Paul Krugman: America’s Greatest Public Health Champion?

Last week the New York Times reported on a study which documents a reversing trend in life expectancy for the least educated whites in the US. The study shows that since 1990, life expectancy for white Americans without a high school diploma has fallen by five years for women and three years for men. Reading this article, one is likely to deduce that these declines are largely the result of individual health behaviours and life style choices.

Per the NYT,  reasons offered by researchers for this decline include “a spike in prescription drug overdoses among young whites, higher rates of smoking among less educated white women, rising obesity, and a steady increase in the number of the least educated Americans who lack health insurance”.

A range of public health experts are also quoted in the piece and offer roughly the same type of behavioural explanations. At the end of the article, Lisa Berkman, director of the Harvard Center for Population and Development studies, at least begins to shift the focus further up the causal chain and notes that the reversal in life expectancies “should be seen against the backdrop of sweeping changes in the American economy and in women’s lives”, highlighting the deleterious impact of low-wage jobs on women’s health.

Two days later it is Paul Krugman, an economist, not a public health expert, who highlights that worsening trends in life expectancies have taken place in the context of increasing income inequality (see also Katherine Greir’s  piece on Alternet, which Krugman cites).

Is this surprising? Not really. Krugman has noted the corrosive impacts of income inequality before; he’s even made direct references to the Spirit Level, a book which systematically outlines how income inequality is related to societies’ physical and mental health, as well as their levels of drug abuse, education, violence, and community life.

Unfortunately, Krugman’s easy receptivity to the political determinants of health is not mirrored in the work of national public health campaigns. In 2010, the US Department of Health and Human Services launched Healthy People 2020, a 10-year agenda for improving the health of Americans. However, despite its stated goal of achieving health equity by 2020, nowhere in its description of the social determinants of health is attention drawn to income inequality. Moreover, attention is scantily paid to the socio-political factors responsible for unequal distributions of resources important for health: resources like income, food, transportation options, social support, etc.

It is now well evidenced that in places where income inequality is greater, population health outcomes, like life expectancy and infant mortality, are worse. Unfortunately American public health professionals, and health journalists alike, continuously fail to acknowledge and translate the implications of this evidence.

Good News for Unions is Good News for Public Health

Last Friday a Wisconsin county Judge, Juan Colás, struck down much of Act 10, also known as the ‘budget repair bill’. The Act, which was proposed and vehemently defended by Republican Governor Scott Walker, passed in early 2011 and effectively eliminated the collective bargaining rights of public employees, setting ablaze an on-going saga of protests, recalls and court appeals.

In his 27 page ruling, Judge Colás declared the Act unconstitutional and while it was overturned only in regards to city, county and school district workers, not state employees, union leaders and public workers alike have hailed the decision.

What does this have to do with public health? Unions have long been advocates for health promoting conditions, from better working conditions and employee benefits, to higher wages and policies that benefit the middle and working class. Their ability to do this has in large part depended on their ability to collectively bargain.

In the context of sustained political attacks against workers’ rights, it is important public health professionals stand with the labor movement, both in celebrating its victories and in supporting its struggles.



Root Causes of Ill Health Fall Flat in Bloomberg’s Soda Ban

While reactions to Bloomberg’s soda ban continue to effervesce, those truly concerned with the public’s health would be well advised to hold their praise.

Yesterday the New York City Board of Health approved Mayer Bloomberg’s controversial plan to ban large-sized sugary drinks. Across the web, the ban has sparked a range of debates. Proposed in an effort to curb obesity, many are concerned about how far the government should go in controlling people’s individual health choices; others wonder about its effectiveness in achieving smaller waistlines.

Back in April, Toronto based family physician, Ritika Goel, wrote about her encounter with the Mayor at the Johns Hopkins Bloomberg School of Public Health. As Goel writes, Bloomberg is well known in public health circles for spearheading a variety of health-related initiatives. Unfortunately, when questioned about one most fundamental determinants of health, income-inequality, Bloomberg was quick to dismiss its existence, let alone acknowledge its significance for improved population health.

For those of us concerned with improving the public’s health, Goel’s article about her experience meeting the Mayor should be carefully considered. For whether the soda ban policy is a step in the right direction ultimately depends on the wider policy approach within which it is enacted. And given Bloomberg’s failure to recognize the health importance of the socio-political context, we have great cause to be wary.

How Not to Think About Social Determinants of Health: A cautionary tale from Canada

In this guest post, Ted Schrecker critically discusses the results of a recently published public health study in Canada. Illustrated are the hazardous implications of de-contextualized conceptualizations of health.

