Socialism and HealthPromoting health and well-being through socialism Spring 2004

SHA Principles The Socialist Health Association promotes health and well-being, social justice, and the eradication of inequalities through the application of socialist principles to society and government.

Underlying these goals are three foundation principles:

DEMOCRACY informed participation local decision making election not selection

EQUALITY fairness affirmative action progressive taxation

UNIVERSAL HEALTHCARE meeting the needs of individuals and communities promoting health and well-being and preventing disease free at the point of use and funded by general taxation.

The SHA believes that these objectives can best be achieved through collective rather than individual action. Its members are committed to a broad public health approach because they consider that the application of medical technology alone will not realise the full potential for health and well-being.

The SHA is affiliated to the Labour Party, and seeks to influence its policies to reflect socialist principles. In pursuit of its objectives the SHA arranges conferences and seminars, publishes reports and provides a platform for debate on health issues to inform SHA contributions to the development of Labour Party health policy.

FROM THE CHAIR

SHA Chair Paul Walker poses a challenging question for SHA members

Welcome to the first of the new style Socialism and Health.

Central Council has determined that we should produce our Association newsletter at least twice a year but in a new form electronic, more eclectic and with photos where appropriate. And with hard copy versions available to members without access to e-mail and for special events such as conferences.

So with this launch edition we are trying something else new. We are using it to seek the views of the rank and file membership on an important but insufficiently discussed public health issue of today by asking the question:

Is it now time to legalise - or at least decriminalise - the use and supply of drugs?

It is a fact of life that, in the absence of a strong religious taboo, homo sapiens has recourse to mind altering drugs of one kind or another. Attempting to prohibit the use of such drugs stands as much chance of success as banning sex.. Probably less chance, in fact!

The only rational response to this evident truth is to provide the requisite drugs within a regulated framework that assures an adequate supply and the purity of the drugs. This should take place within a taxation regime that generates funds to support comprehensive health education programmes aimed at discouraging drug use, and providing specific care and treatment when needed. This is what we do, more or less, with alcohol, except of course that the revenues generated are not hypothecated to spend on health promotion, treatment and rehabilitation but to swell Treasury coffers.

The net result of such action would be a significant reduction in harm from overdosing and adulteration, a sustainable source of revenue for targeted health education and treatment programmes, and the elimination at a stroke of the crime associated with illicit drug use. And as a bonus, licit use would allow us to measure more accurately the true extent and nature of the habit, thus giving a better general insight into societal health and well-being. Can we doubt, for example, that the present epidemic of binge drinking is an indicator of some pervasive societal malaise? Though some would argue that if there is such a malaise, it is one that has existed in this country since time immemorial, as we have a long history of binge drinking.

So should the Socialist Health Association campaign for the legalisation of drug use and supply on the grounds that the direct impact on health and well-being would be positive, and that the indirect effect through reducing crime might be even greater? And on the ground that it would have a differential beneficial impact on the socially excluded? Not trivial questions, and ones that no government in this country is going to take seriously unless substantial and sustained pressure is applied.

There is of course the small matter of the United Nations resolution to which all member states are signed up prohibiting such an approach. However, Portugal and other countries seem to be finding ways round this constraint; so presumably where there is a will there is a way.

BUT WHAT DO YOU THINK?

Please let us know by writing to:

The EditorSocialism & Health50 Wesley SquareLondon W11 1TS

or by e-mail to: jm@jblakeman.fsnet.co.uk

Choosing Health? the consultation we have been waiting for

The government has just begun a major consultation on how to improve the nations health and well-being. It is seeking views from the general public and from organisations on the role that government, individuals, the voluntary sector, the health service, other parts of the public sector, industry - such as food, alcohol and leisure, and the media can play in improving health. This will include the views of people in the groups and areas experiencing the worst health. Responses to the consultation will feed into a new Department of Health white paper to be published in summer 2004, setting out what the government will do to achieve change. It will also feed into government plans for health service priorities and spending for 2005-8; into other government departmental spending plans; and into local authority performance assessment.

