Memorandum submitted by Unite (Amicus
section) (HI 48)
This evidence to the House of Commons Health
Select Committee is submitted by Unite (Amicus Section). Unite
is the UK's largest trade union with 2 million members across
the private and public sectors. The union's members work in a
range of industries including manufacturing, financial services,
print, media, construction, transport and local government, education,
health and not for profit sectors.
Unite (Amicus section) is the third largest
trade union in the National Health Service and represents approximately
100,000 health sector workers. This includes seven professional
associations—the Community Practitioners and Health Visitors'
Association (CPHVA), Guild of Healthcare Pharmacists (GHP), Medical
Practitioners Union (MPU), Society of Sexual Health Advisors (SSHA),
Hospital Physicists Association (HPA), College of Health care
Chaplains (CHCC) and the Mental Health Nurses Association (MNHA)—and
members in occupations such as allied health professions, health
care science, family of psychology, counsellors and psychotherapists,
the family of dental professions, audiology, optometrists, opticians
and building trades, estates, craft and maintenance.
EXECUTIVE SUMMARY
— It is the view of this organisation
that the NHS can make a significant contribution to reducing health
inequalities, particularly thorough targeted support and early
interventions for children and their families as delivered by
health visitors in the home and school nurses in schools. However
without a massive investment in these professions these effects
cannot be felt.
— Unite-Amicus have highlighted below
the contribution these professions could be making and outlines
the further inputs required by government to ensure they are delivered.
OVERVIEW
1. After a period of record NHS investment
over the last 10 years, it is a tragedy that whilst this money
has had great impacts on improving hospital waiting lists and
patient satisfaction ratings, it has not had enough impact on
reducing health inequalities (Wanless, 2007). Unite-Amicus support
the view of many that this is due to disinvestment in public health
and particularly public health practice. Indeed over the past
15 or so years there has been a steady erosion of services which
health visitors once offered. This has been compounded by:
— The loss of a specific training council
in the early 90s,
— A removal of protection of this professional
role in statute in 2001
— The introduction of grade mix into
the delivery of a very complex role
— A subsequent reduction of skilled
health visitors, which we know has contributed to a weakening
of their contribution to reducing inequalities.
2. As the government has demonstrated (Cabinet
Office, 2006) effective outcomes are related to the skills of
the staff making the inputs when tackling inequalities. The Unite/CPHVA
Annual Omnibus Survey (Durdle Davies, 2007), made clear that these
changes had led to many health visitors often not having the resources
to either identify or respond to the needs of many of their vulnerable
clients (Craig & Adams, 2007 see Appendix 1).[370]
32% of respondents reported they could no-longer respond to the
needs of all their vulnerable clients. Further a survey by the
Family and Parenting Institute showed that there is a postcode
lottery of health visitor provision with the lowest caseload sizes
not necessarily occurring in areas of greatest vulnerability (Gimson,
2007).
3. Currently we have the lowest number of
health visitors employed for 13 years (The Information Centre,
2007) despite:
— Very high levels of immigrants, migrant
workers and asylum seekers,
— An increasing number of children
with complex needs,
— An increasing demand on their time
from other agencies particularly social services.
Furthermore there have been:
— Reductions in health visitors trained
by over 40% (Unite/CPHVA, 2007) for the past 2 years.
— Higher levels of stress amongst health
visitors than most sections of the NHS workforce (NHS Employers,
2007). This was reinforced by Unite-Amicus' own survey where 75%
of respondents (n=1,000) reported they were aware of colleagues
off with work related stress and 77% indicated an increase in
their own work places stress during this period (Durdle Davies,
2007).
4. Unite-Amicus believe that many of the
health issues currently requiring increasing investment by the
government relate to this reduction in the universal health visiting
service. For example, obesity, and mental health. This is probably
particularly important in relation to the increases in children
requiring secondary input for emotional and mental health issues.
These issues are most closely related to the family environment
experienced by the child.
5. The health visitor can have a very profound
working with families and particularly when children are vulnerable
to social disadvantage or there are significant inequalities.
Unpublished Unite-Amicus research has demonstrated that the health
visiting service can impact in many ways to promote mental health
in families (Adams, 2006). In so doing a child's self esteem and
emotional resilience grows and that child is more likely to be
successful in school, in the workplace and in developing relationships
throughout his or her life. In this way children can leave a situation
of emotional stress behind and be less likely to develop mental
illness and become a victim of inequality.