In early April 2012, a flurry of news reports described a study of major health risks shortening the lives of people in the Canadian province of Ontario.  A typical report described “bad lifestyle choices” as together taking as much as seven years off Ontarians’ life expectancies.

As is often the case, the reality is more complicated.  The study, led by Ottawa researcher Douglas Manuel, was based on self-reports from 117,674 interviews in three successive surveys conducted by Canada’s national statistical agency (Statistics Canada) and record linkage of 99,929 of the respondents with their provincial health insurance records.  “The primary risk factors of interest were smoking, alcohol consumption, fruit and vegetable consumption, leisure physical activity and stress.”  A procedure known as a multivariable Cox proportional hazards model was used to estimate the life expectancy reductions associated with these “behavioural risks,” to use the language of the study report.  I’ll return to the problematic nature of this language.

In the full text of the report, the authors are commendably candid about limitations related to possible under-reporting of health risks in the survey on which the report was based – limitations, in many cases, related to the simplistic nature of the survey questions.  For instance, the survey asked only about leisure time physical activity, not about activity related to work or quotidian errand-running.  The conclusion that Ontarians’ combined exposure reduced overall life expectancy in the province by 7.5 years is no doubt statistically robust, given the data on which it was based.  Unfortunately, it’s also a ‘so what’ kind of conclusion.  The authors of the report are remarkably unreflective about their focus on proximate risk factors, ignoring the contextual influences that shape individuals’ opportunities to lead healthy lives.

It’s not as if the world just found out about the limitations of risk factor epidemiology, as Courtney McNamara noted in a previous posting.   She emphasized Link and Phelan’s excellent work on “social conditions as fundamental causes of disease,” and  in its 2008 report the Commission on Social Determinants of Health went to great lengths to foreground the “structural determinants and conditions of daily life” that “are responsible for a major part of health inequities between and within countries.”

None of these insights was incorporated into an interactive life expectancy calculator, based on the study findings, that invites Ontarians to respond to a set of questions that are then used to generate an estimate of how long they can expect to live.  Participants are asked such questions as how many servings of fruit or vegetables they ate in the past week; how many were potatoes; and whether any carrots were involved.  Other questions relate to leisure-time physical activity, and a strictly dichotomous question (like that in the original survey) asks whether most days are stressful.

Workers locked out at the Electro-Motive plant, London, Ontario. Photo: CAW Media; reproduced under a creative commons licence.

Now, if you are paying market rent for housing while living on the sub-poverty social assistance income provided by the province of Ontario, having first exhausted almost all your assets as a condition for eligibility, eating the healthy diet defined by the provincial health ministry is an arithmetic impossibility in much of Ontario.  Under these circumstances, hearing a $170k/year researcher and his team tell you that you should eat your carrots and have less stress in your life is not especially helpful.   If you are trapped in a low-wage service sector job, or have lost your factory job because the employer locked you out after you refused a 50 percent pay cut and then moved production to a lower-wage jurisdiction, which recently happened to workers at the Electro-Motive plant in London, Ontario, hearing a $170k/year researcher and his team tell you that you should eat your carrots and have less stress in your life is not especially helpful.  (Were I in such a situation, class warfare is the first phrase that would come to mind.)  And after chasing across town on the bus to shop the specials that are their only chance at a healthy diet, or turning as a last resort to the food banksthat have become an established feature of life in the province (not a lot of carrots there), how many Ontarians living on the margins have time or safe opportunities for “leisure physical activity”?

The researchers’ isolation from the conditions of daily life is revealed with special clarity by their treatment of stress as a variable somehow within the control of those experiencing it.  (In The Status Syndrome, Michael Marmot is eloquent on the weaknesses of this presumption.)  Before giving one more interview or writing one more grant proposal, all those involved with studies like the one just released in Ontario should read, carefully, Barbara Ehrenreich’s account of life in the low-wage service sector.  Nickel-and-Dimed is available both as a book with multiple secondhand sellers and as a feature in Harper’s Magazine, so readily accessible.  This view of stress is of course even more pernicious in contexts outside Canada: for example Spain, where unemployment is now over 23 percent in the aftermath of a financial crisis that began in the United States, or the United Kingdom, where housing benefit caps are driving poor families out of central London or into homelessness even as tax rates on the ultra-rich are coming down.