The deadline for responses is Friday 28th May 2004. Consultation papers, background material and more information are available from the Department of Health Website: onsultations" www.dh.gov.uk/consultations/liveconsultations or by ringing 020 7210 5343. They include:

The main consultation document Choosing Health?A summary of Choosing Health?Fact sheets with specific questions on key areas for action including: health inequalities, alcohol misuse, diet and nutrition, accidents, sexual health, mental health, tobacco, obesity, physical activity, and drug misuseA summary and recommendations from the Wanless Review Securing Good Health for the Whole Population, published in February 2004. This calls for a more systematic evidence-based approach to improving health, and a clear framework for using economic instruments, such as taxes and public spending, to influence peoples health. A template for responses

There will be national theme-based consultations led by task groups on children and young people, health and employment, consumers and markets, leisure, maximising the NHS contribution, working with and for communities, and service delivery.

Strategic health authorities, primary care trusts, councils and local strategic partnerships are also being encouraged to consult as widely as possible.

The SHA will be taking part in this consultation. The Association has long argued that the only way to improve health is to tackle the social determinants of health and ill-health. Health care alone can only achieve limited improvements in the nations health and well-being.

Branches and members are encouraged to meet, discuss and send their views to the SHA. The Associations response will be finalised at the Annual General Meeting on Saturday 15 May in Birmingham, so please get those contributions to the office as quickly as possible. Send them to Socialist Health Association, 50 Wesley Square, London W11 1TS or by e-mail to jm@jblakeman.fsnet.co.uk.

Here are some of the key questions that individuals, groups and communities are asked to address.

What you eat, and how you spend your time at home, school, work and leisure

What would make most difference about the choices that you make? Do you want more, or different information about what matters?

Where would you like information from? Are there choices you would like to make which are not available to you now?

What would help you make healthier choices? In your list of things to be done, what should come first and why?

Everyone should be able to make their own choices

What in particular would make a difference to choices that children, young people, pregnant women, disabled people and older people make? What would make most difference, and why?

People in some groups and areas experience health that is worse than the average, including some people in black and minority ethnic groups and people living in disadvantaged areas

How are your circumstances affecting your health? What would support you and your community to be healthier? Who could help you? What should they do? What are the barriers to overcome? What could local services and organisations do to support healthier lifestyles? What would be better done by the community itself? In your list of things to be done, what should come first, and why?

One persons choice may spoil the chances of good health for others

Have we got the balance right when it comes to smoking in enclosed public places and workplaces; recognising the difference between fun and antisocial behaviour; considering the consequences of unprotected sex?

The role of regulation

Should central and local government have more of a role in supporting people to make healthier choices by making it: easier to access the things that would improve peoples health, such as fruit and vegetables, safe walking and cycling, better communal spaces gyms and swimming pools, sun protection, access to contraception?easier to avoid things that are harmful, such as cigarettes, alcohol, food high in salt, sugar and fat?

If so, how? Should rules be changed on what gets advertised, availability of tobacco, drugs and alcohol to children, how products are promoted and displayed in shops, foods that industry produces? If so, how?

Working together to support healthy choices

What opportunities are there to influence healthy choices by action by parents, friends, school and higher education, employers, faith communities, health and social care professionals, local government, voluntary and community organisations, retailers, manufacturers, industry, trade unions, the media, leisure organisations, national government? What should be given priority? Where could more be achieved by working together?

The Big Conversation

The SHA has taken part in the governments Big Conversation. Here is an edited version of that contribution, highlighting the SHAs position on some key health issues for socialists. This also forms the text of the SHAs new recruitment pamphlet, copies of which can be obtained from the Manchester office at 22 Blair Road, Manchester M16 8NS; by telephoning 0870-013-0065; or e-mailing admin@sochealth.co.uk

A public health approach to well-being

It is fundamental to achieving the SHAs objectives that health, health care and well-being should all be tackled from a population-based public health approach rather than an individually focused medical one.

