The community nurse: Interview with Norma Dudley

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How long have you been working in the NHS for?

Well, I trained as a health visitor in 1980. I trained in Hackney. I’ve done some teaching. So on and off I’ve been working in the NHS since 1980.

31 years?

Well, in fact I trained as a nurse in 1971, so all that time!

Could you please explain the work you do?

I work with mothers and new babies, and families with children under five. I do health promotion. I examine babies when they’re born. I work with women around post-natal health, post-natal depression. I work with children around behaviour and sleep and do screening for growth and development with children under five.

What does a typical day at work involve?

I might have a telephone call from the special care baby unit in the local hospital saying a baby has been born very early and the mother is visiting. I would go and see them and explain what services there would be for them when they and the baby are discharged; talk to them about how they’re feeling, do some counselling, emotional support, think about their family situation so that we can make sure that when the baby is discharged, it’s into a safe and healthy environment. Or I may run a clinic. I run drop-in clinics where parents and children under five can come and see me, get weighed and measured. I also do health screening, which would look at their growth, feeding; give breast feeding advice, give dietary advice and so on.

And how has it changed since you started?

My work has changed because London is always changing; the demography of London is always changing.

But with the introduction of the internal market in the NHS, I would say there has been much less preventive work. The aim of my work as a health visitor really is health promotion, health education, the prevention of ill-health and family problems; dealing with behaviour problems early, before they develop into big problems. With the introduction of the internal market and the services being built by commissioners, who are non-clinical, I often feel there is a focus on quantity of work rather than quality of work.

What the commissioners are interested in is numbers of contacts in the course of a day, but often seeing 10 people in a clinic may be easier and have less effect than doing work with one family that lasts for two days. Myself and my colleagues get increasingly frustrated because the people purchasing the services often refuse to recognise that. I think that, from the point of view of my service, the internal market, the commissioning model, means that we’re providing a worse service than we were.

It all sounds quite grey and shady with commissioners and targets. Could you explain what a commissioner is and what they do?

Until April 2009, I was directly employed by a local Primary Care Trust (PCT) and my job description, what I did in my working day, was prescribed by that trust and was completely led by evidence-based, clinical, medical, public health requirements. Then the internal market was brought in, which means that the PCT no longer actually delivered any hands on care, any treatment, any bandaging, any district nursing, anything like that. They were just buyers of services; purchasers or commissioners.

The organisation that I worked for was “liberated”, but was actually completely disengaged and set off in a free-floating way. The plan at the time was that the organisations that we worked for could be community trusts, but also social enterprises, independent or private not-for-profit companies. There had been a plan for social enterprises to be created at the request of the employees. The employees would have to vote and they could become sort of at arms' length from the NHS.

That didn’t happen because the workforce didn’t want that. What I feel will happen with this NHS [Health and Social Care] Bill is that, rather than that happening on a voluntary basis, [services] may very easily be taken over by either charities or private healthcare corporations. Companies like Care UK or Healthcare International might decide that they want to run a district nursing service or a podiatry service or a health visiting service, and they will be purchased by a GP commissioning body, a GP body that holds the budget.

Before we get to that, could you just explain what you mean by, or what is meant, by an internal market?

When I first worked in the NHS, and for most of the time that I’ve been working in it, it was organised into regions or localities - geographical regions in the country. Everybody working for the NHS - in hospitals and in the community, including the cleaners and going right up to the hospital consultants - would be directly employed by the NHS. They would be accountable to the NHS and all the money that the health authority was given went on either paying staff or buying equipment, buildings or medicines.

The introduction of the internal market within the NHS meant the splitting of the health service into an authority – a quango really – that had the budget and just did the buying of services, while the rest of us – the hospital staff, the community staff, the district nurses, the physiotherapists - would all be the providers of services. Those services would be bought by another NHS body.

Last year it was estimated that the cost of this internal market - that is, the transaction costs between one NHS body and another NHS body - amounted to £20 billion. And actually, under the last government, Gordon Brown said that the deficit in the NHS was approximately £20 billion. So, many of us in the workforce were very frustrated about this, and could see that it was not a useful use of NHS funds.