At stake here is a vital instance of what Kristin Shrader-Frechette and Earl McCoy have called a methodological value judgment.  Perhaps without being aware of it, Dr. Manuel and his team chose an approach that reinforces the neoliberal tendency to privatize risk and responsibility.  Conditions like poverty and ill health are ascribed to the choices and failings of individuals who have little control over macro-scale processes like financial crises and the relocation of production to lower wage jurisdictions, rather than situated with reference to radical inequalities in the opportunity to lead a healthy life.  The Commission on Social Determinants of Health understood the pernicious nature of this approach, implicating “poor social policies and programmes, unfair economic arrangements, and bad politics” as pathways to health inequity and structuring one of its three overarching recommendations around “the inequitable distribution of power, money, and resources.”

The most widely agreed-upon axiom of medical ethics is: first, do no harm.  Studies and derivative knowledge transfer exercises that neglect structural influences on health fail this basic test, for they are far from harmless.

Historical Trauma, American Indians, and Health

In this guest post, Dr. Margaret Moss talks about the health of American Indians and how it has been shaped through historical traumas related to US federal policy. Dr Moss is an enrolled member of the Three Affiliated Tribes of North Dakota and an Associate Professor at the Yale School of Nursing.

I first heard about historical trauma, as an explanatory concept, about 10 years ago in my role as an academic.  Without knowing the term, I had seen and experienced it playing out in those I knew or loved; nursed; or partnered in research with; and even in myself during my ‘more than a few’ decades on this earth.  Historical trauma as a concept has been applied to groups such as those surviving the Holocaust and their descendants, as well as to the Japanese who suffered internment camps in the US during World War ll and their descendants.  For American Indians, “historical trauma is defined as cumulative trauma over both the life span and across generations that results from massive cataclysmic events such as the Wounded Knee Massacre.”  In fact, historical trauma has been used to describe an American Indian holocaust by Braveheart and others (1998). The Lakota researcher also defines it as unresolved historical grief across generations.

I have described in previous postings on my own blog how federal policy periods, specifically aimed at American Indians, were carried out that resulted in loss of life, culture, language, place, sovereignty and family structure.  This list of losses is far from comprehensive.  Some of the more detrimental eras were named:  removal (1825-1850); reservation (1850-1887); allotment and assimilation (1887-1934); and termination (1940s-1961).  I maintain that historical trauma ultimately affects health.  As an American Indian nurse, I am fortunate to be able to combine paradigms in that both groups see health as holistic.  Health in the holistic view includes: physical, mental, emotional and spiritual domains of the person.  Much of the early work on historical trauma focused almost solely on non-physical domains, i.e. grief, stress, post-traumatic stress-like symptoms, etc.

The stunning health differences that are seen between American Indians and either Whites or ‘all races’ as reported by the Indian Health Service in ‘Trends in Indian Health’ (2002-3) can be found on their website: .  The Indian Health Service is a national health agency under the US Public Health Service charged with the health care of members of the 565 federally recognized tribes.  Some of the differences as noted in their report includes: 1) tuberculosis 533 percent greater; 2) alcoholism 526 percent greater; 3) diabetes mellitus 208 percent greater; 4) unintentional injuries 150 percent greater; 5) homicide 87 percent greater; 6) suicide 60 percent greater; 7) pneumonia and influenza 42 percent greater, and; 8 ) firearm injury 26 percent greater.

One difference noted between Holocaust, other trauma survivors, and American Indians is that for American Indians “[t]here has been no ‘safe place’ to begin again”. In other words, catastrophic group traumas such as the Holocaust, had a beginning and an end.  The survivors and descendants are dealing with the repercussions.  However, for many in Indian Country, historical and contemporaneous group and individual trauma continues.  There has been no end wherein now healing can begin.  That is an important distinction. The investigators found that historicalin the case of American Indians may have to refer to its beginnings in the past as opposed to a distinct historic block of time.

This sustained, persistent trauma- both current (see statistics above on homicide, suicide, injuries and firearms) and historically invoked but persisting today- grief- has most likely impacted the inability to make real strides today in raising the health status of American Indians.  Admittedly this is a quite heterogeneous group with variations in lifespan and disease prevalence.  Some of the numbers look close to those for US numbers broadly.  However, when drilling down to some specific groups one finds huge differences.  For instance, the average life expectancy of a male born today on the Pine Ridge Reservation is in the 40s; diabetes rates can be as high as 10 times that of the White or ‘all races’ rates.  There are explanations beyond genetics and socioeconomic circumstances.  One of these is likely the health manifestation of historical grief and trauma coupled with individual current trauma.  And it is the persistence of the stress and crushing burden that feeds into these numbers.

In my own family, I had three Native brothers and sisters.  Two grew up with me, 1 did not. They have all died with an average age of 40.  Between the families was a variance of socioeconomic standing, economic ‘class’, education and reservation vs. suburban upbringing.  It did not matter in the end.


