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Mums & prams High Infant Mortality Rates (IMR) are a distressing measure, but they tell us a lot about the nation's health. In the UK today the risk of infant death is about one in two hundred live births. But still seven times as many babies die in some working class Northern towns as do in the wealthiest parts of the South East. The Sure Start programme, alongside the Government's IMR health inequalities initiative, shows promise in addressing these massive inequalities; but the next step must be to strengthen Sure Start's interdisciplinary framework.

Fundamental issues such as human health and well-being are rarely a challenge for only one part of public sector services.

The really big problems almost always straddle a wide range of service provision, which can add substantially to the difficulties of resolving them - no one service provider alone 'owns' the issue, and it is often unclear who should head up programmes to address the problem.

Differentials in life expectancy
A classic example of this is the challenge in the UK of reducing the gap between the life expectancy of richer and poorer people, to achieve the goal of everyone who possibly can enjoying a long and healthy life.

The better the start in life, the more likely a person is to have a good outcome also in the future. For this reason there has been much emphasis in recent years on Infant Mortality Rates, which are generally agreed to be amongst the most sensitive overall indicators of a nation's health.

Infant Mortality Rates (IMR) are usually stated as numbers of deaths per 1000 live births. The figures are often broken down into rates for the first four weeks of life (neonatal rate) and then for the rest of the first year of a child's life (post-neonatal rate), i.e. from the end of week four till first birthday.

Infant Mortality Rates in Britain
The national statistics show that even since the 1970s, in the UK IMRs have fallen by about 60%. In 1978 the neonatal (first four weeks) rate was 8.7 deaths per 1000 live births, and the post-neonatal rate, up to a child's first birthday, was 4.5.

By 1988 the rates were 4.9 and 4.1 respectively, and in 1997 they were 3.9 and 2.0.

In 2007 the UK neonatal mortality rate was 3.3 per 1000 live births, and the post-neonatal rate was 1.5 - in other words, a child born in the UK in 2007 had a probability of dying before his or her first birthday of just about one half of one percent. (You can see international comparisons here.)

Regional differences
Sadly, these national statistics include both good and bad news. The good news is that decent housing, income and environments can support people in long and healthy lives.

The bad news is that the opposite conditions can be lethal. There are parts of the North of England, for instance, where IMR is about twice that national average, and up to seven times that of the very best outcomes.

Specifically, high IMR and low life expectancy often go hand-in hand in the Spearhead areas; the 70 local authority areas with the worst health and deprivation indicators, and for which a programme of public service interventions has been developed.

High risk factors in health inequality
The target does not however take into account all dimensions of health inequalities in infant mortality. The statistics show e.g. that in 2002–04, the infant mortality rate of babies of mothers:
* born in Pakistan (10.2 per 1,000 live births) was double the overall IMR;
* born in the Caribbean (8.3 per 1,000 live births) was 63% higher than the national average;
* aged under 20 years (7.9 per 1,000 live births) was 60% higher than for older mothers aged 20–39;
* where the birth was registered by the mother alone (6.7 per 1,000 live births), was 36% higher than among all births inside marriage or outside marriage or jointly registered by both parents.

Improving life chances
Obviously, these significant inequalities are just not acceptable. The Government therefore introduced a Public Service Agreement (PSA ) Target in 2007 with the express objective of reducing the IMR gap, so that more babies will live to have long and healthy lives. (Healthy babies also have better long-term prospects, sometimes dramatically so.)

The deal is that the UK Treasury provides the money, and the public sector delivers the agreed outcome, to a clear timescale and against clearly measured outcomes.

Particular emphasis has therefore been placed in terms of health inequalities on achieving a ten percent reduction (between 2003 and 2010) in the IMR deficit between people in routine and manual (R&M) jobs, and the general population.

Practical steps forward
The practical ways in which the Health Inequalities Infant Mortality PSA Target Review (February 2007) can be achieved are focused on two things: sensible day-to-day actions and provisions, and interdisciplinary co-operation. In the words of the NHS summary of the Implementation plan for reducing health inequalities in infant mortality:

'The plan describes how commissioners and service providers can develop local services to help reduce health inequalities in infant mortality through:

* promoting joined-up delivery of the target with Maternity Matters and Teenage Parents Next Steps. This includes
* improving access to maternity care;
* improving services for black and minority ethnic (BME) groups;
* encouraging ownership of the target through effective performance management;
* raising awareness of health inequalities in infant mortality and child health;
* gathering and reporting routine data, including specific maternity and paediatric activity;
* undertaking joint strategic needs assessment to identify local priorities around health inequalities in maternity and infant mortality;
* giving priority to evidence-based interventions that will help ensure delivery of the target.