Because a public health overview is so important, the SHA believes that the Prime Minister should appoint a free standing Minister for Public Health to the Cabinet with specific responsibility for ensuring that all government policies are evaluated for their impact on health and well-being and on inequalities.

Action to reduce health inequalities goes way beyond health care. It covers the widest spectrum of life experiences that can be influenced by government. It requires joined-up thought and action by a whole range of government departments responsible, for example, for the economy, housing, education, the arts, the environment, leisure and transport. Each major government department should therefore have its own health champion, and each departments contribution to public health should be audited annually. National, regional and local government should undertake health and health inequalities impact assessments of any major new policy that is proposed.

Only a senior politician with Cabinet status will be able successfully to tackle this agenda.

Democracy, accountability and participation

The government should enable citizens to participate in NHS governance through regional and local elections. Directly elected regional assemblies throughout the country should plan and commission specialised health care within their area, as happens already in Scotland and Wales, with directly elected Primary Care Organisations commissioning and delivering local services

An alternative model would involve directly elected strategic health authorities, and responsibility for commissioning local services devolved to democratically accountable local authorities.

Whatever the model, local commitment and energy is vital to making real changes to peoples lives, and greater local autonomy is a precondition for this.

Healthier children

A healthier nation begins with healthier babies. It is known that poor health and nutrition in pregnancy cause health problems throughout the lives of the resulting children, yet so many young women are expected to subsist on benefit levels that are too low to support a healthy diet. There should be an immediate increase in benefit levels for pregnant women.

Free, healthy school meals should be universally available. Many children entitled to free school meals dont take them because of the stigma. Children should be able to drink water throughout the day, and free school milk and fruit should be available to all. Budgeting and shopping for healthy food, and cooking it, should be a part of the National Curriculum.

The duty of care owed to children by schools should be extended to their diet. Young children should not be given the freedom to eat too much fat, salt and sugar just because the damage done to their health is not immediately apparent. There should be a total ban on advertising unhealthy food directed at children, and machines vending fizzy drinks and unhealthy foods should be removed immediately from all schools. Commercial schemes that encourage children to eat unhealthy food to obtain benefits for their schools must also be outlawed.

Regular sports, dance and other exercise must be re-introduced to the school timetable to tackle the increasing problem of childhood obesity, complemented by a full arts curriculum that enhances self-esteem and mental well-being.

Parents should be actively discouraged from taking their children to school in cars, and each school should have a target to increase the number of children who walk or cycle, where it can be done safely, to school.

Learning to live healthy lives should have a place in the National Curriculum, where young people discuss their own and their communitys health. Sensitive issues must be tackled head on. The topics of drug, alcohol and tobacco abuse are avoided in many schools because they are controversial, yet children respond well to factual information on such matters. Education in sexual health and teenage pregnancy issues must also be compulsory and not left to the discretion of heads, school governors and parents.

Healthier lifestyles

Healthier lifestyle choices must become easier choices. Government faces a dilemma in striking the right balance between persuasion and prescription over individual lifestyles. However, the SHA believes that at the moment it errs too far on the side of persuasion.

For example, international evidence suggests that banning smoking in public and in the workplace can halve the incidence of smoking. UK local authorities should be encouraged to introduce bans, and pending the introduction of primary legislation they should be supported to do what they can now through existing by-laws.Individuals are often denied the information they need to make informed choices. Manufacturers do their best to confuse the public about health risks, and the government does too little to stop them.

The food industry should be encouraged to reduce the amount of sugar and fat in prepared foodstuffs, and salt should be excluded altogether where practicable. The addition of salt to any food should be a matter of individual choice. All food and drink should be clearly marked with the percentage of salt, fat and sugar contained.