6. Despite misunderstanding by some in government
health visitors have traditionally and continue to focus many
of their efforts on supporting their most vulnerable clients and
many have very well developed specialist skills to do so. In particular
they target those who are victims of significant health inequalities
such as the homeless, gypsies and travellers, prisoner's families
and young mothers. See Appendix 2[371]
for details of how health visitors address the needs of some of
these groups and in so doing address inequalities. (Unite/CPHVA,
unpublished, 2008)
7. In 2007 the Department of Health published
a review into the role of the health visitor (DH, 2007). Unite-Amicus
completed a response to this document (Adams et al, 2007)
and this has been included in Appendix 3 for the committee's information.[372]
Unite-Amicus are very concerned that unless the government moves
very quickly to stem the loss of skilled health visitors the potential
impact of their service on health inequalities will continue to
diminish.
8. Unite-Amicus is equally concerned by
the continuing low numbers of trained school nurses. Following
specialist practice training school nurses are well equipped to
support the most vulnerable school age children.
NHS CONTRIBUTION
TO REDUCING
HEALTH INEQUALITIES
9. As is demonstrated in Every Child
Matters; Change for Children (DfES, 2006) health is a key
aspect of any desire to reduce health inequalities, as is evident
in the name itself. One of the advantages that the National Health
Service has had previously is that of its acceptability of its
services to those individuals and families that have historically
had difficultly in accessing other services. In fact the advantage
that every person in the country should be able to say they have
a general practitioner, every ante-natal mother has a midwife
and every new family has a health visitor should not be understated
or underestimated. These professionals really understand communities
and those who live in them. Through their universal access they
are perfectly placed to assess need, identify vulnerability and
activate other services to alleviate it by, for example, improving
access to financial support or better housing. As Sure Start and
family centres have found, accessing the most vulnerable children
can be very difficult where there is not good support from health
services and health led Sure Starts' have been found to produce
the best outcomes for children (Barnes et al, 2005)
10. The ability of a child to embrace education
is closely related to their degree of "happiness" or
emotional health. The education system is most challenged where
the children are most challenging. Early intervention to better
support families so children enter education with sound cognitive
development and emotional resilience is therefore logical. There
is also no doubt that children benefit from access to two parents
who love them. Many have to be helped to be able to demonstrate
love to their children and to understand their social health needs.
Health visitors will provide this support where they are properly
resourced. There are also well researched health visitor interventions
to support the inter-parental relationship which is usually key
to a happy home (Simons et al, 2003)
11. A reverse question could be set regarding
every other public service, agency and department that deals with
any issue. For example, how can local authorities contribute to
health inequalities, given that many of the causes of inequalities
relate to other policy areas?
DISTRIBUTION AND
QUALITY OF
GP SERVICES
12. One of the key issues raised by Unite-Amicus
members concerning General Practice services are that unlike the
rest of children and young peoples services being more based around
locality or geographically based, GP services are still provided
via lists (where practices can decide whether to accept patients).
This has the effect of creating confusion and difficulties regarding
inter-agency and multi professional team working. Members report
that as well as having to liaise with many agencies they also
have to be linked to multiple GP practices; these often have many
partners.
13. Care must be taken that GPs do not reject
the most vulnerable as they are burdensome. Also, many very vulnerable
people do not access GPs eg the homeless, travellers and asylum
seekers. Systems need to be set up to improve access, we believe
walk in centres have been helpful.
EFFECTIVENESS OF
PUBLIC HEALTH
SERVICES
14. This raises two issues in so far as
are smoking and obesity an example of causes of health inequality?
You can look at the inequality being that some people smoke and
if they smoke then they are more likely to be unwell, or that
there is a section of society that has poorer access and ability
to remain healthy and they are more likely to be a smoker/obese
due to stress or lack of access to healthy foods. This maybe highlights
some of the problem with some public health services, in that
the service is designed around smoking cessation. This will by
its nature be more appealing to those people who know they want
to give up, and therefore, does this support those in "higher"
socio-economic groups. Those services that provide universal access
will be able to uncover hidden vulnerability and ensure that inequalities
are reduced by supporting client centred interventions. Someone
who is unhappy and living in conditions of misery may smoke, drink
or take drugs to help alleviate the stress. A holistic and client
centred approach needs to be taken to help such individuals.