It emphasises the importance of partnership working; outlines the role of government departments, strategic health authorities (SHAs), primary care trusts (PCTs), local authorities and Sure Start Children’s Centres.'

Specific, realisable targets for practical action and delivery
Progress may be slow, but none of this is rocket science.

Large-scale studies have demonstrated that just a few health messages about avoiding early years risk can have a big impact. Indeed, the Review of Health Inequalities has been able to quantify four measures, and suggest another one, which would have appreciable impact on the ‘10% reduction in IMR gap’ target. These were:

* reduce prevalence of obesity in the R&M group by 23%, to current general population levels – 2.8% gap reduction
* reduce smoking in pregnancy from 23% to 15% in R&M group – 2% gap reduction
* reduce R&M group sudden unexpected deaths in infancy by persuading 1 in 10 women in this group to avoid sharing a bed with their baby, or letting it sleep prone (on its front) – 1.4% gap reduction
* achieve teenage pregnancy target – 1% gap reduction
* also, early booking and improved teenage pregnancy services – not possible as yet to quantify probable gap reduction, but positive impact on gap anticipated.

Getting it right
The scope for getting this right in very simple ways is therefore enormous. Whilst guidance at national level, such as the Department of Health's Child Health Promotion Plan (June 2008) is essential to provide a framework, much of the responsibility for success has to lie with the authorities 'on the ground', who have to co-ordinate the action.

In reality, only at the local level is it possible to get practitioners to work together well, to ensure that all those - including so-called 'hard to reach' minority ethnic familes, travellers and e.g. very young parents or parents with mental health problems - who would benefit from services, advice or support, in fact receive them. Although programmes such as the Family Nurse Partnership (a joint Department of Health / Department for Children, Schools and Families project whereby specially trained midwives and health vsitors work closely with vulnerable, first time, young parents) are starting to reach those with most disadvantage, in some places still this doesn't always happen.

It is disappointing therefore to read claims in this month's Regeneration and Renewal that the PSA Inequality target will be missed, despite the many billions of pounds (£9bn in 2007-8) which have been invested in Sure Start services to deliver early years provision.

An expected move
This probably why the Government is launching a public consultation on proposals to give Sure Start Children's Centres a specific statutory legal basis, as part of the forthcoming Education and Skills Bill.

Such a move was indicated as a possibility when The Children's Plan (the ten year programme for Every Child Matters) was introduced in December 2007. It would establish Sure Start Children's Centres as 'a legally recognised part of the universal infrastructure for children's services, so their provision becomes a long term statutory commitment and part of the established landscape of early years provision'.

The best way forward
This is a much better idea than the alternatives proffered in some quarters - more Health Visitors as a stand-alone, for instance. (What about the GPs / family doctors? How do they fit in?)

A review of progress has shown (as my own consultancy work also indicates) that the PSA infant mortality target was not known or understood by practitioners (NHS, local government and Sure Start staff etc) despite individual examples of leadership and good practice.

Reaching out
And nor, in my experience, do practitioners and policy makers automatically know that impact has to be measured across the whole relevant population of infants, not just those who attend particular service provision, be this Health Visitor clinics, Sure Start or whatever.

About 80% of early years formal care is actually undertaken by small private concerns, child minders and so forth, a 'group' which, whilst of course the subject of statutory regulation and monitoring, it is particularly difficult to bring together in any meaningful way. But what happens in small relatively isolated provision will have a big impact on children's future lives.

The PSA IMR Review has therefore identified the criticality of making the 10% gap reduction target part of everyday business – integrating into commissioning plans and provider contracts; taking responsibility and engaging communities; matching resources to needs; and focusing on what can be done.

Multi-disciplinary and future-facing
The challenges of equipping professionals to work together across disciplines are complex; not every practitioner would say, if asked, that they actually want to be so equipped and so far out of their comfort zone. But these challenges must be met, as is beginning to happen, with skills audits by NIACE which indicate the centrality in Sure Start provision of effective multi-agency leadership and partnership development.

The National Audit Office reports that, whilst most Sure Start Children's Centre managers understand they must approach the work in a multi-disciplinary way, this is not always so for local authorities, who 'had not all developed effective partnerships with health and employment services'.

