On one level, it seems unfair. When Labour came to power, ministers were told the NHS was underfunded. So they doubled its budget. They were told patients were waiting too long for elective operations. So they slashed waiting times. In England, very long waits for in-patient procedures have been eliminated; the longest queues have fallen from eighteen to under six months.

Ministers were told heart disease, cancer services and treatment in A&E departments were substandard. So they made these a priority, invested heavily and used the crude, but powerful tool of targets to improve care. Ministers were told the NHS needed more clinical staff - there are now 25,000 more doctors and 80,000 more nurses than in 1997. They were also told that staff were underpaid - today medical and nursing salaries in the UK compare well with those of almost every country in the world bar the US.

So why all the negative headlines when the very real accomplishments above cannot be disputed? It seems we are witnessing a real fall in confidence about the NHS, with people feeling it is getting worse rather than better. But when you look at patient experience, it is slowly improving. Polling shows that patients using the NHS are consistently happier than the public at large.

So what should Labour have done better over the past decade? The Government has been the architect of some of its own woes. At least some of the current financial strains could have been avoided if budgetary discipline had been imposed earlier. The need to change the shape of care and reduce hospital costs could and should have been pushed through when the extra money was flowing in, not just at the point where it was about to be turned off.

There were large pay hikes for hospital doctors, GPs and other staff. It was ambitious, not to say foolhardy, to try to transform the pay of more than one million staff simultaneously. The new GP contract, which has some beneficial features, was offered on extravagantly generous terms. The NHS has paid out a fortune, and at the same time achieved the seemingly impossible by infuriating the staff in the process.

Another serious charge is of hasty and sometimes inconsistent reform. Labour dismantled then resurrected a market the party inherited. It invented new primary care groups, remade them into primary care trusts, then merged them again into half the number. It demolished regional health authorities, put in 28 strategic health authorities, and then merged them back down to the ten original regions. The Government is moving towards a market in healthcare at breakneck speed, and yet huge issues about how that market will be regulated remain unresolved.  

Failure to secure value for money is what the Tories will attempt to pummel us with at the next general election. Ever since the Government opened the spending taps, ministers have felt vulnerable to the charge that they are securing poor value for taxpayer's money.

There is further trouble on the horizon with the reconfiguration of hospital services. The political impact of these reforms has the potential to dwarf all the difficulties to date. Previous governments have chickened out of necessary hospital closures, aware of the widespread criticism they are likely to provoke. Closures may be the right thing in some circumstances - but perhaps not now, when they will be portrayed as `cuts' to meet Labour's deficits. The next general election is likely being planned for May 2009. This leaves little time to ensure that major changes, such as downgrading of accident and emergency departments, are completed before the countdown to election begins. What is more, from April 2008 the period of big investment - more than 7 per cent per year every year in real terms since 2000 - will cease. That means the unattractive appearance of a service struggling to meet demand, without the excuse of being chronically underfunded.

Given staff disillusion and public distrust, the question now is whether there is time for the tough decisions to be made and for change to be embedded, before all is swallowed up in the political whirlwind of a general election.

Some of the negative polls, which seem to suggest that the public trust the Tories with the NHS more than Labour, reflect a reluctance to credit an increasingly unpopular administration with anything. But as Gordon Brown is smart enough to realise, there is no future for a government that blames the public for its unpopularity.

It is now ten years since Tony Blair told voters they had 24 hours to save the NHS. By the time of the next election, Labour must ensure that it is credited with the improvements that have undoubtedly happened in the NHS. Labour inherited a crippled NHS from the Conservatives. After ten years under Labour, the NHS is off the critical list, but it still requires a long period of rehabilitation.

Suresh Pushpananthan is a member of the Central Council of the Socialist Health Association (www.sochealth.co.uk).

]]> 2007-04-12T11:55:34-05:00 http://www.labourhome.org/story/2007/3/12/3139/13350 Tribune.

