Editorial Inside this issue: Can Barack Obama bring universal health coverage to America?
The School Food Revolution-
Dying early from health inequalities
Rethink urged on NHS outsourcing
The SHA and the New NHS in England
Christine Dore 06/06/1931—9/12/2008 Christine was an active member of our Central Council for more than 20 years and Chair of Somerset Coast PCT until 2006. She was also curator of the Dunster Dolls Museum and an active member of West Somerset Labour Party and many other organisations in Somerset. Christine was quiet and gentle but very determined and effective. One of her great projects was the rebuilding of the Minehead Community Hospital which will include new health, leisure and education facilities on a single campus. Building starts next month
This has been a difficult issue to put together. In the Summer I thought we could report on the policies and events of the Labour Party Conference, but the conference took place at the low point of the Party’s fortunes, with loads of speculation about a leadership challenge. It was hard to get excited about putting together policies which seemed destined to go nowhere, even though some of our proposals were accepted. The impact of the banking crash just struck as the conference started — making it clear that a giant rethink of priorities would have to happen and that the world in which the four year policy making process had happened had utterly changed. Since then we have been watching the end of international capitalism as we have known it, and wondering what these events meant for health. It still isn’t clear what happens next, except that the great crisis has wiped out the Conservative political advantage, reinstated Gordon Brown as a Great Statesman and encouraged talk of an early General Election. And it seems fairly clear that the huge increases in NHS expenditure will not be continuing. Whether the crisis will finally kill off PFI and other complex financial transactions in health remains to be seen. There are some signs that some of the big corporate players are less keen on moving into the NHS, but this may not last. Health is a good business to be in during a recession. At the same time the differences between the NHS in different parts of the UK are widening. England will soon be the only part of the UK where people have to pay prescription charges. Scotland look likely to bring in direct election to NHS Boards. Wales is bringing in integrated Health Boards which will run hospitals, Community services and Primary Care. PCTs in England are separating out their provider functions and the process of creating Foundation Trusts is coming to an end—exposing a couple of dozen non viable hospitals to some sort of failure regime which may reveal the limits of the market model.
Can Barack Obama bring universal health coverage to America? Tom Smith Since being elected the President of the United States, most international debate has focused on Barack Obama's foreign policy challenges. But since his election healthcare has emerged as his number one domestic priority. At the beginning of December the President-elect asked the American public to meet with each other in their neighbourhoods to come up with ideas about how to improve the healthcare system. It seems that Obama is preparing America for major reform. How many health secretaries have written books on health reform? The importance attached to health by Obama is signalled by his appointment of Tom Daschle as Health and Human Services Secretary. Rare amongst health secretaries, Daschle has actually written a book on health reform, published in March 2008. The Wall Street Journal explained the book argues that any reform must be comprehensive, stating that we can no longer afford incrementalism or inaction. According to the Washington Post, the appointment confirms that the incoming Obama administration has made health care reform a top and early priority for action in 2009." It has been universally popular amongst the health policy experts and advocates of universal healthcare. The American Prospect's Ezra Klein called Daschle's appointment "huge news, and the clearest evidence yet that Obama means to pursue comprehensive health reform." It also suggests that Obama sees health reform as fundamentally a political problem. It's the politics, stupid The last attempt at health reform in the States fell on political grounds and the BBC's Adam Brookes says the decision to appoint Mr Daschle shows that Mr Obama feels he needs a Senate heavyweight to help him persuade Congress to back major reforms. Mr Daschle was the Democrats' Senate Majority Leader from 2001 until 2003. His experience contrasts with that of Hilary Clinton who when she was charged with reforming healthcare had no legislative