15. In general the most cost effective interventions
for smoking and drinking are probably those which reduce access
eg via taxation in general. However someone who is miserable may
chose suicide as a way of coping if other "props" are
not available. They are less likely to respond positively to "blanket"
public health measures. Those with good emotional resilience are
less likely to be substance abusers so early emotional support
is worth investing in.
16. The question regarding public health
interventions having the effect of increasing health inequalities,
may be in fact true, in that a proportion of the population will
have greater health benefits than others. What should not be ignored,
in that a greater positive impact is a good outcome, but also
a more minimal improvement is still an improvement.
An example from a Unite-Amicus member would be:
"When the new advice came out regarding
delaying weaning babies onto solid foods until six months, people
in higher socio-economic groups responded more quickly to the
advice, but the lesser response from lower socio economic groups
is still having a positive effect on their children's health".
17. This also raises the question about
social marketing in that to make something attractive to a group
of people you can't just market it to the most socially excluded
as they will see it as a stigmatised service.
18. An example of some of the problems experienced
regarding the current "targeting" in health inequalities
could be shown by the following example:
Unite/CPHVA has consulted with its school nurse
members to find out how the DH's National Child Measurement Programme
guidance is working in practice, and how it could be used better
to prevent and treat overweight children in primary school. The
department's target is that over 80% children will be measured,
increasing year on year. The school nursing service varies tremendously
with some areas employing health care assistants solely to do
this work. In other areas school nurses are extremely hard pressed;
we had examples where a school nurse and her colleague have a
case load of 9,000 children. School nurses take their public health
role seriously and are extremely frustrated that there are too
few of them to carry out all the work which the various public
health documents recommend in order to reduce health inequalities
in children.
There is a general lack of belief that the data
collected is an accurate reflection of the population. The nurses
report that in every class, two or more children opt out from
being weighed, and these are nearly always the overweight children.
The nurses do not understand why a statistical sample of 11 years
olds can't be used for national data collection. There are ethical
concerns around the fact that as the data is collected anonymously,
the school nurse has no mechanism to follow up overweight children.
The health service will know that the child's BMI is too high,
but the parents will not. Therefore the child is not helped by
this system, and nor are the health inequalities issues dealt
with.
IMPACT OF
SPECIFIC INTERVENTIONS
19. One of the key issues raised by Unite-Amicus
members regarding any initiative is the short term nature of any
funding versus the desire to have long term outcomes and benefits.
Members have contacted us with examples of issues raised with
this approach. For example, a Unite-Amicus member reported that
an regional area affected a massive reduction in the number of
women smoking during the ante-natal period. This was achieved
by a health visitor and midwife working together in a Sure Start
centre in a team approach. When the Sure Start service was "mainstreamed"
into the Children Centre, the midwife was "pulled" back
into the acute service (returning to be hospital based) and the
improvement in stop smoking was seen to reverse.
20. This experience of Unite-Amicus members
appears to be supported in the document "Our Future Health
Secured" (Wanless et al, 2007) in that "this
[conceptual public health] framework was not taken forward and,
as a result, health policy has remained focused on short-term
imperatives, public health practitioners feel undervalued and
significant opportunities have been lost".
21. In some areas, Sure Start Local Programmes
have attempted to ensure that black and minority ethnic populations
are fully engaged. The report "Sure Start and Black and Minority
Ethnic Populations, (Craig et al, 2007)" highlights
the importance of health services being integrated into these
services, "acknowledging the key role health visitors play
in delivering the programme and praised staff for their success
in creating links with BME parents who felt that social services
had little understanding of cultural and traditional parenting
practices" (Tweddell, 2007). However this cannot be a short
term approach as to affect change in a population takes more time
than 3-5 years.
22. An even more insidious outcome of the
recent amalgamations of primary care trusts in England have been
larger wholesale reductions in services where we have been provided
with examples of services being cut. An example given by a Unite-Amicus
member is the South East was that previously services had been
developed to support women who have had a miscarriage. On the
amalgamation of 2 trusts, the group leaders were asked to stop
providing this well evaluated service as they couldn't provide
it to all areas in this new trust, so it had to stop (Adams et
al, 2007). Unite-Amicus believe this is a perverse outcome,
especially when the Government is pushing an agenda where they
support services being provided to those families that require
them.