And the commissioners are the people who choose which providers are best suited to a particular patient?

Well, that’s right. Also [they choose] how much of any particular service they would commission for an area. In London, for example, the commissioners would be for each London borough and they would decide at the beginning of each year how much in patient care they would commission from the local hospital.

One of the problems was that if [more] local people turned up in casualty, or were referred by their GPs, and needed more Accident and Emergency (A&E) treatment, more operations, or there were more babies that had been commissioned for, then that hospital went into deficit. And so if the hospital staff were working very hard providing a good service that local people needed, they would be accused of over-performing!

That actually happened to a local hospital: Whipps Cross. The strategic authority for London was very critical of Whipps Cross because they had a deficit of so many millions. They accused the hospital of over-performing, whereas what they had done was providing a good service to the local population. The result was that, among other things, the authority for London – NHS London – planned to downgrade Whipps Cross and turn it into a sort of walk-in centre for minor ailments. It would have been a disaster for the community. We had a very robust, well-supported local campaign with lots of lobbying to keep our local hospital open. Arguments were being made that we should all go to the new PFI hospital in Romford - you know, value for money, better care, excellence, all of that kind of thing, and it was really only because we lobbied the local council very effectively [that this didn't happen].

That was directly a result of the internal market. The hospital had done nothing wrong. The hospital had been very efficient, but because the commissioners got wrong how much healthcare local people would need, we ended up on the point of almost losing our local hospital.

So that was because it was being treated as a commercial unit that had to be in the black, whereas previously it would be given the amount of supplies it needed?

Well, it would have had a budget but it would have been possible for local politicians to make representations to have that budget increased. The hospital itself would have been responsible for its own budget and its own planning and, if they planned effectively, they would have a sense of what kind of care was costing how much money, and how much the population would need it. They could monitor the birth rate, they would look at the kinds of surgery they were having to be doing, or what kinds of cases came into A&E. Then they could make a case for increasing their budget. With commissioning, there were non-clinical people stretching the budget in a certain way. Also the commissioning function was in itself costing money.

When you say non-clinical people, where were they mostly from? What were the typical backgrounds?

I think a lot of them come from the financial sector.

So their priority was balancing the books, if anything being in surplus?


What were the effects of this in terms of patient care? Was there an effect in the type of treatment that was given to people?

Yes. For example, in my service we were told to discourage people from going to A&E, certainly if they have small children. Hospital avoidance teams were set up. Now sometimes, if you can do enough health education and stop people being ill, stopping them going to hospital is a good idea, but we were always told to send people to their GP, not to the hospital, because it would cost more if they went to the hospital. There was an awful lot of pressure on staff being told how much each A&E attendance would cost. I felt - lots of us felt - that that could be quite dangerous, and that our concern was to educate people about the most appropriate kind of care at any one time.

But Labour increased the funding over their time in office?

Labour increased the funding. Actually, Labour did quite a lot of good things. Waiting lists went down under Labour, there was a lot of investment in new hospitals.

But many new hospitals were Private Finance Initiatives (PFIs), which means that they couldn’t borrow money at the public sector borrowing rate, I believe, and therefore, in the end, would cost the taxpayer much more. The introduction of the internal market under Labour, as I said, was costing about £20 billion a year, which, I would suggest, is not a good use of public money if you’ve got a limited resource.

The other thing is bringing in unqualified people. The sort of job that I do, I’ve got a lot of clinical knowledge but it’s a kind of soft job. So when they wanted to make 40% of us redundant, the management said, “actually anybody with life-skills can do your job.” And you can see why they would say that. That’s fine if everything’s alright, but if there’s a problem, it’s recognising where the risks are.

Could you give an example from your work of the skills that are necessary?

Okay. There was a client who lives locally who had become quite psychotic after she had had a baby. She was turning up at the GP’s surgery, shouting. The midwife didn’t recognise that she was becoming very depressed. She was in a sort of post-natal psychosis. She was turning up at the GP’s surgery, shouting and swearing at the receptionist who had her thrown out. We had a healthcare support worker in the clinic, who said, “oh, there’s that stroppy woman.” I went to talk to her and she fled out of the clinic, but I realised that she had a psychosis, so I was able to go and talk to the GP and say the next time this woman comes in, hang on to her, we need to do a psychiatric referral. And she went home and smashed in her in-laws house. The GP managed to get round to see her and she was sectioned and she went to the hospital up the road. It’s understanding what you see. And that’s because I’ve done my training and I’ve seen it.

