The coalition’s plans for the NHS could alter it irreversibly, by shifting the balance of control to local government and by altering the way in which market mechanisms work within it. Government claims of ‘radicalism’ are justified by the unexpected enthusiasm for local council influence over health services, and by the departure from Labour’s use of market mechanisms, but there are significant problems that the Coalition will struggle to overcome.

 The legacy: New Labour & the NHS

 New Labour not only increased the funding for the NHS, but attempted to reshape it, with some success. A mixture of methods was used to change the way it worked, some traditionally socialist and others mimicking the market. Socialist emulation was tried, with praise and prizes for innovators, as was agitation that by-passed slow-moving bureaucracy. The NHS Modernisation Agency’s slogan was ‘Towards a million change agents’, in other words, every NHS employee would become an innovator. Payment by results in general practice lifted the quality of care of long-term conditions like diabetes, high blood pressure, chronic bronchitis and other lung disorders, and heart disease. Target-setting changed hospital activity and helped to reduce waiting time for surgery as well as in Accident & Emergency departments. Focused funding overcame supply bottlenecks and increased the speed and quality of cancer services. There were some unintended consequences of all this change, and the pace of reform was probably too fast, but overall the traditional socialist methods worked.

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Irwin Brown of the Socialist Health Association looks back to a lost opportunity.

 There is a growing divide between those who believe in partnership, cooperation and integration within the NHS and those who want a market with competition, multiple commissioners and providers. The debate becomes real with the recent announcement of the pilot use of a 111 number for urgent care, to try (again) to stem rising demand for 999 based emergency calls and A&E attendances. A move followed by the announcement that NHS Direct, previously sold as the way to reduce demand for emergency services, is to be axed, no matter what the evidence from the 111 pilots.

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It is often said, probably correctly, that the biggest health gains have come through public health not through medicine. Things like immunization, clean water, adequate sewerage, decent housing and even decent education all contribute to improving health and increasing life expectancy. Increasingly we learn from political geographers like Danny Dowling that life expectancy and poor health can be predicted from post code at birth just as educational attainment, crime rates, and teenage pregnancy rates. We all have the equal opportunity to climb as high as our “parent’s” income permits.

Fixing the positioning and role of public health as a public sector function has been complicated by the establishment of the NHS as the only major personal public service completely outside any democratic control and thus as an island with its own culture, run in the interests of a loose coalition of vested interests. Responsibility for public health has moved around between health bodies and local government.

It appears everyone agrees we have to move more around education and prevention and to tackle the causes of ill health, not just treat the poor health when it happens. Making people healthier has to be achieved by an integrated approach guided by clear policy and driven by inspirational public leadership; the kind of leadership which cleared the slums. Instead, we have fragmentation, an unstable policy base and In the NHS public leadership is vested in the PCTs which are led by people who are unelected and unaccountable and if the ConDems are to be believed – incompetent.

To many this appears that Local Government must have a much greater role, even though they don’t want it, they have the power to do pretty much anything so long as they can argue that it improves the “well being” of the community they served.

The link between well being to public health is obvious and powerful and the White Paper, in one of its better portions, makes the links and states how local authorities will have explicit functions around public health (with funds attached) as well as having some vague and ill defined role of “promoting” integrated commissioning of care. Health and Wellbeing Boards are to be set up, but not as a formal Council Committees and without a Portfolio Holder/Cabinet Member responsible.

Local authorities will have greater responsibility in four areas:

· leading joint strategic needs assessments to ensure coherent and co-coordinated commissioning strategies;

· supporting local voice, and the exercise of patient choice;

· promoting joined up commissioning of local NHS services, social care and health improvement;

· leading on local health improvement and prevention activity.

The recent letter to Directors of Public Health from Professor Dame Sally Davies – Chief Medical Officer (Interim – does this make her a Management Consultant?) tells of the development of a National Public Health Service (PHS) within the DH – good centralising move, but sheds little real light on what is expected locally. The claim is of an exciting vision for an integrated service but with both the DH and the local authorities still in the mix this is a false hope. More is promised later in the year.

You are left with the feeling that the proposals don’t actually join up. Local authorities have a role but not the responsibility or even the authority to make things happen. The GP Consortia Commissioners have the authority to commission the health services and are accountable to the DH (sorry Commissioning Board), but they have some sort of responsibility to take part in the Health and Wellbeing Board – Councillors meet GPs!

The only sensible path to integration is to give all the responsibility and authority to the local authorities for all aspects of care as well as public health. For many aspects of commissioning, especially of health services, the responsibility might be delegated to other bodies (such as with Practice Based Commissioning) and it would have to be informed by working with health professionals, and patient groups. The Strategic Needs Assessments which local authorities have to carry out could be the driving force for integrated commissioning in a way that just has not happened so far.

That gives a real platform to drive integration but also saves a great deal of bureaucracy and management cost as local authorities already have in place much of what will have to be duplicated to create the governance and performance management infrastructure for the GP Consortia. And, the health of the public will benefit.

Irwin Brown

Socialist Health Association

Dear Secretary of State

You have announced your intention of publishing a White Paper on the future of public health later this year. This is encouraging and I hope that you will take the opportunity of the new coalition government’s mandate for change to undertake a radical shake up not a mere tinkering at the edges.

Assuming that your underlying aim is to improve the health and wellbeing of the population of England you will be aware that the most effective ways of achieving this lie outside your own direct control, albeit within your corporate control as a member of the Cabinet. These include improving educational attainment, reducing inequalities in wealth and empowering the people through devolving power from the centre to local authorities and to communities and neighbourhoods.