23. A major problem since the financial
cutbacks in public health community practice has been the subsequent
loss of leadership and innovation. Unite-Amicus experience suggests
that in response to intolerable working conditions many public
health practice leaders have voted with their feet by taking early
retirement or leaving the NHS. Innovation has been quashed by
unrealistic caseloads and a lack of valuing of specialist services
and professional expertise.
SUCCESS OF
NHS ORGANISATIONS CO-ORDINATING
ACTIVITIES
24. One of the key problems with the attempts
of the NHS organisations to co-ordinate their activity is the
large variation that presents itself across England (Triggle,
2007). When it is considered that in one strategic health authority
they may have upwards of five different organisational structures
that are intended to provide the same services, it can be seen
how this causes problems. There may have structures where health
staff are employed by either a PCT, the acute service, a mental
health trust, a local authority, a childrens trust, a not for
profit cooperative, a private limited company, a foundation trust
etc (Amicus, 2005). This situation may become even more complex
with future fragmentation of services being supported by policy.
It is clear to Unite-Amicus that the losers are likely to be the
most vulnerable.
EFFECTIVENESS OF
THE DEPARTMENT
OF HEALTH
IN CO-ORDINATING
POLICY
25. With the devolvement of decision making
from the "national centre" to local decision makers,
members have raised more frequent concerns regarding the decisions
that are being made locally. An example would be with the decisions
made around the number of staff employed. Which (2007) has highlighted
several of the "postcode lotteries" regarding provision
of service. One, that of the number of health visitors, directly
impacts on Unite-Amicus members. Nationally the government has
recently provided support to the role of health visiting and a
call for more health visitors. This message is being ignored by
some local PCT's and their commissioners in favour of using less
qualified staff, or by bringing in management consultants to reduce
the service further (Harris, 2007 & Snow, 2007).
26. When challenged, PCT's are repeatedly
arguing that as they are not being instructed to improve this
situation, then they use their resources to tackle those targets
which face tougher sanctions if not met. More recently, Unite-Amicus
and its members have had to lobby MP's in London constituencies.
In Enfield (Tarver, 2007) members have seen reductions in staff
numbers (whilst having increasing numbers of families in the area)
making the trust bottom in the "league table" for the
number of health visitors to children. This is combined with having
the highest rate of infant mortality in London. Sadly this is
not related to just one area, and just in London in 2007, similar
situations were challenged in Redbridge, Waltham Forrest and Hounslow.
In fact if you look at the league table produced by the Family
and Parenting Institute (Gimson, 2007) and compare that with the
index of multiple deprivation rank for the area covered by each
trust, you find that there is no correlation between deprivation
and numbers of key health promotion staff (Appendix 4).
27. Another example of local areas "ignoring"
national policy is that of school nurses. The Government, under
the 2004 White Paper "Choosing Health" (Department of
Health, 2004), allocated £42 million to PCT's, children's
trusts and local authorities to provide at least one full-time,
qualified school nurse to work with each cluster or group of primary
schools. In "Children's Health, Our Future" (Shribman,
2007) the number of school nurses was reported to have risen by
34%, but from Unite-Amicus figures, the target set will not be
reached until 2023 at current training levels, with no school
nurses leaving employment (Nursing Time, 2007). An example of
this was Hounslow PCT who in September 2007 had none (Parish &
Doult, 2007).
PUBLIC SERVICE
AGREEMENTS
28. This seems unlikely unless a needs led,
well trained health visiting service delivering interventions
based on best evidence of effectiveness is supported much more
robustly by government. To ensure public protection the role of
the health visitor should once more be protected in statute as
it was previously for almost 100 years. Furthermore the profession
itself should be given more control to determine the shape of
its training, health visiting leaders and specialists for vulnerable
groups should be encouraged and supported and innovative practice
valued. Over the past 15 years nursing had been very influential
in the direction of health visiting, to its detriment as the role
of the health visitor is a very different one based as it is on
promoting health. To invest in health visiting and hence early
intervention could produce massive savings to other areas of government
expenditure related to inequalities in the longer term.
