality this. Choosing between different in 5-year age bands for each sex by income inequality and income level. hospitals is lower down their list of priorities”. Results: At ages 15-29 and 25-39 variations in income inequality seem more closely correlated with mortality worldwide than do variations in material
He added: “If the NHS is going to wealth. This relation is especially strong among the poorest countries in Africa. offer more choice in the NHS, it Mortality is higher for a given level of overall income in more unequal nations. needs to be done in a way which Conclusions: Income inequality seems to have an influence worldwide, espehelps all patients to make choices, cially for younger adults. Social inequality seems to have a universal negative and not just the educated and afimpact on health. fluent”.
Health Policy Challenges SHA first response to the Labour Party Health Policy consultation In general we are happy with the NPF documents on health – as far as they go. However there are some structural difficulties in the relationship between Government health policy and the Labour Party's health processes. Although the Party aims to produce forward looking policy the pressures on Ministers to develop policy in real time outstrips the ability of the Party to keep up. The SHA – and the Party – would like to see more stress on prevention, on well being, and on quality of life. Ministers share this aspiration but the pressure of events inside the NHS repeatedly diverts them from the difficult job of organising cross cutting action which is essential to the success of most key prevention programmes. Furthermore many programmes require a degree of regulation which is seen as politically dangerous. So we see measures to effectively devolve power and responsibility for NHS services to local communities as essential to make political space in which the more fundamental challenges at national level can be addressed. The four areas which we want to see addressed more effectively in the next Manifesto are these: 1.
Inequality in health is a symptom of wide inequalities in our society. Despite valiant efforts to address the problems of the poor we have only managed to hold the level of inequality as it was in 1997. We have not been able to reverse the increase in inequality which occurred under Thatcher. As the NPF documents make clear social exclusion is an issue which extends far beyond the
remit of any one department. We would like to see some mechanism for ensuring that measures to address social exclusion – which are often politically and administratively challenging – get the attention they deserve. The reduction in inequalities in health must be a key driver of the NHS and all policies should be evaluated in terms of their impact on inequalities in access and quality of care through the process of health impact assessment. 2. Health and Well-Being There is of course an issue of personal responsibility in many issues of well being, but to stress them to the exclusion of measures which should be taken by Government either locally or nationally is to play into the hands of our opponents. We should strengthen the cross-cutting interDepartmental, inter-agency approach to prevention to tackle the major public health challenges of obesity, alcohol abuse, sexual ill health, and smoking with the application of much stronger gov-
ernment regulation where appropriate. 3. A cooperative health service We have strong reservations about the degree to which the NHS should or could be organised on the basis of competition between different publicly funded organisations, and we want to see greater emphasis on co-operative ways of working as a means of promoting efficiency, innovation and quality of care. We were very pleased to see the Secretary of State announce a moratorium on structural change in the NHS and suggest that this should stay in force for at least 5 years 4. A personalized health service, by which we mean one that responds to: 1. The individual patient at the point of care 2. The collective interests of patients in a locality 3. Diversity in all its forms
Member Survey During July we conducted a survey of membersâ€™ views on the NHS, at the point where dissatisfaction with the NHS was at its height 51 members responded.This is a summary of the results