experience. Obama seems keen to avoid making the same mistake. According to one US newspaper, ‘you don't tap the former Senate Majority Leader to run your health care bureaucracy. That's not his skill set. You tap him to get your health care plan through Congress. You tap him because he understands the parliamentary tricks and has a deep knowledge of the ideologies and incentives of the relevant players. You tap him because you understand that health care reform runs through the Senate. And he accepts because he has been assured that you mean to attempt health care reform.’ The Economist says that health reform is a hugely political issue in the US, but implores Obama not to shy away from the challenge. This time there are some factors in favour of health reform, it argues. 'There is momentum for reform in Congress' and even big business is behind the idea of universal coverage because of soaring costs. Financial challenges The bumpiness of the political road ahead is illustrated by the arguments in the Senate over the Democrats' stimulus plan. As in England, the Democrats plan to put money into the economy so as to counter the shrinking tendencies within the corporate sector. Individual states face particular pressures. The Economist this week says they face a $70bn budget gap this year. To cover this, ‘half have already started cancelling infrastructure projects, cutting healthcare benefits or laying off workers’. At the beginning of December, Barack Obama indicated that he wanted to provide funds directly to states to ensure no reduction in services. This move will be opposed by Republicans. A plethora of plans for reform and little consensus between them Even though there is support for healthcare reform there is little agreement on exactly how it should be taken forward. Arguments about reform have already played an important role in
the Presidential election. When battling for the Democratic nomination, Clinton and Obama repeatedly clashed over a seeming detail of reform. Both candidates promised to move towards universal coverage, but a key argument was about how quickly. Clinton wanted to see a mandate placed on all Americans, requiring them to arrange insurance, with a variety of schemes made available. She argued that ensuring universality was key to solving the financial pressures. Obama supported the direction of travel, but not the mandate, arguing this would increase costs. Once he had secured the Democratic nomination, Obama duelled with John McCain over how best to provide coverage to the very ill, the people that regular insurance companies would not cover. McCain said they should be covered in specific schemes, Obama argued they should join public schemes so as to share the risk. Obama has appointed Tom Daschle as health secretary so is presumably in sympathy with his views. What does his book say about the uninsured? The Wall Street Journal explains. â€˜Mr. Daschle wants to open to all Americans the Federal Employee Health Benefits Plan - a menu of private-insurance options now accessible only to government workers. He would offer, in addition to the current plans, a government-run program, presumably similar to Medicare, although he provides few details. There would also be some form of means-tested premium support (or tax benefits) for Americans who couldn't afford one of the available plans.' It's time to get real In their Presidential debates, John McCain accused his rival of having a reform plan that would cost a fortune. Barack Obama managed to deflect the charge, but McCain had a point. Achieving universal coverage will mean some people paying more, and it will also require more constrained choices. These downsides of reform have not yet been communicated. The Economist says, Obama 'convinced voters he would somehow expand healthcare without
resorting to radical plans'. 'It's time to get real'. In order to reform the US health system, Obama will need to win the argument for reform with the electorate and convince them that they may have to make trade-off's between free choice and a comprehensive system of care, universally available. Is anyone prepared to make tough choices? As the Washington Post pointed at the beginning of December, 'few politicians talk about tradeoffs. The fee for service payment is driving up costs and the system is hospital centric. The appointment of Tom Daschle suggests that the Obama administration may provoke debate on what is effective in healthcare and what the government can fund. His book suggests the creation of a "Federal Health Board. Its duties would include "recommending coverage of those drugs and procedures backed by solid evidence. It would exert influence by ranking services and therapies by their health and cost impacts." Daschle admits that the board is based on the National Institute for Clinical Excellence in Britain and the Federal Joint Committee in Germany. As the Wall Street Journal explained to Americans not familiar with these bodies, 'both are charged with managing the public's access to higher-cost drugs, medical devices and procedures, but both are growing increasingly unpopular in their home countries -precisely because they've become a triumph of costcontainment over patient access and choice. All eyes on America An article in Time magazine this week examined the expectations and hope attached to Barack Obamaâ€™s election outside of the US. Shocked by the expectations, it made the point that Obama had been elected US President; not SecretaryGeneral of the UN. And they are right to remind us that it will be American voters who determine whether Barack Obamaâ€™s first term has been successful or not. Obama will be judged on domestic issues, the most important of which is healthcare.