Access to Contraception as a Human Right

In this piece, guest blogger Maria Pawlowska outlines the major arguments for why access to contraception should be treated as a human right. Also highlighted are the different implications of realizing this right in both the developed North and global South. Maria is a healthcare analyst with a passion for reproductive health and gender issues in health care provision. Maria has a PhD from Cambridge, where she was a Gates scholar, and has worked with the Global Poverty Project and RESULTS UK.

Margaret Sanger, an American sex educator, nurse, and legendary birth control activist once said that “No woman can call herself free who does not own and control her body.  No woman can call herself free until she can choose consciously whether she will or will not be a mother.”  Nowadays, these words are true as ever and encapsulate the main premise behind a recent joint publication by the UN Population Fund (UNPF) and the Center for Reproductive Rights (CRR) – that the right to contraception is a human right.

Michele Bachmann’s recent foray into damning a public HPV vaccination program for potentially harming ‘innocent girls’ shows how much politicians can get away with when it comes to reproductive health. When have you last heard anyone complaining about polio vaccinations? Oh right, it’s not a sexually transmitted disease…

It would have probably been even worse today if not for The Programme of Action from the 1994 Cairo International Conference on Population and Development (tellingly rejected by the Vatican). This document was an important milestone in changing the perception about reproductive health which is no longer a shameful issue to be dealt with in secrecy, but an important public health concern and a domain in which states should work to improve their citizens’ quality of life. Therefore, the current perception of the importance of contraceptives in particular and reproductive rights and health in general should not be taken for granted. Most governments nevertheless still hate mentioning anything that can be interpreted to even mildly refer to sex about as much as they dread the thought of having to raise taxes 6 months before a major election. However, the The Programme of Action has made its mark. Importantly, it was also the first to suggest that access to contraceptives is a human right.

You may be thinking “What? I can’t remember condoms and the Pill being mentioned anywhere in the Universal Deceleration of Human Rights (UDHR)?!” You’re right – it isn’t explicitly mentioned (in the UDHR at least).  However, the issue is a little bit more complicated than that, but really pretty straightforward.

Let’s deal with the more complicated things first (and not to worry, they really aren’t that difficult to grasp). As I mentioned in my previous post, the UDHR is not the only ‘UN-approved’ human rights document out there. There are actually a number of declarations (non-binding) and covenants and conventions (binding) which are part of the human rights legal framework and include, for example, the International Covenant on Economic, Social and Cultural Rights (ICESCR) and the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW). When stating that access to contraception is a human right, UNPF and CRR drew on all these documents and did not limit their analysis to the UDHR.

And now for the straightforward part, in which we will see that access to contraceptives really is a human right – one grounded in the basic principles behind the very notion of human rights. Women’s right to contraceptive information and services is, in fact, an element of a number of key basic human rights such as the right to life, the right to the highest attainable standard of health, the right to decide the number and spacing of one’s children, the right to privacy, the right to information, and the right to equality and non-discrimination. Not only is guaranteeing access to contraception an integral part of these rights, but it is also a means to securing their fulfilment.

Moreover, guaranteeing access to available, acceptable, and good quality contraceptive information and services free from coercion, discrimination, and violence is critical for achieving gender equality and ensuring that women can participate as full members of society.  The importance of contraceptives is highlighted by the fact that a range of them is included in the World Health Organization (WHO) Model List of Essential Medicines. UN bodies (such as the Committee on Economic, Social and Cultural Rights) have indicated that provision of the drugs on this list is a core minimum obligation of states in realizing the right to health. Importantly, the obligation to provide contraceptives is classified as “immediate” – often also called the “minimum core obligations” – meaning that this obligation is not dependent on the socioeconomic context and thus should be fulfilled immediately.

A rights-based approach (RBA) to the provision of reproductive healthcare and contraceptive information and services can guarantee the fulfilment of states’ obligation and the concomitant realization of women’s fundamental human rights. And it’s really crucial to understand that access to contraception is mostly about preventing unwanted pregnancies in the developed North, but in the global South it really is a life-and-death matter. While the life-quality enhancement and human rights fulfilment related to the provision of appropriate family planning is difficult to overestimate, the tragic and potentially life-threatening consequences of restricting access to contraceptives may result in devastating social, economic, and public health consequences. For example, of the approximately 80 million women who annually experience unintended pregnancies, 45 million have abortions. As a result, approximately 68,000 women die from botched back-alley abortions each year and complications from unsafe procedures are a leading cause of maternal morbidity.  Research has shown that satisfying the current unmet need for contraceptives could prevent roughly 150,000 maternal deaths and 25 million induced abortions worldwide annually.