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Welcome to the August edition of the Marmot Review Newsletter. Since the last update there have been a number of additions to the website that reflect the ongoing work of the Marmot Review Team, which we have detailed below.

We would be grateful if you could pass on this newsletter to anyone who might be interested,

Kind Regards,

The Marmot Review Team.

Professor Sir Michael Marmot and the BMA

It has been just over a month since Professor Sir Michael Marmot was appointed president of the BMA. His acceptance speech at the BMA annual representative meeting is now on the website, along with a profile and interview of Sir Michael in his new role. Professor Marmot has also responded to the BMJ Inequalities Report, for the full response please click here.

The Health Secretary Andrew Lansley MP gave a speech to the UK Faculty of Public Health last month, in which he mentioned the Marmot Review and pledged his support for its recommendations. This is also available on the website

Case Studies and Local Examples

The website is regularly being updated and improved, for example we now have a full section on case studies from the report.

We have also gratefully received many emails detailing examples of local implementation or interesting projects in response to our last newsletter. Some of these are now up on the website – this is an area that we hope to enlarge and update over time, so please do continue to email and tell us about any interventions, strategies or activities that you know are helping to tackle health inequalities in your local area.

© Copyright The Marmot Review 2010

Dear Editor

Of course Evan Wood is right to promote an evidence based approach to tackling drug related harms. After all we doctors have pioneered the evidence based approach and now accept that all policy and practice should be so based.

But there is more to the present UK drugs policy than the ignoring of evidence. As if this were not bad enough it is compounded by two equally reprehensible features – outdated moralising originating from the religious right in the US and a double standard that regards alcohol and nicotine as acceptable psycho-active substances but not heroin, cannabis and cocaine.

As Steve Rolles and Fiona Godlee suggest in the same edition of the BMJ the regulated legalisation of drugs must be the future but a necessary first step is an impact assessment of current policy compared with regulated legalisation. To press for this the medical, public health and scientific must act together as Evan Wood proposes. An opportunity perhaps for my own discipline of public health to take a lead in initiating such a coalition for whereas drug misuse per se is undoubtedly a public health challenge the sort of prejudiced evidence-blind thinking that lies behind current drugs policy is a much greater one.

Yours sincerely

Paul Walker

I was also puzzled by John Humphries response to the piece with Dr Sam Everington. Maybe he’s never heard of the Peckham Pioneer Health Centre before ? The legacy of the Peckham Experiment is still kept alive by the Pioneer Health Foundation (PHF) www.thephf.org who continue to lobby, educate and enthuse about the ideas and principles which remain as important as ever. However I do want to point out that the Pioneer Health Centre was not run by general practitioners. The doctors George Scott-Williamson and Innes Pearse were biologists trying to explore the nature of health. They conducted annual ‘family health checks’ and the results were communicated to the members of the family who took action as they felt necessary. Any treatment required was carried out by GP’s in the area who were not part of the health centre. Similarly the Bromley-by-Bow centre, where Sam Everington works was not set up by the GP’s, who came into an existing project some years later. The importance of integrating health services with community health and wellbeing projects is crucial but I think really successful projects that are initiated by GP’s are few and far between. The new world of GP commissioning proposed by the coalition government in the white paper Equity and Excellence: Liberating the NHS may open up opportunities but I think the initiative and control of such centres needs to come from communities who invite their local practices and schools in, rather than being bolted on to existing services. The focus should remain ‘health’ rather than treating illness, or education. The Peckham principles should guide communities in how to do this.

Jack Czauderna

Vice-Chair PHF

This is a bold White Paper, even if it contains a great deal that Milburn and Blair would have introduced, if only they had had the courage, and so therefore represents yet another turn in the cork screw of healthcare policy. The vision offered is beguiling and logically coherent. The real tests, however, are more practical and pragmatic.

Whilst the White Paper recognises the need for substantial improvements in productivity, releasing £20 billion to reinvest in the NHS, there are no details of how these savings are to be made, though there is a recognition that the NHS will end up employing fewer people. The proposed reforms may deliver substantial benefits in the longer term, but over the next year or two they will have little or no impact, other than perhaps increasing costs, for example, through redundancies.

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The reactions of the medical profession and the wider world to the publication of the coalition White Paper are nothing new. When we formed Nene Commissioning in Northamptonshire in April 2007 we attracted a similar mixture of cynicism, incredulity and doom-saying; ‘…involve GPs in commissioning decisions? But they haven’t got the skill or the will to do it…it’ll be a disaster!’

However, our consortium of practices (originally 61 and now 76) has consistently proven the cynics wrong with a number of wide-ranging transformational schemes which have radically altered the experience for patients and professionals alike.

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It is generally accepted that the weakest part of the long drawn out saga of reform of the NHS has been “commissioning”. Equity and Excellence spells out the intention to have another go, this time with consortia of GPs as commissioners. In terms of the public, and many in the NHS, there is little understanding about what commissioning is. Is it necessary; is it a fancy name for contracting; does it only come if you have a market and privatisation; and does it exist outside the public sector? The DH made a special attempt to define commissioning and set out 11 competencies which would define a world class commissioner but it is not clear how much of this will survive.

Everyone agrees we have to have something which allows decisions to be made rationally about how publicly funded resources are allocated and it is accepted that demand for health provision will always far exceed the resources available. Commissioning is the collection of activities which attempts to make sure public money is well spent and that we get value for money and it is also the mechanism by which competing priorities for public funding are resolved. It is not about all the little decisions which are delegated to those considered appropriate but about the strategic decisions. So it will exist even if there is no market system and even if it is not explicitly defined. How do we get the biggest health gain from the available resources?
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