Which of these issues are a problem in your area? Yes No Waiting times in casualty 37.3% (19) 62.7% (32) Access to Urgent Care 29.4% (15) 70.6% (36) Access to dentistry 68.6% (35) 31.4% (16) Quality of Service for Chronic Illness 58.8% (30) 41.2% (21) Community Services for elderly /disabled 74.5% (38) 25.5% (13) Services for BME communities 39.2% (20) 60.8% (31) Physical Access to Hospital services 27.5% (14) 72.5% (37) Social Care 70.6% (36) 29.4% (15) Services for Mentally Ill people 74.5% (38) 25.5% (13) Services for drug and alcohol misuse 51.0% (26) 49.0% (25) Sexual Health services 43.1% (22) 56.9% (29) Maternity Services 19.6% (10) 80.4% (41) Vaccination services 9.8% (5) 90.2% (46) Residential care for elderly people 72.5% (37) 27.5% (14) Early discharge of patients 39.2% (20) 60.8% (31) Delayed discharge of patients 49.0% (25) 51.0% (26)
What issue about the NHS nationally concerns you the most? 1. mental health the loss of in patient services. 2. That in the national conversation is focused around hospitals, and not health outcomes, particularly health inequalities. We will never begin to address health inequalities without shifting significant resources away from secondary care and into primary care. 3. The accountability of healthcare providers 4. That The Cleaning Should Be Taken Back In House. And The League Table Should Be Scrap. 5. PFI and use of private companies to provide health care 6. responsibility for long term care (particularly for frail, older people) having been taken out of mainstream NHS provision and split across social and health lines; the grotesque concept of charging such people for addressing their basic care needs 7. Racism Discrimination Not enough staff to patient ratio 9. prescriptions. I think far too much is given on prescription items such as aspirin paracetamol gluten free products even sun tan lotion etc. It seems once patients have free prescriptions they want everything on it. Who checks if they use the aspirins etc or pass them onto family and friends. 11. Health Inequalities Difference in outcomes based on geography, race, faith & culture, income, relative deprivation, gender etc - and the lack of progress over 10 years in tackling the issue 12. STAFF RESISTANCE TO CHANGE Lots of good ideas are blocked because of the resistance of professional staff or their organisations
13. GP SERVICES. Surgery hours not related to economically active. Preventative medicine only practised where direct monetary gain is involved. Lack of info on services available. Poor communication. Unhelpful and obstructive medical secretaries. Lack of confidential complaints or concerns raising procedure. 14. The constant reorganisation in an attempt to resolve problems that are inherent to emergent health problem that need stability or other political actions to address them. 15. Management of services at the point of delivery. Users of the NHS are not concerned with how the system is organised (internal markets) or even funded (PPI) behind the scenes. They are concerned with things they come into direct contact with: 1) badly organised surgeries so patients can only make an appointment on the day- often in a very brief period in the morning-, not in advance, yet there seems to be only one telephone line so communication is impossible. 2) Badly organised clinics in hospitals, with long waits with others who arrived later being seen first, never seeing the same doctor twice, conflicting views/information or just lack of information. Doctors who cannot communicate even the simplest information. 3) Rushed decisions about release from hospital, based on apparently inadequate information leaving patients (especially those living alone/ elderly) unsure and therefore unhappy. 4) Conditions which do not `fit into' standard group are often not dealt with quickly enough and get pushed around without resolution, and require much action on the part of patients. Many of these aspects require better management
- there has been improvement but not enough. I have first-hand experience and think that better direct management ON THE SPOT not by some one in an office far away- is the answer. Too much is left up to poorly trained staff (e.g. receptionists who should be organising more but cannot handle computer systems and records adequately, and the better staff are so busy and have no back-up. 16. Currently, the complete disruption of medical training by Government interference and mismanagement. Despite careful preceding suggestions, these have been rushed into attempted implementation with no heed for the voices raised in warning. 