It really is a no-brainer – preventing unwanted pregnancies allows women and families to lead a measurably better life and prevents deaths (of mothers as well as children). Access to contraceptives is a human right and it’s important to keep that in mind, when we veer towards perceiving it as a privilege of the richer or better educated.


Occupy Healthcare but don’t forget about the Social Determinants of Health

The Occupy Wall Street Movement has opened up many opportunities to make clear the links between economic inequalities and inequalities in health. A growing number of doctors, nurses, patient advocates, and public health professionals are taking advantage of these opportunities and drawing attention to a range of health concerns. However, conversations and actions so far have largely focused on issues of access to healthcare, medical debt, cuts to healthcare budgets, and the pitfalls of for-profit medical systems.

One of the biggest health related actions of the Movement took place on October 26th when Healthcare for the 99% (a coalition of physician unions, nurses unions, and various healthcare campaign groups) organized a march in New York City against the for-profit health insurance industry. Just yesterday, a group of health advocates in Boston organized a Health Justice Day of Action where in addition to a variety of health focused events, a team of volunteers dispensed free flu shots. In the UK, protesters in Cambridge occupied the offices of the Healthcare firm Atos, and on Twitter, the hashtags  #occupyhealthcare and #occupyhealth document  that more and more people are making the link between economic inequalities and healthcare related concerns.

Less visible in the Movement are messages about the social determinants of health (SDOH).  The need for better integration of SDOH messages have been noted by blogger Nate Osit, who emphasizes the need for a more global SDOH outlook in occupying efforts, and blogger Vinu Ilakkuvan, who has written about the need to move ‘beyond healthcare’ and highlighted examples of successful efforts toward this end. However, SDOH concerns aren’t completely absent from the Movement. The People’s Health Movement has stepped up to endorse the Occupy Wall Street Movement, directing attention to the importance of SDOH and urging its affiliates to “participate in this movement to overcome ill-health caused by social, political and economic systems that reproduce inequality and social injustice”. Moreover, “a group of (mostly) San Francisco Bay Area health professionals, providers, students, and advocates” have developed an Occupy Public Health site which includes, among other great resources, a lesson plan for teaching occupiers about the SDOH.

In an effort to support occupying actions directed at the social determinants of health, Healthy Policies will be hosting a Twitter chat tomorrow (Monday November 14th) on how SDOH messages can be better integrated into the Occupy Healthcare movement.  This chat is part of a larger effort organized by the IMAXI group, who are coordinating a series of social media events to bring people together to discuss the state of the world’s health every Monday, from the 14th of November until Human Rights Day a month later.

The Twitter chat will begin at 3PMEST/20hGMT and last for 30 minutes. To view the chat search Twitter for #SDOHchat; to participate, tweet your thoughts, adding  ‘#SDOHchat’ to your tweet.  A transcript of the chat will be made available shortly afterwards.

Debating the future of the English National Health Service

This post is the second half of a two-part series by guest blogger Kate Thomson which explores proposed changes to the National Health Service in England. The first post provides useful background information (particularly for those living outside the UK) on these proposed changes. In this post, Kate explains in greater detail the areas of reform which are of greatest contention. Kate is a Senior Lecturer in the Department of Public Health at Birmingham City University and is currently researching health reforms in the Russian Federation.

In a previous post, I outlined some of the major changes taking place within the English health service (NHS) via the Health and Social Care Bill. Here, I go into more detail on some of the main areas of contention.

Who are the providers? Competition and ‘choice’

The extent to which NHS services will be opened up to the private sector is one of the battleground areas in debates about the Bill. Government contends that ‘competition’ between providers incentivises quality improvement. Opponents suggest that increasing private sector involvement is an ideologically-informed step by a government that is inclined to be ‘on the side’ of big business. The link between provider competition (regardless of whether or not private sector providers are involved) and quality has been questioned. Key evidence cited by the Prime Minister as supporting this link has been subject to critical appraisal by a number of scholars who question its conclusions.

The term, ‘any qualified provider,’ is used in the Health and Social Care Bill to emphasise that healthcare services should be commissioned(purchased) via a competitive process. NHS providers, in other words, will not automatically be preferred over new and/or private sector organisations.  As well as ‘qualifying’ on grounds of quality and capacity, it seems that there will also, in practice, be financial criteria: is the company /enterprise solvent enough to bear the ‘risk’ of providing such services?