Where there are targets, and where people are pushed harder to meet targets and criticised if they don’t meet [them], then that is a huge discouragement from making very thorough and detailed assessments and actually perceiving problems. So there is, I would say, an incentive to gloss over problems. There is an incentive not to see, for example, post-natal depression; not to see those problems because if you see it, you have to treat it, and to treat it is often long, complicated. Then you have to justify why you have spent three days doing a referral for a particular family when you could have seen six families. That’s the kind of problem that health visitors are facing with their managers.

For example, where I work the commissioning was done by someone who doesn’t understand health visiting and she commissioned our service for each practitioner to do about 55 visits a week - 55 contacts a week. Now that was a complete mistake. However, because that is what the contract says, the commissioners are pushing our service to provide that number of contacts. The provider organisation has been put into performance measures for not complying with those targets and our managers are being criticised as their staff aren’t meeting those targets.

It’s been very difficult for those of us who are clinicians to make our voices heard. We have been told that we mustn’t meet the commissioners to talk about our service because that would be a conflict of interest, because we are then trying to persuade the purchasers to buy our service. In fact, all we would be doing is making a clinical representation!

I am a workplace representative for my union and I have tried to support colleagues by sending clinical papers to the commissioners to explain the needs of the population and that some of the work is very complex, with very hard-to-reach families. It doesn’t seem to have had any effect at all. I get the feeling there is no interest from the commissioners and, a lot of the time, they regard it as an excuse.

Who set those contracts?

It was a manager in the provider service who is a midwife and not a health visitor, who said, “why aren’t you doing more health visits?” She’s just made a mistake. But there’s a kind of madness that that can happen. There’s a madness that the clinician in the service can’t be listened to. We – my colleagues – have asked for several years for a commissioner to spend a day with us; to come and sit in a busy baby clinic with us, to come and do some home visiting, to see the nature of the work that we do, to understand why one visit for ten minutes isn’t enough, to understand why we spend money calling people with mobile phones because a lot of the people that we visit don’t have landlines.

A lot of people that we work with are very suspicious of authority, so it takes a long time to get their trust. If you want a good public health service, it’s very important to reach the hardest, to reach people to persuade them to have their children immunised, for example. It’s a problem for them and it’s a problem for society as a whole. At the moment, my service is not following up children who don’t turn up for immunisations because we’re not commissioned to do that. So if we find work to be professionally necessary, if we are not commissioned to do it, we can’t do it.

So now, before the new reforms that have been proposed have come in, how do you think your particular area of work, and the NHS in general, could be improved?

I think that the NHS in general should be more publicly accountable. I certainly think there should be elected bodies, a good level of public participation, transparency of the budgets. The NHS tends to be run by quangos and there is very limited public accountability. There were local bodies which looked at the quality of care in the NHS: Community Health Councils.

Community Health Councils were like consumer groups that monitored the quality of care in the locality. There was criticism that they didn’t have enough power, but they were useful. At the moment, the health scrutiny committee of the local council has a supervising, over-seeing role, looking at the quality of care in any area. My experience is that local councillors on the health scrutiny committee have so much to do anyway, they know very little about health and are completely dependent on what the commissioning bodies want to tell them. I don’t think it’s a very effective scrutiny.

The Conservatives pledged to recruit an extra 4,200 health visitors if they won the election.

They have just published a new health visitor implementation plan and they do have a commitment to training and employing more health visitors, and obviously I’m very pleased about that. The question mark for me about that is who will employ them. For us in the community, there is a big question mark about who our employing body will be.

Who do you hope it will be, who do you worry it will be?

I’m worried that it would be an independent body, a charity or private sector provider. I am hoping it would still be an NHS body. It would also be possible for it to be the local authority, and as long as we had good medical, clinical supervision, I wouldn’t have a problem with that at all. In fact, when some of my colleagues, or my colleagues who have just retired, trained, they started off working for the local council.