17. No-one clearly in the position of Matron or Sister any more so patients do not know who to turn to, and staff, ( nurses, cleaners, porters etc ) do not appear to have proper supervision 19. Expectations. Costings and availability of new services taken for granted and an unwillingness to think of more tax. 20. Artificial separation of "commissioners" and "providers", which I think is at the root of many of the problems of the NHS at this time. In my opinion, there is no need organisationally to separate the two functions, and the structure and operation of the NHS would be better without it. 22. affordability of the current enterprise, ability to maintain an efficient service that is acceptable to the population 23. the spin against the achievements in the NHS 24. Action to address health inequalities by addressing the wider determinants of ill health, I was hoping for a greater emphasis and shift in policy/resources towards the preventative agenda. 25. Lack of sufficient funding and continual reorganisation of the NHS. 26. Access to primary and continuing care 27. Short termism. Lack of strategic planning for the future is just one of many issues neglected as a result of the absence of serious consideration of clinicians perspectives and expertise. Leads to huge wastage as (for example, in clinical psychology, medicine and physiotherapy) huge amounts of funding is invested in training of staff, only to lose these staff overseas or to private practice when funding for posts is unavailable to employ those staff. 29. Health inequalities - many deprived communities are still not able to access services of a similar quality to those enjoyed by neighbouring communities that are better off 30. The commissioning of private companies to provide NHS Health care. Rather than "driving up quality" my concern is that such companies, as they are unable to charge any more for NHS care, will sacrifice quality, terms and condition etc in order to reduce overheads. 31. Continued dominance of the medical model and the acute sector. Need to strengthen value of care and more further to preventive/health promoting services. 35. The seeming inability to gel the various factions of
Pagearen't 10 the workforce into one supportive unit. if the GP.s moaning, it's the consultants. if they are not moaning the RCN are giving the SoS the cold shoulder. There seems that satisfaction and unity are impossible to obtain 36. Foundation trusts, that have taken any opportunity for influence away completely from local people. 37. Health Inequalities exacerbated by wasteful use of resources (see GP, Consultant Contracts and A4C) 38. Democratic deficit at all levels and the need to transfer the responsibility for commissioning to those local authorities that can demonstrate the capability to deliver this function and the benefits that enhanced local accountability would bring to local citizens. Such a transfer would be essential from the perspective of a potential establishment of an 'arms length' NHS Board which would otherwise increase the current democratic deficit. 39. Incompatible policies. The purchaser-provider split mimics the market, but we want to melt away the boundaries between primary and secondary care, and work collaboratively. My ultimate fear is that hospitals will be taken over by private equity firms and we will no longer own our NHS. 40. The tendency for the NHS to be run in the interests, or from the point of view at least, of those who work in it, not those who receive a service from it. 41. inequality of all health services, particularly intersted in child and adolescent mental health - lack of appropriate, accessible, flexible provision 42. So many reforms since 1994/05 that they have conflicted with each other e.g. PCT restructuring with Connecting for Health and Practice Led Commissioning; local quality assessment framework with distant provision of out of hours services with little clinical governance and reduced quality but vastly more expensive 43. the purchaser-provider split and internal market. consequent fragmentation and loss of continuity in NHS England, and inevitable creation of failing units. 44. Commercialisation. The increased outsourcing of services. The fact that some of these services remain free at the point of care is a red herring. There is no evidence base, within the UK, to demonstrate whether this is cost effective or safe. There are lots of examples of suboptimal standards of care and fraud. One outsourced, the costs of bringing these services back, to within the NHS, will be prohibitive. That will mean that we get more spin about the ICATs providing quality at affordable prices. 45. Deficit - It affects every aspect of the service. Mental Health has always been the cinderella service and as far as that is concerned it is now being pushed aside in favour of Medical Research and other academic pursuits which take precedence over human contact and input. 46. Intrusion of the private sector in primary care - they aren't interested, and the government seems to be tying itself in knots trying to involve them.