The School Food Revolution- Public food and the challenge of Sustainable Development Kevin Morgan and Roberta Sonnino. Easthscan www.earthscan.co.uk..... £38.00 hardback
Rising obesity and celebrity focus has placed the school dinner at the heart of the agenda to improve health. A few years ago, when the authors conceived this research, academics generally viewed the subject as risible. This book will wipe the smile off any academic sceptics face, as the school meal is shown to be the key instrument to improve children’s health throughout the world. The school meal is revealed as a “prism” through which to view compelling questions: does the state have influence over standards for health, can public procurement be a creative force for sustainable development and, can the “obesogenic” environment be reversed for the next generation? The answers to these questions highlight the potential of the state, through its levers in the public sector, to be the driving force to promote the health of its citizens. Of the eight chapters the restless policy “wonk” might be tempted only to read the first two and the end, where the key arguments are set out. The constant struggle from theory to practice is explored with a well-referenced discussion of the key debates around sustainable development. Missing out the case studies however, would be a mistake. Through their meticulously detailed and clearly written narrative, the authors illustrate a rarely glimpsed ‘line of sight’ from the policy–top to the on-the –plate bottom of school meals delivery. They identify that food and how it is transported and its waste disposed, lie at the heart of debates on public health and the environment, but also social inclusion. While they are clearly passionate advocates, they never drop their critical faculties as they examine the alluring slogans, such as “ re-localising the food chain”, where they wisely assert that “delivering sustainable development is not simply a matter of choosing between global and local”. Much hope is placed on the rise of a “green state” where democratic governments set the context, “discipline “ the main actors, in particular those in the commercial food chain, through skilful use of their “powers to steer”. But, the ‘Green
state’ must also engender cultural change to transform their citizens into “sustainable consumers”. There is a good chapter that explores the crucial issue of public procurement , the battleground where free market rights clash with attempts to put wholesome local produce on the school menu. The Italian case study demonstrates that the ‘public plate’ can be reclaimed from the “Byzantine” market restrictions by skilled and creative public procurers backed by political will. The case studies show a wide range of practice and possibilities, and are full of tips to practitioners and activists about how to make change happen. The Rome authorities placed quality at the centre of their “revolution” and criteria. In New York schools, the nutritious meal was disguised as fast food, and provoked another example of the endless squabbles between pragmatists and purists. The UK case studies include London where it traces the food strategy from its aspiring strategic vision in a ‘Sustainable World City’ through to the struggles of cash-strapped boroughs to embed the gains in a Sustainable School Food Service. There is a charitable aside on the value of celebrity contributions in Greenwich. There are 3 case studies from rural Wales , Scotland and England which demonstrate that with commitment and tenacity the wholesome food in the surrounding fields can be brought to the school dinner table. Inspiring though the UK studies are, they indicate the high hill to climb before their success becomes the norm in the UK. The unsung heroes are the school meals staff who achieve miracles within a per head budget that equates with a couple of chocolate bars. Throughout the book the practical lessons are wrapped with thoughtful summaries of the political and policy history where the sad tales of neglect and false parsimony are laid bare. Significant historical landmarks are, as with long lasting public health changes, embedded in law. The removal of the legal requirement for the school meal in the early 1980s initiates the sorry
road to the neo-liberal market and its ‘turkey twizzler’ leitmotif. Thanks to the Gates Foundation, the case studies are completed with a chapter on the developing world where basic daily requirements remain the challenge for many. The role of the World Food Programme is considered with a masterful discussion of the exit strategies needed to ensure aid leads to development not dependency. There, it is hunger that is the concern, which they argue is the missing Millenium Development Goal. The final chapter draws together the theoretical implications of the empirical findings. They consider that school meals are part of a “moral economy”, arguing that the quality of school meals is a measure of the public ethic of care. Thus the public realm, through its state structures must take the necessary action on a ‘whole school approach’ and a supply chain based on quality. If it is serious the state must “go green” and demonstrate the values necessary for sustainable development if it
wishes them to be owned and followed by its citizens. ‘Green states’ however, are part of the wider world and they warn against uncritical localisation, a “spatial fetish”, categorising global as always bad. Comprehensive community food planning backed by the state is the tool to achieve the school food revolution. This is an important work which should be read by every discipline and practitioner whose boundary it crosses. Its conclusion is that the state not only can, but is duty- bound to put a nutritious and sustainable school meal on its children’s plates. They challenge the state and its agents to worry less about being a“nanny state” and more about being held to account as Pontius Pilate. As with school meals, such a concern was until recently risible within government circles. However, this publication coincides with the reconsideration of like-minded Keynsian ideas. This book sets out an alternative to markets to those in government who want to improve the health of their citizens. Eddie Coyle
Dying early from health inequalities – something we must be able to fix. Melanie Johnson For many years people have known what the principle causes of health inequalities are – broadly poverty and its associated deprivations. So why is it that we can’t yet fix it? Health inequalities in terms of the difference in life expectancy between the most healthy and the least healthy in our society have remained the same or worsened despite improving health across the population, which has benefited all. Nearly a decade less life for some is a result that we mustn’t tolerate and yet making progress at reducing it is proving very hard, even if some recent evidence suggests that social mobility might be improving. Some would say that it’s mainly a matter of improving incomes – and the Government has taken steps to lift children out of poverty with some success. Given that no political party returning MPs to Westminster advocates equality of income, differences will always exist and probably on some scale. Must this then mean that the health gap will remain?