Policies on drugs and alcohol should concentrate on harm reduction and be based on sound evidence, not moral presumptions. Legislation should be introduced urgently restricting smoking to consenting adults in private.

Poor diet and lack of exercise play a major part in the ill health of poor people. Access to exercise should be made easier, and people encouraged to reduce their intake of calories. The EU should not subsidise sugar or tobacco production. This gives a mixed message when government is exhorting people not to smoke and to reduce their consumption of sweet foods. The money should be invested instead in health promotion messages.

A healthy income

Most poor people would be able to live healthier lives if they had the means to do so. It is time for the UK to have a proper measure of the income level needed to avoid both absolute and relative poverty and ensure good health, satisfactory child development and social inclusion. This measure should determine benefit, pension and minimum wage levels, and it should inform the practices of debt collectors and the courts.

Healthier communities

Many local health services have a poor record of engaging with deprived communities. Too often poor people receive poor services from unenthusiastic professionals who live elsewhere and do not engage with those communities.

The government must maintain its commitment to reduce health inequalities over the long term. Some key determinants of ill health, such as poor educational attainment, income inequality, and child and family poverty are seldom mentioned in a health context, and these must be addressed more robustly. The resource allocation formula should take better account of economic and social disadvantage to produce a more equitable distribution of the nations resources. The many excellent local initiatives to tackle poverty and deprivation must be accompanied by robust monitoring systems that can measure progress made in developing healthier communities.

The current political focus on hospitals makes no sense, even in health care terms. While medical interventions contribute increasingly to life expectancy and the quality of life in developed countries like the UK, there are still great gains in health to be made through healthier lifestyles and primary care. All local directors of public health should therefore be joint NHS and local government appointments, and local government should share with primary care trusts the statutory responsibility to reduce health inequalities.

Targets for improving the health of populations should take priority over targets for treatments, waiting lists and operations and they should be integral to the role of all senior managers in local and regional government as well as in the NHS.

Active patients

People are experts in their own health. The clinician/patient interaction should not be defined as a customer/provider relationship but as a co-production of equal partners.

The new statutory rights for patients and users in the Health & Social Care Act 2001 and the Race Relations (Amendment) Act to influence the planning and delivery of health care are welcome as a potentially powerful means of achieving the patient-centred health service envisaged in The NHS Plan. However, the mechanisms of this influence, such as local authority overview and scrutiny and patient and public involvement forums, must be properly resourced.

A healthier workforce

The NHS must engage with its staff, develop their vision and utilise their unique experience of delivering health and social care. Money on its own will not raise the morale of health workers, but neither is there any sense in contracting out support services to an underpaid workforce. Securing the lowest tender price at the cost of impoverished workers should be recognised as the poor long-term bargain that it is.

The NHS could also focus much more on recruiting and training staff from deprived communities, and paying realistic wages. It must bring its occupational health service up to the level of good private employers to ensure that the health of its own workforce, long neglected, is assured.

Seamless health and social care services

Social care cannot be considered separately from health care, and greater co-operation between the NHS and social services is essential. Lip service is paid to the idea of a whole systems approach, but there is no evidence yet that this is delivering significant change. Much more needs to be done, although the development of care trusts and childrens trusts must not be at the expense of democratic accountability.

More resources are needed to keep people in their own homes. Personal care contributes greatly to keeping people out of hospital, yet the role of carers is neglected. They also need proper support and resources.

Services in the community are rationed in a way that would be unacceptable in acute health services. It is as much a priority to ensure, for example, that people with disabilities can function fully in the community as it is to ensure that they do not have to wait too long for an operation.

The poor image of social workers has become acute, and there should be regular campaigns to counter the low morale of social workers and the negative and unfair media coverage they often receive. Charging

Prescription charges should be abolished, and all services based on need should be free. Particularly perverse are the domiciliary and intermediate care charges that drive people into residential accommodation rather than remaining in their own homes.