Will these 4,200 support workers be life-skilled rather than properly skilled?

No, I think they will be trained. One of the problems is that, because our job is so pressurised now, lots of qualified nurses don’t want to then go and do their health visitor training. So they’re looking at different routes of training, but it would still be with the proper training. In fact, that’s the only training that NHS London have been told to increase rather than cut.

So it sounds quite good to be a health visitor under the new reforms: more of you, better trained!

Well, it’s quite possible that it would be. It’s very strange. They’ve talked a lot about early intervention. So I would say, of all the aspects of health, I would be least worried about health visiting, because they’ve said it over and over again. Who knows? It’s a funny old business.

Our local MP is Iain Duncan Smith and we’ve done a huge amount of lobbying with him, and he’s very keen on health visitors. He talks about how that’s going to save money for society down the line. He’s been incredibly supportive to us actually, so it’s all been very odd. That would be useful but that’s set in the context of everything that’s happening in the NHS. I wouldn’t stop campaigning just because they’ve said they’re going to give us some extra health visitors, you know.

I’m not just a health service worker; I’m a health service user. You can’t just think about yourself and your own service. I am worried because my concern is the NHS as a whole.

The reforms currently going through in the Health and Social Care Bill are said to be making the NHS more modern, more effective, efficient and accountable to patients. Andrew Lansley, the Health Secretary, said: “while the previous Government increased funding for the National Health Service to the European average, they did not act similarly to increase the quality of care,” which is roughly what you’ve been saying.

He said, “we are not distracting the NHS from the need to improve services for patients. We are enabling the NHS to improve services for patients …. Under the Bill, patients will come first and will be involved in every decision about when, where, by whom, and even how, they are treated … There must be no decision about me, without me.”

So, they’re saying it is going to become a more patient-centred NHS, more accountable to patients. Do you think that will happen?

No, I can’t see how that will happen because the new purchasing bodies, the so-called GP commissioning bodies, will not be elected in any way at all, and they will have fairly tight budgets so that the care that people get will be very much restricted by the budgets. And hearing GPs talking about this, they have said they don’t believe they will have a free choice in the kind of care that their patients get. They will be very much budget-led and will be urged to look at competitive tendering for a range of healthcare. My concern is that, rather than being at the centre, the patient will be pushed further and further away from the centre of the decision.

How would that work for health visitors?

That’s going to very much depend on how those purchasing bodies decide they want to use the service, so I’m not sure. If it’s the way that commissioning is at the moment, it’ll be according to numbers of contacts and that, I would say, would be risky because there will be pressure to see lots of people quickly.

We feel there’s an element of professional risk, but I feel there’s an element of professional madness about it because it’s very, very disjointed. If I can talk about child protection, something that’s very topical, very much in the news.

Say a woman who is pregnant is referred to social services. She is perceived by the midwife that she saw to have problems that may lead to a risk to the pregnancy, or a risk to herself and the baby. It is our practice to get to know that woman before she has that baby and get to work together with the midwife and social care to ensure, or do the best that we can to ensure, that the woman would have a safe pregnancy and the baby would be safe after birth. It could be that the concerns are so great - that someone was subjected to very severe domestic abuse, or was a substance abuser, or had very severe mental health problems, or had a history of either neglecting or hurting her children - that after birth, that child may not be automatically given to its mother, but the mother and baby may need some supervision or even there might be a case for removing the child. A thorough assessment would have to be made of all the risks, both to the mother and the baby, and any kind of vulnerability and likelihood of things going wrong based on what we know. There’s a whole body of evidence about child protection.

We have been told recently that we shouldn’t get involved with such mothers pre-birth, because that’s the midwife’s responsibility and we’re not commissioned to do that. We have made professional representations about this, saying we don’t think it’s safe practice because it’s important to build a relationship with someone with whom one is going to be doing that depth and complexity of work.