plan was too many to concentrate the mind across so many organisations both within and beyond government and provide a strong focus for action. The very diverse causes of health inequalities flowing from poverty and deprivation and the fact that these span many government departments and agencies is a major issue. Government has got better at tackling issues cross-departmentally. We could help more by making sure that campaign organisations whose concerns relate significantly to health inequalities work together to agree a top 5 areas where progress would be of major benefit and lobby together to make the changes which would support progress on them, not only at policy and national level but also at more local levels where that is feasible. Many organisations combining energies in such a Health Equalities Alliance with a mutual core agenda would re-energise and maximise their efforts and focus the Government more strongly.
Inequalities in health start before birth and build up over a lifetime, initially caused by poverty and deprivation and later contributed to as adults by the choices we make. So tackling health inequalities will always be a mixture of tackling the underlying causes, supporting healthier lifestyle choices and ensuring good quality services are available for all. The Government has sensibly focussed on children and their families where the opportunities to get things right from the start are the best with programmes like Sure Start, more and better childcare and nursery provision, and the tax credits – and this strategy of starting young has to be part of the answer. And Alan Johnson has kept health inequalities at the top of his priorities. But progress is still slow.
A second improvement would be to have a model for judging how well local delivery is going. We have this in Health with the National Service Frameworks. Another analogy might be with the Framework for the Inspection of Schools – provided by Government and Ofsted as the basis by which school standards are judged. Whatever its flaws, having such a framework from the early 1990’s was a big step forward as it provided a model which those of us elected to local authorities had tried to remedy the lack of on a localised basis with varying degrees of success. What that model tells us is the key characteristics of good schools and it made it much easier to explain and judge whether a school was doing well by its pupils – by parents as well as by various authorities.
Firstly we need an agreed menu for change. This must be simple with just a few top priorities that key stakeholders sign up to act on. The Choosing Health White Paper provides something of this for the areas of public health where choices affect health outcomes. But there is nothing really comparable for the health inequalities where choice is not the primary issue. Although good work was been done by the Acheson Inquiry, having 82 action points in the resulting Treasury
There is a lack of a similar model for work on those inequalities in health which are not the result of individual choices. Many of the responsibilities for these policy areas lie outside the Department of Health. It would help everyone to have a model, the Health Equalities Framework, with the agreed status of the Ofsted Framework for schools. And just as that Framework has different manifestations for Primary, Secondary and Special schools, so this
Rethink urged on NHS outsourcing
should for key areas like housing, etc. When I became Minister for Public Health in 2003 and took on health inequalities I was immediately struck by the quantity of the analysis of the causes (and the availability of the statistics) of health inequalities and the contrasting paucity of information about what works in tackling the problem and making change happen. I asked the Department of Health for detail on ‘cures’ and found there was extraordinarily little to go on. The disease was well-documented but not the cure. So my third improvement would be to increase the effectiveness of what we do, something too often neglected by campaigners and policy makers alike – I suspect because it means getting stuck into what works and why and finding ways of spreading good practice where results are being delivered at home and abroad. This is not high policy, it requires evidence and means working closely with people designing and delivering services. Many are prone to feeling that this is desirable, it should be done and is being done by someone else – somewhere. There is certainly much good practice in the public services and in areas tackling the causes of health inequalities. But we frequently don’t identify the best – the most effective in terms of outcomes – and when we do we are very bad at making sure it is taken up more widely. Three years or so ago I saw some excellent work in Sheffield being done to identify those at risk of heart/circulatory disease which was leading to a much improved health outcomes for all but was leading to those regarded as most disadvantaged catching up with those more advantaged in health and income. In other words this was successfully tackling some in-life health inequalities through improved care and medication. Anyone would say this should by now – assuming the outcomes have been sustained – be underway in many areas, particularly where there are deep health inequalities. Too much good practice is spread too little and it is something we must remedy. I am convinced that we can be more effective than we are still at present and help more people to have longer healthier lives.