Pending fundamental change, the government should introduce an immediate flat fee for a whole prescription.

Mental health room for improvement

Mental health services remain under-developed and of low priority. Mental health policy appears to be in the grip of the law and order lobby, whose policies are misguided, counter productive and damaging to service users.The government's decision to delay publication of the new Mental Health Bill is a welcome sign that it has heard the overwhelming opposition toprevious proposals. The SHA looks forward to a new draft Bill incorporating the constructive suggestions made by so many mental health organisations.

In particular, the SHA believes that mental health care services should be the place where the government first implements its commitment to provide a wider range of choice for patients.

The Labour Partys policy making process

There are differences of opinion within the Labour Party on some important matters that would be better discussed than buried. Some health policies advocated in manifesto for the last general election bore little relationship to those that came through the national policy forum process, and the government has implemented other controversial policies without discussion within the Party.

The SHA therefore advocates a reform of the national policy forum process to give Party members real opportunities to influence government.

Promoting difference

There is an increasing divergence between the health and health care policies in England and those in Scotland and Wales. The SHA supports this trend on the basis that pluralism promotes innovation; and would like to see formal arrangements established so that all home countries can learn from the experience of the others.

A holistic approach to health and well-being

The SHA believes that everything that government, industry, communities and individuals do impacts on health and well-being. And that promoting health and well-being must be an objective not always necessarily the prime objective of all organised activity.

Building on good foundations or seeking our new mutual friendsAs the first ten foundation trusts go live, SHA member Geraint Day argues in favour of the changes.

Well, the Bill got through the wrangling in the Palace of Westminster in November. That is, the Health and Social Care (Community Health and Standards) Bill. It covers a host of topics, only one of which was NHS foundation trusts.Not that one would have thought so from the tenor of the debate around that particularpart of the Bill. The arguments around foundation hospital trusts got increasingly bitter and acrimonious in some quarters as the time of final parliamentary decision-making drew near.So what now?NHS foundation trusts are in many ways a logical extension of the government's stated intentions in its NHS Plan issued in the year 2000: to extend autonomy and free up the creativity of dedicated NHS employees and local trust boards and management.

If one were to rely only on the likes of the Daily Mail one might be forgiven for thinking that the NHS was already in total meltdown. Yet, whatever the reality - and the Labour government has the avowed intention of improving whole swathes ofpublic services - there is clearly a huge amount of goodwill towards the national health service. Bodies such as leagues of friends, local fundraising charities, patient groupsand volunteers demonstrate this.The structures being prepared for the governance of NHS foundation hospital trusts have been deliberately modelled on the experience over 150 and more years of large organisations such as co-operative societies, friendly societies and mutual organisations. While most of these do not operate in healthcare delivery, they are based on community-based democratic control. Leading practitioners from the co-operative and mutual sectors (e.g. building societies) have been giving advice to the Department of Health (DoH) and the 25 first wave of foundation trust applicants on how to run community-based democratically controlled (warts and all!).Incidentally, the name foundation almost certainly derives from a name used in the Spanish mutual healthcare sector. A visit to Spain by UK health officials and the Secretary of State for Health (Alan Milburn MP at the time) preceded the use of the name in British (or at least English - for the foundation model is as yet confined to parts of the NHS in England) circles.And it is from overseas that some of the continuing lessons must be learned as foundation trusts come into existence. That is to say, that in Spain, Brazil, Japan and the United States of America - among other locations -are to be found democratically controlled mutual healthcare providers, with millions of members between them. One of them - Group Health Cooperative, in Puget Sound, Washington State, was set up at around the time of NHS inception, and was deliberately modelled on the Rochdale Society of Equitable Pioneers that opened for trading in December 1844.

That is, as a consumer co-operative trading not in food and other commodities, but in the provision of healthcare. They learned the lessons about badtimes as well as good, and it is well that the opportunity exists for learning from other healthcare organisations.