If we look at the serious case reviews – those are the investigations where things have gone very badly wrong – we find that one of the problems is lack of holistic care, lack of communication between services, and that's where things have gone wrong. It’s because somebody has fallen through a hole in the middle and one service hasn’t told another service. And if we look at the report of, say, Lord Laming, we find that the best practice is the most joined-up form of care that you can have.

But isn't this exactly the justification for the reforms that are coming through now? These kinds of bureaucratically driven targets, commissioners having all the power, non-clinicians having too much power over professionals...

Yes, but I can’t see how having a commissioning body run by a business manager will improve that situation at all. And they will be business managers. In London they have signed a contract with KPMG. It will again be driven by the financial requirements, even more so, I think, if EU competition reform comes into play. Most GPs have said they don’t want to run the business themselves.

But, ideally, would you like to work closer to GPs?


So isn’t it a good thing if GPs are commissioning you and your services directly, in communication with you?

I suppose there is a danger that there won’t be a national standard and that it will depend upon how any particular GP consortia choose to use their funds and how much they decide to spend on public health and on preventive care. So the problem with it could be that it could be very ad hoc and very piecemeal.

Why do we need commissioners at all is what I would say. Why could you not have a centrally and regionally planned NHS looking at the health needs of any local population? You could use local data and healthcare could be planned locally. It would have to obviously be planned in advance, and your data is never going to be totally up to date, but we will have a reasonable estimate of local health need. And I can’t see any reason why that could not be done in the same way as local authorities have a budget and will make a case for the needs of their particular population.

Who would decide that?

You would probably need a body that was made up of clinicians from local hospitals, from local communities, from public health, with patient representatives and maybe some elected representatives with scrutinising bodies, rather like the old Community Health Councils. I haven’t thought of a model but there’s no reason why that wouldn’t work.

Okay, so in London, we don’t need to speculate about the private element to it because a contract has already been signed with a consortium headed by KPMG.

It’s over-seeing the commissioning bodies and it’s also over-seeing community organisations. So, for example, I work at the moment for a large provider organisation, an arms-length provider organisation covering three London boroughs. That was due to be taken over by a bigger provider organisation, that was due to be taken over by a mental health trust. That was going to happen on April 1st. The NHS bill may go through at the end of March, around about that time. The merger of the provider organisation that I work in with the neighbouring one was going to make an enormous NHS provider organisation. It has been put on hold. It is being looked at by Monitor [the regulating body].

Monitor is saying this model hasn’t been market-tested and this is too big a monopoly provider of health services. For me, alarm bells are ringing already. A senior manager had said if they’re not going to take us over, we’re going to be flogged off to the cheapest provider. That’s hearsay but obviously there is a sense of unease about that. Why on earth can’t the NHS be a monopoly provider? The fact that that’s criticised makes me suspicious.

The argument that they are using is that more competition between providers gives a better standard of care to the patient because it makes them more accountable.

When we’ve seen contracting out of services -we’ve seen the contracting out of social care, we’ve seen the move within social care away form directly employed family support workers, home helps, bath attendants for elderly people in their home to carers working for a range of agencies - the effects have been disastrous and the clients themselves have had very little say over the quality of care that they have had. We have evidence of that. I don’t think there is any evidence to suggest it would be any better in the health service.

I cannot imagine what the advantage would be of one district nursing service competing with another district nursing service. And the idea of one hospital competing with another hospital is very worrying because what we should all be doing, and what we do in the health service because we’re not competing with each other, is share good practice. We don’t have secrets from each other. So I think it would make things much worse.

For example, I meet colleagues from trusts all across London and we would discuss things like our models of care. We would talk about it and we would take ideas from each other; we would pool our ideas. I have just done, for example, a care pathway for babies who have been in the special care baby unit. Now, another neo-natal nurse has said, “could I have a look at your care pathway, because I’m going to be doing some work in the community.” So I’ve sent it to her. I won’t be able to do that if we’re competing with each other - not that my pathway is best practice, but it’s a model of care that she might want to look at to inform what she does.