Kevin Coyne
National Officer for Health, Unite-Amicus
January 2008
REFERENCES
ADAMS, C. (2006) Mental Health Promotion
in Families with Pre-school children: The role and training needs
of health visitors. Unpublished doctoral thesis.
ADAMS, C et al (2007) Unite/CPHVA
Response to Facing the Future; A Review of the Role of Health
Visitors. Unite/CPHVA. London. http://www.amicus-cphva.org/docs/CPHVA%20response%20-%20Facing%20the%20future3.doc
AMICUS (2005) Health Sector Briefing: Commissioning
a Patient Led NHS; Implications for community staff and their
clients. Amicus. London. http://www.epolitix.com/NR/rdonlyres/310FC759-37D8-40EC-BD5B-27A1482018C1/0/HealthSectorBriefing.pdf
BARNES, J et al (2005) Changes in
the characteristics of Sure Start Local Programme areas 2001-2
to 2002-2003 Sure Start National Evaluation Summary.
CABINET OFFICE (2006) Reaching Out: An Action
Plan on Social Exclusion. HMSO. London. http://www.cabinetoffice.gov.uk/social_exclusion_task_force/publications/reaching_out.aspx
CRAIG, G et al (2007) Sure Start and
Black and Minority Ethnic Populations. HMSO. London. http://www.surestart.gov.uk/publications/?Document=1905
CRAIG, I & ADAMS, C (2007) Survey shows
ongoing crisis in health visiting. Community Practitioner.
Volume 80.11, November 2007, pp.50-53.
DEAPRTMENT FOR EDUCATION AND SKILLS (2006) Every
Child Matters: Change for Children. HMSO. London. http://www.everychildmatters.gov.uk/_files/F9E3F941DC8D4580539EE4C743E9371D.pdf
DEPARTMENT OF HEALTH (2004) Choosing Health:
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DEPARTMENT OF HEALTH (2007) Facing the future:
A review of the role of health visitors. HMSO. London. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_075642
DURDLE DAVIES (2007) Results of the CPHVA
Omnibus: Autumn 2006. Unpublished.
GIMSON, S (2007) Health visitors: An endangered
species? Family and Parenting Institute. London. http://www.everychildmatters.gov.uk/_files/F9E3F941DC8D4580539EE4C743E9371D.pdf
HARRIS, C (2007) Members have no time for
Merridian: Concerns for services over consultant's role. Community
Practitioner. Volume 80.10, October 2007, pp4.
NHS EMPLOYERS (2007) The Healthy Workplaces
Handbook. NHS Employers. London.
PARISH, C & DOULT, B (2007) Minister's
trust should have 14 school nurses-but it has none. Nursing
Standard. Vol. 22, No. 1 pp7. 12th September 2007
SHRIBMAN, S (2007) Children's health, our
future. HMSO. London. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_080379
SIMONS, J et al (2003) How the health
visitor can help when problems between parents add to postnatal
stress. Journal of Advanced Nursing 44, 1-12.
SNOW, T (2007) PCT loses health visitors
but pays £360,000 for consultancy review. Nursing Standard.
Vol 21.51, 29th August 2007.
TARVER, N (2007) MPs intervene to solve health
visitor shortage. Enfield Gazette. 13/12/2007.
THE INFORMATION CENTRE (2007) NHS Staff 1996-2006.
The Information Centre. Leeds.
TRIGGLE, N (2007) NHS "now four different
systems". BBC. London. http://news.bbc.co.uk/1/hi/health/7149423.stm
TWEDDELL, L (2007) Nurses Key in BME family
care. Nursing Times. 17th July 2007. Vol 103, No. 29.
TWEDDELL, L (2007) School nurse recruitment
at risk. Nursing Times. Vol. 103, No. 30 pp5. 24th July 2007.
UNITE/CPHVA (2006) CPHVA Training survey
2005-06. Unpublished.
UNITE/CPHVA (2008) The distinctive contribution
of health visitors to public health practice. Unpublished.
WANLESS, D et al (2007) Our Future
Health Secured: A Review of NHS funding and performance. Kings
Fund. London. http://www.kingsfund.org.uk/publications/kings_fund_publications/our_future.html
WHICH (2007) Who's winning the postcode lottery.
October 2007, pp12-17.
Appendix 4—Index of Multiple Deprivation
versus rank of Health Visitor numbers across England
370 Not printed. Back
371
Not printed. Back
372
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