As the present Secretary of State for Health, Dr John Reid MP, said in a speech a few weeks ago,the NHS can learn from overseas good practice. Here is an ideal opportunity now that foundation trusts are to be a reality.Although mutual healthcare is as yet a rare thing in the United Kingdom, there isone British body that isalready a democratically controlled mutual. It has been around for nearly a century.

The Benenden Healthcare Society has as many members as work in the NHS, roughly (about 1.2 million). The members of this friendly society are people who work - or have worked - in the public sector. It runs a hospital in Kent, and provides access to other healthcare in other parts of the country for its members. As if to emphasise that its purpose is to be complementary to - not in competition with - theNHS, people working in the NHS are not allowed to become members.There is one part of the recent arguments about foundation trusts that should leave a nasty taste in the mouth of anybody who purports to be a democratic socialist. At least one Labour peer expressed horror at the idea of political activists and others getting elected to governing bodies or boards of directors of foundation trusts.

Critics who are frightened of elections need to take comfort that aspiring to an active member isone antidote to being taken over by pressure groups. (Anyway, not one NHS committee member or board member can be appointed or removed by the public now - what sort of accountability is that?)

Who do these people think elect or even become politicians in the Commons and on local councils? It is an idea not uncommonly heard from some supposed left-wing think tanks from time to time. The irony there is that hardly any think tanks have any sort of membership or democratic base to hold them to account. It seems that anybody can set up a think tank and pontificate in a political vacuum. I have previously dubbed that sort of thinking the New Elitism - as opposed to the New Mutualism.

It is around the experience of large mutual organisations that progressive people in that sector have already been bringing expertise to bear to advise the would-be foundation trusts - people from the consumer co-operative sector, building societies and other mutuals.

The think tank Mutuo (which is at least allied to that democratic set of enterprises, the mutuals) is one of the leading lights here. And its name also derived from Spanish; an unusual coincidence given my earlier remarks about Spain and mutually run healthcare. Co-operativesUK also contributed to the DoH's reference sourcebook on foundation trusts (NHS Foundation Trusts A Guide to the Governance Arrangements).As part of putting the foundation concept into practice, the "boards of governors" (or member councils or whatever each trust will call them) would harness some of the local goodwill andenergy for thebenefit of the NHS trust and for patients. Some of the 25 applicants for foundation trust status had already wanted to adapt patient groups or create new ways of actively involving patients in their NHS trust.

What could be better than truly to involve people in their NHS?

One other question for now, in the wake of the concluded parliamentary debate. Should the foundation approach have started with primary care? Probably yes. But even 25 English hospital trusts do not the whole NHS make. So it should be possible - and discussion is already taking place - to introduce similar locally accountable and autonomous units into Primary Care Trusts perhaps, or even around some progressive GP co-operatives. The most important thing is to do it properly, and among the 25 applicant trusts there is some real creativity and enthusiasm coming through. Watch this space.

Geraint DaySHA member, member of the Co-operative Party national executive committee, and member of the DoH's NHS foundation trusts external reference group on governance. Hehas been an advocate of mutual healthcare for nearly four years as the concept has developed from concept to reality.

AGM and Public and Patient Involvement event

Saturday May 15th 10 am 4 pm

New Directions in Patient & Public Involvement

Main speakers: Lord (Philip) Hunt, Chair of National Patient Safety Agency Prof Jenny Popay, Commission for Public and Patient Involvement Sally Brearley, Chair of Health Link

To be followed at 4 p.m. by the ANNUAL GENERAL MEETINGof the Socialist Health Association

Birmingham and Midland Institute,Margaret Street,Birmingham B3 3BS

Book your place fromMartin Rathfelderadmin@sochealth.co.ukSocialist Health Association22 Blair Road, Manchester M16 8NSTel: 0870 013 0065

www.sochealth.co.uk