And what will the accountability be? If you have a problem with NHS services at present, there is a fairly good complaints system. I have used it myself and it’s pretty effective. I don’t see how that is going to be nearly as effective with a whole range of different providers and without universal standards. If we look at something as simplistic as hospital cleaning, there has been a lot of evidence to show that there has been a rise in MRSA since cleaning services have been contracted out to private providers. When you think about how straightforward cleaning is in comparison to a range of complex medical treatments, if it’s been difficult to monitor the quality of cleaning services so that they don’t effectively minimise cross-infection, how much more difficult is it going to be to supervise standards across the whole range of medical providers? And how much is it going to cost to scrutinise and supervise a whole range of different clinical providers?

We campaigned about a cut in the health visiting school nursing and district nursing service where I work. We did that by actually taking a lot of mums and babies, service users, to a meeting of the PCT board and we lobbied the board. Our very vocal mothers said why they didn’t want to lose a service. So although the Primary Care Trust, as it was then, was not elected, it did have to hold its meetings in public, so it did have to face the public and it did have to publish the board papers on the web, every month. Although most people didn’t read the board papers, we had some very diligent local councillors, one of whom had been a district nurse, who used to scrutinise the papers every month and go along to the board meetings and try an ensure that, you know, public health needs were met.

Do you think that patients will have sympathy with arguments like, “we want to make it less top-down, more accountable, we want patients to be in the centre”?

Of course they will. But everything in the past few years that said ‘patient-centred’ has actually meant the reverse. There is a kind of Orwellian reality about it, that the more they say the client or the child is at the centre, actually they’re about the last feature to be considered.

Many years ago, there was a move to make 40% of our service redundant because the PCT was short of money and we’re a soft target, because we’re preventive care, rather than hands-on treatment. When we were discussing this with our management, we said we were very busy. We run drop-in baby clinics. There will be two people working in a morning or a half-day session, and we will have 60-70 clients and they’ll wait for an hour to see us. Some people will sit there and wait for an hour and a half. So we’re clearly fulfilling a need. The manager said the clients may like your service but they don’t need it.

So I actually feel that saying the client is at the centre, or the patient at the centre, is actually spin because we know, given restricted budgets, that people can’t have just what they want. I would accept that, as long as care is clinically driven and the best quality of care is given according to the judgement of the clinician, it shouldn’t be the case that every patient should have exactly what they want, because they may not be aware of best practice.

People within the existing system actually have a lot of choice. With Choose and Book, if you live in London, you can go to a whole range of local hospitals or you can go to a central London teaching hospital for a particular episode of care, a particular treatment for a particular issue. I don’t see how that would be improved with the new consortia.

When did Choose and Book come in? Was it under the internal market?

It was actually. In fact, what happened with Choose and Book is that most people chose their local hospital.

But won’t it be a move away from targets if there are all these different providers?

If you have a planned health service, there is no need to have as many targets as we do have. There could be standards, requirements. The service would need to be audited to a certain extent. I would say that, at the moment, the amount of audit, the amount of targets, are counter-productive. But that’s not a necessary corollary to having a nationalised service. That’s a matter of choice.

What I see is that this government is going further and faster than Labour dared to do. And I believe that it’s being done quickly because when the general public really realise what’s going on, they won’t be happy about it at all. I think we’re going to blink and the NHS as we know it is going to be gone.

As a health visitor, how would working for an even more competitive provider, that is, even more concerned with competitive targets, affect the care you give someone?

Well, if my understanding of the way that our service can be more competitive is that we spend less time with each individual... The expensive thing is my time, so that would mean that I could quite possibly not do a good holistic assessment. Also many of the referrals I might want to make, or services that I want to provide, would take me a certain time to do. So I might not do all of them. I may think, “actually, I can’t do that housing letter.” I’ve already been told that we’re not commissioned to do housing letters any more; that’s got to go to Housing. Now, Housing may not be interested in my client’s plight but I am, and I can see that the health of that family and the well-being of that family would change if their housing was improved. So I will spend a long time writing a housing letter [and] phoning Housing, because actually my professional motivation, the reason I do my job, isn’t just to be paid but it’s to make that person’s life better. And if I’m not allowed to do all the holistic things, all the pieces in the jigsaw that will shift something for that family, then I think my work’s going to be meaningless. I’m going to be scratching the surface or doing an intervention for the sake of an intervention; to tick a box rather than to actually make a difference.