An unintended consequence may be tension with another much lauded principle of public sector reform – the Big Society, an idea which promotes extended involvement by charities and ‘social enterprises’ in providing public services.Such organisations are meant to be able to act more flexibly and be more in touch with needs ‘on the ground’ than state bodies. However, there is evidence that they may be ‘squeezed out’ of competitive tendering processes.All this adds up to what commentators have called an ‘intrinsic bias’ in the commissioning processes towards private, for-profit bidders.

Objections to private sector involvement go beyond the ideological (principled resistance to the idea of public money going ‘outside’ the system and into the pockets of shareholders). It is likely that there will be less competition to provide services in the most difficult and complex areas of care (e.g.intensive care), than in areas with relatively predictable costs and outcomes (such as non-urgent surgery). This could make it difficult for NHS hospitals that provide a range of interventions to compete in the local market; will a district hospital, for example, be allowed to ‘fail’?

Evidence is already emerging that newly formed clinical commissioning groups (CCGs) are directing GPs in what are effectively rationing decisions (e.g. relating to overall number of referrals to hospital; or access to specific interventions). This does not appear to fit with the model of shared decision making between practitioner and patient (‘nothing about me without me’), touted in government rhetoric. Nor does it entirely match the notion of clinically-led decision making about appropriate treatment  and availability (as opposed to decisions made by ‘bureaucrats’).  Such developments raise serious questions about equity and appropriateness in access to care.

Beyond problems around equity and consistency of ‘rationing’ decisions, CCG responsibilities raise the possibility of conflicts of interest. To a greater degree than in the past, ‘commissioners’ (CCGs) will be able to both plan (purchase) and provide services (i.e. they may ‘commission’ from their own members, such as GP practices or ‘spin-off’ enterprises). They will also be in a position to explicitly ration (limit access to certain treatments ‘on the NHS’) while offering themselves to patients  as willing providers of a fee-paying service.

The rhetoric of reform links competition with ‘choice’ for patients/consumers. ‘Personalisation’ is a health policy buzzword. Health and social care services are to be tailored to individual needs, with increasing individual choice about what, where, how and by whom care is provided. One of the mechanisms for this is the ‘personal budget’ – a direct payment, initially for patients with long-term conditions, to spend on an individually-determined package of services. Undoubtedly there are benefits from self-determination – an empowered service user getting the services they desire. Demand for under-resourced services may stimulate supply (and quality improvements).  However, there are also potential difficulties, such as the burden of administering such budgets; the negotiation of boundaries between personally budgeted care and access to commissioned services; and the possibility that less popular, yet important, services, could be undermined.  Personalisation and choice also need to be fully realised principles within the entirety of the system, rather than becoming ways of describing mechanisms for choosing services.

Public Health

In parallel with these changes there are proposed changes to the provision and structure of Public Health (which had its own White Paper in late 2010). The headline change was a move of public health responsibilities from within the NHS, to local authorities. This offers the opportunity for public health concerns to be effectively ‘joined up’ with the very wide range of policy decisions and service provisions offered by local authorities (the generation of ‘healthy public policy’ at the local level). However many public health practitioners fear dilution of expertise and reductions in clout and budgets to act. Amendments to the Health and Social Care Bill emphasised CCGs’ responsibilities for health improvement and public health; and for the health of all in their geographical area (not just ‘their’ patients). However, the demarcation of responsibilities in practice, between health care commissioners and local authority public health bodies, is yet to be clarified. There are certainly grave concerns about the impact of restructuring and other elements of the Bill, among many public health specialists.


Finally, it is worth questioning the extent to which the reforms will reduce ‘bureaucracy’ in the NHS. The Bill was promoted as a way of creating a leaner health service, that operated closer to the patients and their clinical needs.  However, as the Bill has developed, proposed CCG roles have changed such that these will now be quite large organisations with a layered structure, and with a duty to consult with experts and the public, to inform their decision making. This is actually a rather different model to the original vision of GPs (primary care physicians) making decisions as a collective. Doctors are concerned about how far the burden of ‘bureaucracy’ for these organisations, will fall upon them. Perhaps an additional layer of oversight or management will be brought in – however this moves closer to our starting structure of Primary Care Trusts and Strategic Health Authorities.

Internal contradictions within health policy are nothing new to the NHS. Tensions, for example, between devolution of decision-making and imposition of national standards; and between the ‘choice’ agenda and the requirement to spend budgets in the most rational and equitable way, were features of the previous government’s approach too. We will discover whether the current reforms spell ‘the end’ of the NHS, or a more efficient and ‘modern’ reconfiguration, as the changes bed down over the coming months and years.