The government needs to rethink its approach to NHS reforms, says UNISON, in the wake of a damning new report on the cost of commissioning and outsourcing. It should concentrate on giving NHS patients the care they need – and value for money – rather than using reforms to outsource services and 'throw precious money away to the private sector' says the union, following publication of the report, Driven by Dogma, by the Office for Public Management. The report says outsourcing in the NHS has failed to deliver value for money, patient involvement or improved working conditions. The government's pre-budget report in November made much of the potential efficiency savings to be made by the NHS from shared services operations with the private sector. But first hand evidence in the new report, looking at the experience of those commissioning and delivering services, reveals that in fact promised cost benefits have simply failed to materialise, and quality has suffered. “At a time when finances are increasingly tight, the NHS cannot afford to be throwing precious money away to the private sector and wasting time and resources on the complexity of the commissioning process,” commented UNISON general secretary Dave Prentis. “Patients want more involvement in decision-making and staff want to spend more time on providing excellent patient care than tendering for contracts. Unfortunately this report shows that the various reforms to outsource or privatise parts of the NHS are working against these goals.” The report draws on the experiences of NHS senior managers and commissioners to highlight the sheer complexity of the commissioning process, and the mountains of bureaucracy and paperwork attached to it. “My experience has been that the problems associated with monitoring contracts far outweigh
The research provided compelling evidence of the following:
the benefits of the outsourcing,” said one of those interviewed. “We will go on spending more and more money on this – contract negotiation skills, transaction costs, etc” added another. UNISON points out that there are alternatives: Scotland has recently announced that it will no longer permit any contract cleaning and Wales has done away with the purchaser-provider split in favour of a more integrated system. The report makes clear that markets should not be the only option and that those working in the devolved administrations did not feel they were disadvantaged by the minimal use of outsourcing in their systems. This research was a qualitative investigation of some of the emerging and persistent challenges that exist when the private sector is involved in the tendering for, and delivery of, public services in the health sector. The research was conducted by the Office for Public Management (OPM), an independent public interest company, on behalf of UNISON, the largest public sector union in the United Kingdom. The research involved two main stages: • a scoping stage where evidence was collated from past research to identify key lines of enquiry regarding known challenges to outsourcing in the health service; and • a primary research stage which involved a large number of interviews and other methods being used to ascertain the views of a crosssection of health service professionals from board level to floor level including directors, commissioners, managers of provider services and cleaners.
• Those responsible for implementing outsourcing policy see it as being primarily driven by political will rather than evidence-based practice. The increase in tendering and use of the private sector is strongly driven by the compulsory nature of trust policies or outsourcing being the only option offered to trusts wishing to make service changes; • Little hard evidence is available to suggest that outsourcing impacts positively on value for money or quality of care. Conversely there are several examples of outsourcing having a directly negative effect on the value for money and quality of care in services; • Where improvements were identified through outsourcing it was often felt that these could have been delivered through investment in expanded public provision or adaptation of current services. Marketisation is not a clear route to improving healthcare, for example health management professionals in Wales do not feel they are disadvantaged by the minimal use of outsourcing in their system; • Outsourcing is seen by those working in the NHS as being the cause of a downward pressure on terms and conditions, fragmentation of services and a divisive effect on the ethos of the public sector and the NHS; • Outsourcing is seen by scrutineers such as patient and public involvement representatives and overview and scrutiny committee members as a challenge to the lines of accountability due to the increasing complexity of outsourcing arrangements and diversity of approaches.