I don’t think you can make money out of complex care with vulnerable people. You may save money for society in the long term (and interestingly, that’s what Iain Duncan Smith said with his early intervention). But in the short term, you don’t make money at all and I do things that would not be commissioned for. Like I took a single mother to hospital who wasn’t prepared to go. She had a hole in her retina. She had a certain amount of learning difficulties and she didn’t understand why she needed to go to hospital. When I rang, they said if she doesn’t have this treatment she could go blind. She’d been the victim of domestic abuse, she had three children to bring up. So I thought, actually, it’s a good use of my time to go to hospital and sit with her. It’s not actually my job but I thought, actually, getting her to have her treatment was very worthwhile in the long term.

But I would have to justify that now and they would say, “you’re a skilled person, you shouldn’t be doing that.” But if I wasn’t a skilled person I wouldn’t be doing it! I understand the long-term problems of that; I’ve got enough nous to ring up and talk to the sister in charge and say why she needs that treatment.

One of the things that I used to do, based upon evidence of poor dietary intake of children in this borough, was that, once a month, I would run a health education group for mothers of new babies. We called them weaning groups: how to introduce your child to solid foods, what sort of ingredients to give, how to provide a healthy diet for your child in the future. And I would do things like demonstrations of how to puree, why you don’t need to give your child processed food, and generally talk about food values, what children need. I would have about thirty mothers and babies every month. Now we’ve been told that we’re not commissioned for that any more - it’s not necessary. I think that that will make a difference to those children’s lives. In the long term, it may save the NHS some money. But the managers that I work for, one of their targets is child protection, so they want me to focus on safeguarding children. Of course that’s important, but it doesn’t have to be one thing or the other.

And you don’t see something like that started again if the reforms go through?

No. And the other problem is, of course, that if there are cuts in lots of other services, we also won’t have the appropriate services to refer people through. There are a lot of cuts, say to Sure Start children centres, so you may not have a speech therapist, social workers, less nursery schools. It all depends on the political commitment, really. If you have a political commitment to vulnerable people, and children in early years, and there’s a government that’s prepared to pay for that, then our service would work.

At the moment there is a local campaign, which is a good example of why I think public health will suffer under the new system. We have a local campaign about a community clinic at Leyton Green. The PCT has been proposing to sell it to raise money. The importance of the clinic really is that people don’t have to belong to a GP practice to be able to come. The health visitors run baby clinics there three times a week; the elderly go there for their chiropody; there’s a midwifery clinic there and the school nurses work from there. The plan is that all those staff will be located about three miles away, in the south of the borough. It’s the poorest ward in this borough; English isn’t the first language of a lot of people. So you’ve got a lot of vulnerable people, and we also provide immunisations.

Now, mostly GPs are responsible for immunising all their patients. GPs in my experience – I don’t want to run down GPs at all – tend to be interested in their own patients. So they may well have a baby clinic in their building, but it will be for their patients only. In our public health drop-in clinics, we’ll immunise anybody; we don’t care if they’re registered with us or not. If I see them in a clinic and I find that they haven’t completed their course of dipthera, polio, tetanus or whatever, I’ll say, “look you’ve got a doctor here, why don’t you have it done now?” It seems from everything that I’ve read that, when we have budgets held by GPs consortia, those kind of sites across London won’t have anyone to own them. So I think that generally the public health will suffer.

It’s like my colleague who does all the immunisation follow-up and all the data in this borough has been told now that nursery nurses won’t be following up children who don’t attend immunisations, because they’re not commissioned. She’s tearing her hair out, saying we’ve been up to 98% [immunisations] in this borough and we’ve not had a child death from measles. Hepatitis B rates are really good. If we’re not commissioned for that, I think that’s going to be really difficult. And with all those things, it’s always the most vulnerable people who suffer.

It sounds like you’ve been quite successful with the campaigns that you’ve been involved in so far. Do you think you’ll continue to be successful?

The big campaign now is stopping the bill.
See also:

The GP
May 10, 2011

The radiologist
March 24, 2011

The biomedical scientist
March 24, 2011