Patient and public experience in the NHS—a chart book Sheila Leatherman, Kim Sutherland—Health Foundation Shortly after coming to power in 1997, the Blair government outlined a ten year quality agenda for health, promising to put quality at the heart of the NHS. This chartbook focuses on a particular facet of quality: patient and public experience. It concentrates on the responsiveness of the NHS to the needs and desires of the patient and public, and assesses the degree to which patient centredness - an explicit policy goal - has been attained. Numerous government policies have sought to elevate the importance of the patient experience through a wide range of reforms: improving access, offering choice, improving amenities, etc. The heightened emphasis on the needs and expectations of individual patients has resonated across a broad spectrum of issues, including personal choice of providers, technological advances (such as a patient accessible medical record) and greater emphasis on patient views and feedback within regulatory and performance management frameworks. The government sought to establish a ‘patient-led’ NHS, but what exactly does this mean? General surveys indicate that the NHS provides a service that is valued by patients: results consistently show that about three quarters of patients rate the care they have received as excellent or very good. Such overall evaluations give a valuable picture of quality, but are often too general to be useful either in delineating where quality of care is deficient, or in shaping future policy and direction. A distillation of data from multiple sources shows that patients and the public prioritise: information and involvement in decision-making about care being treated as an individual choice where it makes a difference predictable and convenient access equitable treatment and health outcomes being safe and protected from harm in healthcare settings. Using a wide variety of sources, this chartbook presents data relevant to each of these priority areas. So what does this information show? Relative successes include the following: improved access to care for inpatients, outpatients and primary care the vast majority of patients feeling that they are treated with respect and dignity cost concerns not inhibiting patients seeking medical care when needed (an accomplishment compared with other countries) systems being in place to deal with adverse events. The following areas of improvement are needed:
more predictable access to timely and technologically advanced clinical interventions better engagement of patients in decision-making and self-care decreased variation in healthcare outcomes such as life expectancy and infant mortality increased patient safety, in particular prevention of hospital acquired infections. There appears to be a mismatch between what the public and patients say are priorities for quality and what the government has chosen as being most important in policy initiatives. In May 2007, the Picker Institute released the findings of a survey that sought to identify which aspects of care hospital patients regard as most important in England (Boyd, 2007). The survey asked patients to score the importance of 82 different aspects of care. The results suggest that a truly ‘patient-centred’ NHS would place a high priority on communication, patient–professional interactions, and treating patients as individuals. Patients rated many of the key components of the current patient choice agenda – such as choice of hospitals or admission dates – among the least important aspects of care. Clearly, the government’s intention and actions to make the NHS more responsive to patients and the public has been a fundamental and much needed change. A great deal has been done to reinforce the obvious commitment of the public to the institution of the NHS. However, it appears that there are several areas that are both meaningful to patients and where immediate policy, managerial and professional attention could realistically be focused: better provision of information to and communication with patients engagement of the patient in shared decisionmaking about treatment options geographic convenience and ease of transport to health Services improvements in patient safety. In the past ten years, credit is due to the NHS as it has purposefully developed policies, strategies and initiatives to support, listen to and engage with patients. There are challenges ahead in providing healthcare to an ever-more sophisticated population that has increasing awareness of and expectations for quality, perhaps as a result of political rhetoric, government promises and exposure to the publicly released data on NHS performance. The challenges ahead are significant, but those who strive for improved quality in healthcare have a great asset – the patients and public – to guide future policy and direction.
Future Events Dealing with complaints constructively London Friday 9th November
Already fully booked
Getting the balance right - Hospitals and Primary Care
Coventry Friends Meeting House Hill Street, CV1 4AN Tuesday 4th December 10am - 4pm Main Speakers: Derek Turner Bryan Stoten Chair - The NHS Confederation and of Warwickshire Primary Care Trust Dr Sally Ruane Deputy Director - Health Policy Research Unit De Montfort University
Prof Richard Hobbs
Professor of Primary Care and General Practice University of Birmingham
2008 5 Jan Socialist Health Association Council London – acute care 8th Mar Socialist Health Association AGM London – inequalities 5th July NHS 60th anniversary Tredegar 20th Sept Socialist Health Association Council Manchester 21st Sept Labour Party Conference Manchester th
Next year’s conference programme will include:
Local accountability in Foundation Trusts Mental Health, Choice & Coercion Information on prescription Unequal babies The Association has booked a hotel in Manchester for the duration of Labour Party Conference 2008 to facilitate discussion and co-operation between members. Any member wishing to take advantage of this facility please contact the office. Costs for our events above vary but are reduced for SHA members (and delegates from affiliated organisations, such as Amicus and Unison). Further details will be on our website www.sochealth.co.uk or available from the office.
Articles, Letters, Announcements and Comments should be sent to the editor Gavin Ross, 21 Connaught Road, Harpenden, Herts AL5 4TW. The deadline for contributions to the Winter 2008 edition is 30th December. Tel/Fax 01582-715399 or by e-mail to firstname.lastname@example.org
Socialist Health Association 22 Blair Road Manchester M16 8NS Tel 0870 013 0065 email@example.com