Reforms to the NHS in England: a brief introduction

In the first of a two-part series, guest blogger Kate Thomson  provides helpful background on the proposed reforms to the NHS, as embodied in the Health and Social Care Bill. Also outlined are the major concerns and debates surrounding the Bill. Kate is a Senior Lecturer in the Department of Public Health at Birmingham City University and is currently researching health reforms in the Russian Federation.

What’s going on with the English National Health Service (NHS)? If you’re based outside of the UK but follow health policy discussions on social media, you may well have noticed that major changes are afoot, in the  shape of the Health and Social Care Bill.

The NHS’s origins in the immediate aftermath of  World War 2, have generated a fierce sense of loyalty, or at least, ownership, among the population over successive generations. It was said that even the most forthright and radical of Prime Ministers, Margaret Thatcher, declined to make significant changes to it, understanding that politicians ‘meddle with the NHS’ at their peril.  In fact the system has changed in many ways over the past 60 or so years, and perhaps most dramatically within the past 15 years, during the term of the Labour administration (1997-2010).

The most significant change made by the Labour government was structural: a radical extension of the ‘purchaser –provider’ split introduced in the early 1990s. What came to be called Primary Care Trusts (PCTs) handled the NHS budget for each locality. They planned and bought (‘commissioned’) services appropriate for their populations –including hospital services. Combined with stronger entitlements for patients to choose where they had treatment, this generated an ever more competitive environment- crudely put, hospitals had to compete for patients by demonstrating good outcomes and satisfaction levels. Services could be commissioned from the private sector (e.g. private hospitals) too. Health policy making powers were devolved to the constituent parts of the UK; the NHS in Scotland, Northern Ireland and Wales started pursuing and structuring services in different ways.

Equity & Excellence

In May 2010 a Conservative – Liberal Democrat Coalition government was formed. July of that year saw publication of White Paper, Equity and Excellence: Liberating the NHS. Major re-organisation of NHS services in England was proposed.  This caused some disgruntlement given that pre-election promises had included ‘no top-down reorganisation’ of the NHS.

Of particular note were the proposals to abolish Primary Care Trusts (PCTs) and move to a system of commissioning care based around ‘consortia’ of General Practitioners. GPs are primary care physicians and usually the first point of  contact with the health system. The ten Strategic Health Authorities (which oversee the NHS in regions) were also to go, to be replaced eventually (2013) by a single Commissioning Board. Over the following months, NHS organisations started gearing up for these changes, with some PCTs divesting themselves of resources and merging with others. GP practices started forming groups with other local practices to ultimately form Consortia. Some had already been involved in planning and commissioning services as a result of the ‘practice-based commissioning’ policy, but this principle was to be rolled out on a much greater scale.

The White Paper formed the basis of the Health and Social Care Bill which was presented to Parliament in January 2011. Rumblings of discontent from professional groups and other commentators, about the direction and speed of the proposed changes, led to the announcement of a ‘pause’ in the progress of the Bill. This prompted a ‘listening exercise’ – an extended consultation period, led by the NHS Future Forum, which reported back to the Department of Health in June.  After the listening exercise, amendments were made to the bill (some of which are outlined below), and it progressed through the House of Commons (lower chamber) in September.

Post ‘listening exercise’, the new commissioning bodies are now called ‘clinical commissioning groups’ (CCGs), rather than ‘GP’ consortia. This is to emphasise the involvement of other members of clinical teams-not just doctors- in providing expertise to, and making decisions within, CCGs. CCGs now have to have at least one nurse representative and must also consult with a range of other experts in making their decisions. ‘Pathway’ CCGs have been identified to try out the mechanisms.  Other amendments include tweaks to terminology (e.g. from ‘any willing’ to ‘any qualified’ provider); some clarifications about roles and responsibilities (e.g. the national Commissioning Board); and alterations to the timeline for implementation.

In October, the Health and Social Care Bill had a second reading in the House of Lords (the upper chamber). Unions and others had campaigned to persuade members of the Lords to reject the Bill.  However, this motion, and another to refer it to a Select Committee (which would significantly delay its progress as well as making significant amendments likely), were defeated. At the time of writing, the Bill is progressing through the ‘Committee stage’ in the Lords, which involves very close scrutiny of the details in the legislation.

Reaction and debates

There has been considerable resistance to the proposed changes from professional and public sector groups. The Keep Our NHS Public campaign (a public organisation); the British Medical Association (representing doctors), Royal College of Nursing ,Royal College of GPs and a collective of public health specialists, among others, have written very considered and constructive, yet in places quite damning responses.  Some summaries of professionals’ and academics’ responses to the Bill are available here and here.