The NHS has seen unprecedented levels of funding in the last few years. The vast majority of it spent on acute hospitals. Despite this, health inequalities have persisted. I argue that public health and preventative measures should be given greater priority under our next Prime Minister. Since the Black Report was published in 1981 health inequalities have stubbornly refused to shift. The fate of the Black report was representative of the Tories' commitment to inequality. It was commissioned by a Labour government in its death throes, delivered to a Conservative one that cared little for the notion of inequality and even less for Black's costly recommendations.

Since 1997, the Labour government has made substantial efforts to increase the attention given to health inequalities as part of wider health policies. The health of the population as a whole has improved since 1997, but wealthier people have benefited more than poorer people.  A boy born today into the lowest social class in this country is still likely to die nine years before a boy born into the highest social class. A resident of Kensington can expect to live approximately 11 years more if a man, and 9 years more if a woman, than their counterparts in central Glasgow.  

In 1997, Frank Dobson commissioned an updated review of health inequalities. Sir Donald Acheson, the former Chief Medical Officer, carried out an independent inquiry that found widespread evidence of persistent health inequalities. He recommended action in the NHS, on poverty, housing, education and employment.

Wider determinants of health such as education, employment and financial status play a more important role than health policies. The government's 2003 report, Tackling Health Inequalities: A Programme of Action, supported existing initiatives designed to improve health and reduce the health gap. These included targeted action in the areas of education, welfare to work programmes, housing and urban regeneration initiatives.

In reality, it is too early to fully assess the impact of the health policies of the last ten years. There has certainly been some improvement in life expectancy and infant mortality. It is unclear how much of this is due to reduction in poverty and how much to effective health policies.

The huge cash injection over the last few years has undoubtedly improved healthcare provision. Tackling waiting lists is important for the poor who often linger on them longer than the rich who can afford the private fees necessary to jump to the front. However, the government have concentrated their efforts far too much on hospital care which is not the most sensible way to address inequality. A stronger public health agenda is required. It is surely far better to prevent illness than to treat it once it has ravaged someone's life. It is also more cost effective to do so.

Poor people smoke and drink the most, and eat the worst. Britain suffers a relatively high incidence of heart disease and smoking-related illnesses such as cancer; they are concentrated among the poor, who are more likely to get them and more likely to die if they do. The death rate from heart disease in people under 65 is almost three times higher in Manchester than in well-heeled Richmond, Surrey. An unskilled man under 65 is four times more likely to die from lung cancer than his professional counterpart.

Smoking is now concentrated among lower social classes. For example, 42% of male unskilled workers smoke, compared with 15% of professional males. As people get fatter, another class divide is opening up. Some 28% of women in the bottom social class are obese - twice the rate among those in the top class. Action is needed now on these key threats or the financial and population implications will be disastrous for the NHS as it seeks to manage the failure to prevent the onset of ill-health. The ban on smoking in public places is a good start, but we should also increase the age at which cigarettes can be bought to eighteen.

The political returns from investments in public health are difficult to measure, and take time to materialise. Voters would rather hear about slashed waiting lists than about the number of people who are taking more exercise. The government needs to be bolder in taking the steps that are necessary.

Although the NHS is largely free at the point of use, there continues a system of charging for drugs, eye tests and dental services amongst others. Those who are deterred from taking their medication by the cost of prescription charges are those most in need. If the NHS is to play it's part in reducing health inequalities these disincentives must be minimised. The cost of travel for treatment is going to become more important as specialist services are concentrated in fewer locations under the proposed reconfiguration plans. Increasing travel costs will only exaggerate the malicious effects of health inequalities.  

In addition, the government's choice agenda is likely to further widen such inequalities. The Choose & Book policy will benefit the middle classes disproportionately as the more articulate are able to elbow their way to better and quicker treatment. I have yet to see a patient in my outpatient clinic, through the new Choose & Book system, that is not a well educated, middle class person.