THE SHA AND THE NEW NHS Dr Brian Fisher Having initially made such dramatic improvements in so many aspects of the NHS, the government is now engaged in a huge and rather dangerous experiment. They are deliberately playing with chaos theory to destabilise the NHS. First, Labour set in place clear organisational boundaries through systems such as NICE and the Healthcare Commission. Care was improved significantly with central direction through targets and a system-wide process of learning across the NHS. Although people moaned about the targets and gaming by different parts of the system reduced efficacy, the targets have proved the most effective mechanism for change: waiting times have dropped in primary and secondary care, heart disease and cancer care has improved, smoking has reduced, links with local authorities and PCTs have begun to bear fruit. The current phase is quite different: the government now has the following aims: • To reduce dependence on the centre • To reduce the responsibility of the DH, so that a bedpan dropped in Tredegar will never get heard in Whitehall again • To ensure that the NHS knows what it is paying for • To change the position and relationships of the two big monopolies in the NHS – primary and secondary care • To introduce a self-sustaining improvement process into the NHS in England so that incentives drive up care with less and less central direction These aims are not wrong – and they may well be right. However, the approach taken is without evidence and may well be dangerous. The DH feels that destabilising vested interests in England is best done by the systematic introduction of competition from within the system and by introducing the private sector from without. If this brings forth howls of distress from the vested interests such as GPs, then the DH will feel that this is a job well done. In the opinion of the government, central direction has failed to improve the system adequately because of the inertia of existing monopolies – fragmentation is essential to progress. The dangers of this approach are many: • Competition has huge transaction costs • Private providers will leave the system if it becomes unprofitable • Private providers are likely to find profitability
only by • Selecting clients carefully • Offering cut-price medicine • Private providers cost more as they have to pay shareholders • Fragmentation carries clinical risks • It may not work • It is destroying morale across the NHS • The greed and fear which drive markets are poor drivers for health care • A system that, on the one hand incentivises hospitals to suck patients in and, on the other, encourages practices to keep patients out is wasteful and militates against integrated care It needs to be said that the government retains central control as a means for improvement, as evidenced by its demands on GPs on extended hours, its approach to inequalities and its excellent early approach to prevention and wellness. Nonetheless, the general direction of travel, in the opinion of the SHA, is dangerous and wrong. The SHA is committed to being a critical friend of the government. We applaud the successes and will work with the DH, ministers and the Labour Party to improve these aspects of policy. It is also increasingly apparent that Wales and Scotland are travelling a different path, refusing the incorporation of the independent sector in the same way. This may enable us to see which direction is better for patients. The SHA will, over the next few months develop clear policies in three key areas: those of INEQUALITES, INTEGRATION and INVOLVEMENT. The first draft of our inequalities policy has already been published (ref) Integration will look at how we can take the most progressive aspects of current policy and use them to improve coordination and cooperation across the NHS. Involvement will suggest next steps in improving accountability across the service, including exploring aspects of democracy. We hope to use the debate around the Constitution to highlight this area.
Future Events Accountability and the Scottish Health Service Glasgow 13th February With Bill Butler MSP Dr Brian Fisher Dave Watson (Unison) & Scottish Health Council (tbc) Architects for Health debate on polyclinics At The Reform Club London Thursday 5th February. Accountability and the Health Service Liverpool 23rd January Debbie Abrahams director of the International Health Impact Assessment Consortium at the University of Liverpool. Ged Taylor, Formerly Chief Executive Cheshire West PCT & Steven Twigg, former General Secretary of the Fabian Society, and MP for Enfield Southgate Patients Crossing Borders Seminar on the proposed European directive on the application of patients' rights in crossborder healthcare London 19th January Linda McAvan MEP Labour spokesman on European Parliament's Environment, Public Health & Food Safety Committee Baroness Howarth Chair of the Lords EU sub-committee & Jenny-Lee Spencer NHS European Office Costs for the events above vary but are reduced for SHA members (and delegates from affiliated organisations, such as Unite 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 Spring 2009 edition is 1st March 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 (office closed 1st-7th January) email@example.com