Major concerns and debates around the bill include:

  • the extent of market competition – the role of the private sector, impact on NHS services and smaller-scale providers (charities, social enterprises);
  • vulnerability of services (or even population groups) not regarded as priorities by commissioners;
  • the blurring of roles (especially for GPs) leading to potential conflict of interests, and to reduced time caring for patients;
  • extent to which the proposed changes will really reduce ‘bureaucracy’;
  • cost of implementing the changes in a time of financial austerity;
  • perceived fragmentation of the NHS as a national institution; and withdrawal of ultimate responsibility of ‘state’ to provide health services;
  • the place of public health responsibilities within the new structures.

Some of these issues are going to be discussed in greater detail in my next blog post.

  1. British Medical Association (2011) BMA Statement on the Health and Social Care Bill, 20 July 2011    [accessed 17 October 2011]
  2. Royal College of Nursing (2011) RCN Briefing on the Health and Social Care Bill, October 2011 [accessed 17 October 2011]
  3. Beckford, M. (2011) Nearly 400 public health experts warn Lords to reject NHS reforms, 3 October 2011 [accessed 17 October 2011]

Better Governance to Improve Health

In the context of the recent World Conference on Social Determinants of Health, guest blogger Amir Attaran discusses the role of governance in improving the health of societies. Amir Attaran is a professor and Canada Research Chair in Law, Population Health and Global Development Policy at the University of Ottawa.

(Originally published in Portuguese in O Globo (Rio de Janeiro) on 19 October 2011)

If you are over 40 years old and reading this, consider yourself lucky, because historically you should be dead. Just two centuries ago, and for millennia before that, human life expectancy was half of what it is today. For doubling our lives, we must thank medical and public health science, and the legal and economic governance of modern, liberal societies.

But medicine and public health science are now close to a plateau, where life expectancy increases more slowly, at greater expense. As people live longer, lifestyle choices—diet, exercise—produce obesity, cardiovascular disease, diabetes, and cancer. In an ageing population, long life increasingly is not healthy life.

These transformations demand us to reevaluate the methods of using science and medicine to cure disease, and instead to ask how the governance of societies can prevent disease. Well before 2050, when the most typical Brazilian will be a woman over 80 years of age, societies must reorganize themselves so all their members can lead healthy lives. That means the governance of liberal societies, which formerly improved our health, now must adapt not to destroy our health.

This week in Rio, the World Health Organization is holding the World Conference on Social Determinants of Health, hosted by the Government of Brazil. It is a very important event: the first of its kind. Appropriately the agenda emphasizes governance over science or medicine. Governments need persuading that health is a good reason to use the controls of law and taxation –controls all governments possess to nudge society’s direction justly and not tyrannically –both to improve absolute health outcomes of all society, and relative health outcomes between the powerful and weak.

Not all governments accept this version of liberalism, and worse, many use the controls to destroy health rather than to improve it. Governments legislate agricultural subsidies of fast food (so a fatty burger and a sugary cookie are cheap) but do not legislate agricultural subsidies of slow food (so comida caseira and fruit are expensive). Or governments invest in highways to vast suburbs where the relatively wealthy must drive, but not safe downtowns where all of us can walk safely. What to legislate or what to tax are difficult choices, but with governance like this, is it any wonder that more people suffer obesity and hypertension which can kill them?

What worries me most, as a professor in both science and law, is that the unsurpassable influence of governance on health is either appreciated by too few, or too frightening to many. In many countries, even rich ones with universal health care systems like the UK, a distance of 10 kilometers or less separates neighbourhoods where for social reasons lifespan differs by 10-20 years (in Rio, 12.8 years). Yet governments avoid using the legal and economic controls. Even the WHO, which should know better, avoided mentioning “law” or “tax” once on the official agenda. Instead its agenda touts fuzzy goals like “Promoting participation and community leadership” – an irony because at WHO headquarters in Geneva, even NGOs which are officially recognized by WHO are not allowed participation in working groups. Thus even the WHO is not setting a good didactic example or leading by example.

Brazil has many social problems, but is trying hard and setting a better example that many so-called “advanced” countries. Recently in the British medical journal, The Lancet, our research team pointed to laws in Brazil which help procure cheaper medical supplies—a law that even Canada, my country, lacks. Good governance in Brazil means social services are increasing and income inequality is declining, while in Canada social services are declining and income inequality is exploding. It is not only symbolic that Brazil’s Vice-President and two Ministers will attend the conference, but Canada sent no Minister and only bureaucrats without authority.