The government must show that it is as committed to tackling health inequalities as it has been to tackling waiting lists. The jury is still out on how far this commitment is serious and sustainable, or whether concerns about the state of hospital services will continue to monopolise Ministers' time. Successive governments have failed to shift the balance away from short-term imperatives and the NHS has remained a `sickness service' for too long. A long-term, sustainable public health agenda aimed at preventing illness rather than treating it is required. For a Chancellor that is sensitive to accusations that the government has pandered to the middle classes and done too little for the poor, such dramatic inequalities should be viewed as an opportunity to make his mark as Prime Minister.

Recommendations

*The Choice agenda within the NHS must be redesigned to minimise health inequalities rather than widen them. If the government is to keep the flawed Choose & Book system it should insist on all GPs offering choice, not just the 35% of practices serving the better off.

*Increased financial assistance with travel costs for those using distant hospital facilities. Comprehensive bus services must be provided to the new regional `super-hospitals' that will be created under reconfiguration plans.

*Increase the number of school nurses as promised in the government's 2004 Choosing Health document. Health inequalities are determined from childhood. Healthy lifestyles need to be taught in schools.

*Food and drink served in schools must meet strict nutritional standards. All junk food to be banned from schools.

*Increase the age at which cigarettes can be bought to eighteen.

Suresh Pushpananthan is a member of the Central Council of the Socialist Health Association (www.sochealth.co.uk).
]]> 2007-03-12T03:13:04-05:00 http://www.labourhome.org/story/2007/2/23/74511/8912 Tribune.

If anyone has recently been into an NHS hospital as a patient or visitor - you may have noticed the wall-mounted combined telephone and television units. The exhorbitant prices they charge can be problematic for those that regularly use hospital services.

I explain why these charges are so high.

Has anyone got any experience of using these over-priced facilities? Immobile Phone Charges in the NHS

The NHS was founded on the principle that healthcare should be free at the point of use and based on need, not ability to pay. Nye Bevan's original vision only lasted 4 years before being steadily eroded by a stream of healthcare costs with charging for prescriptions, dental services and spectacles beginning in 1952.

Further costs, including transport and parking, are not prohibitive for the occasional short hospital stay.  However, they are particularly burdensome for the elderly and those with chronic conditions who often find themselves catapulted further into poverty by the misfortune of falling ill. In 2000 the Government made a commitment in the NHS Plan to provide a personal bedside television, radio and telephone to all patients funded by the private sector and paid for by users as part of the Patient Power programme. One of the principle grievances my patients have about their stay in hospital is the high cost of using these amenities.

Ofcom investigated Patientline and rival Premier Managed Payphones after relatives of sick patients complained about the rip-off rates people are being charged with costs of £3.50 per day to watch television and incoming call costs of up to 49p per minute - double the cost of a call to Australia. A recorded message, which cannot be skipped, makes incoming calls even more expensive.

The Health Select Committee investigated healthcare charges and concluded that the cause of these very high charges is the Government's decision to install bedside units which can also be used by health professionals to access electronic patient records and allow electronic prescribing. However, most hospitals have not taken up these services and do not intend to do so. The Government was unwise to insist on such an ostentatious and unnecessary adjunct to the already extravagant National Programme for IT. To insist the cost was picked up by companies is tantamount to passing the costs on to patients.

A simple way to avoid excessive telephone costs is to use the mobile phones which most people now have. However, there has been a blanket ban in most hospitals due to an erroneous fear of `interference' with medical equipment. The Medicines and Healthcare products Regulatory Agency (MHRA), the agency responsible for medical safety, has found that there are no technical reasons why mobile phones should be banned outright from hospitals, only in critical care areas. The vast majority of ward beds do not fall into this category.

However, concession agreements entered into by the companies with NHS Trusts included that mobile phones would continue to be prohibited within hospitals. The Ofcom investigation noted that in some cases there was evidence that the provider had applied pressure to maintain a total ban on the use of mobile phones in hospitals. The only reason to maintain a blanket ban on wards is to protect the monopoly for Patientline and similar companies.

NHS Trusts cannot be expected to share the extra costs of phone calls as their current priorities are to balance budgets in an extremely difficult financial environment. The Department of Health should either provide funds to decrease the cost of phone calls in hospitals or lift the blanket ban on mobile phone use in hospitals. The sick and poor, while confined to hospital, need not suffer the additional misfortune of social isolation.

Suresh Pushpananthan is a member of the Central Council of the Socialist Health Association (www.sochealth.co.uk).
]]> 2007-02-23T07:45:11-05:00 http://www.labourhome.org/story/2007/2/10/142420/880 Reconfiguration of NHS services is causing significant political waves. Thirteen ministers have been campaigning against proposed closures to NHS services in their constituencies.

They are Hazel Blears, John Reid, Tessa Jowell, Harriet Harman, Jacqui Smith, Phil Woolas, Ivan Lewis (Health Minister!), Mike O'Brien, Derek Twigg, Joan Ryan, James Plaskitt, Kitty Ussher (PPS), Mary Creagh (PPS).

This article concerns reconfiguration of maternity services. The reconfiguration of NHS services has recently dominated discussions about healthcare reform bringing with it intense controversy. The proposals to close smaller maternity units across the country and replace these with larger regional units has ignited strong community loyalties to local institutions and mobilised local and national political forces.

The size and location of UK hospitals has largely been the product of historical chance rather than rational planning. When the NHS was established in 1948, a patchwork of hospital services that had previously been run by local authorities and voluntary organisations were nationalised. Enoch Powell's 1962 Hospital Plan for England and Wales was the first large scale reconfiguration programme within the NHS. This created district general hospitals designed to serve populations of between 100,000-150,000 and this basic model has remained in place since this time.  

The recent trend towards increased specialisation and sub-specialisation in medicine favours a health system consisting of large hospitals offering a wide range of specialist care. This theory of healthcare has now replaced the model envisaged by Powell. Trauma and other highly specialist services should be concentrated in fewer, larger centres to maximise treatment outcomes and save lives. However, maternity services are more complex. There are many other factors beyond survival alone that need to be weighed in the balance with maternity services.

Childbirth is undoubtedly one of the most important experiences in most women's lives and one which they hope to cherish forever. Many women hope for a natural birth in their community with minimal medical intervention. The vast majority of the half a million births a year are uncomplicated, and there is no need for women to give birth in `super maternity units'. We should follow other European countries and resist the excessive medicalisation of birth whilst remaining focussed on providing a safe service. Can we really tolerate pregnant women being treated like battery hens?

The Government's plans to improve maternity services and offer greater choice - as set out in the National Service Framework for Children, Young People and Maternity Services - are being jeopardised under the current reconfiguration plans. The Government rhetoric focuses on increasing choice in the NHS, yet the current policy appears to erode choice for pregnant women. How can the government reconcile the perverse situation where parents are losing their right to choice while giving other patients meaningless choice through the flawed Choose and Book system?

It is inevitable that some maternity units, especially the smallest units in large urban areas, will have to close. The decision as to which maternity units are to be shut should not be left solely to Strategic Health Authorities and Primary Care Trusts whose current priorities are to balance budgets. The Independent Reconfiguration Panel - a body of experienced clinicians and managers that provides advice to the Secretary of State - should evaluate all proposed service closures to ensure that quality of service and safety are the only factors influencing the choice of which units are to close.

The reconfiguration of maternity services will continue to cause political waves. The potential for short-term financial and political concerns to influence local decisions makes it all the more important that there is real transparency about the factors affecting each proposed closure. The ultimate aim must be the provision of high quality maternity services to all. In addition, parents-to-be should have a choice of how and where they will give birth, something that is vulnerable under the current proposals.

Suresh Pushpananthan is a member of the Central Council of the Socialist Health Association (www.sochealth.co.uk).
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