The onus is now particularly on local government and NHS providers. If it takes more legislation to ensure they all collaborate properly with Sure Start Children's Centres (and vice versa), so be it. It's children's futures which are at stake.


Read also: Early Intervention In The Early Years

See also: 'Changes for the better?' - The Every Child Matters policy, published in 2003, was a landmark proposal for child social service reform. Five years on, Ruth Winchester asks the professionals how things have developed, and what progress has been made (The Guardian, 22 October 2008)

Hope St & Mt Pleasant-  Science Centre  06.7.15 011 (81x87).jpg Who owns Big Science in the UK? Does government science policy sit within wider public policy, or is it stand alone? The Cooksey Review has stirred strong feelings amongst medical scientists, and also further afield. Few science policy questions can be determined without understanding the wider public policy context.

Who pays for what in the constant race to stay at the global cutting edge in science and technology is a hot debate. Often neglected is an acknowledgement of the multiplicity of stakeholders, but this is an area which the scientists themselves sometimes ignore.

Getting to the bottom of who can / should pay for science and innovation in the UK is a difficult task. When all relevant interests - science and technology, policy makers, the economy / electorate - are perceived there is more clarity, but only rarely does this happen. The issue is however making headway as a result of changes resulting from the 2007 Budget, which promises an increase in investment in public science of 2.5 per cent from 2008-09 to 2010-11..

Both the Cooksey Review on funding for health research, and the (connected) introduction of the new Department for Innovation, Universities and Skills focus on ensuring that progress in scientific research and wider value for money go hand in hand.

Value for whom?
The really big question here is, who benefits from investment in what sort of science? This is surely the nub of the issue, but it needs a wide perspective to answer the question properly.

The emphasis seems so far to be on the 'translation' of blue sky research findings into marketable commodities - an entirely sensible idea in general., but not a complete one. The core issue of how much benefit accrues to whom when commodities become marketable is not easily resolved.

Whether the product eventually taken to market is a medical drug, a form of renewable energy or a development in nanotechnology, there are likely to be direct and indirect benefits and costs.

Medical priorities in research
One person's or sector's gain may be another's loss - an obvious but frequently forgotten matter from the perspective of practising scientists.

This may be particularly true in the case of medical scientists, who are currently it seems most agitated, and who often have a specific, and possibly tragic, individual human condition in mind as they undertake their work. Nonetheless, this human priority cannot stand alone.

Medical scientists have not always covered themselves in glory when it comes to collaborating within the Big Science framework - the Daresbury crisis of a few years ago comes to mind - and for some of medical researchers the universe probably finishes at the point where abstract research translates (to use the new term) into pharmaceuticals. This is why, when public money is involved, others must take a wider view.

Science policy and public policy
Policy in government-sponsored science is not, contrary to much of the discussion, a singular issue. For a start, there is policy about science; and then there is policy relating science and the general public interest. These two are inter-connected, but not always the same.

Science policy variously (as examples, and in no order of priority) might be about:
* 'translating' or bringing blue sky research to the market;
* meeting a specific human or technical need;
* continuing promising lines of investigation which may or may not eventually go anywhere;
* establishing or maintaining national reputation, or that of an institution and / or individual/s.

Public policy relating to science might, e.g., concern:
* developing local science-based businesses;
* linking scientific and technical / medical research outcomes to the wider economy;
* developing programmes or projects in geographical or otherwise specifically identified areas, to progress regeneration or other ambitions for general benefit;
* seeking answers to particular policy conundrums or challenges, by way of developing the evidence-base available to decision-makers.

Contextual perspectives on science
To make sense of these difficult and often conflicting priorities between science and public policy requires seeing the wider contexts in which science and technology operate.

Social, economic and political backdrops are not secondary matters when government is paying directly for science to be done. They are central and critical, right from the beginning.

'Translating' science is ultimately about taking blue sky research to market, but it is also in another sense about making sure that stakeholders - the general public - know and are comfortable with what, through their taxes, they are paying for.

Consensus on taking science forward
From this point of view scientists need to accept that, if government pays directly, it wants to know how the research will take public policy forward.

Politicians are not usually keen to write open cheques for unknown outcomes, nor should they be.

Scientists paid by government are usually there to do their part within a policy framework geared to fairly tight timescales, to make the evidence-base available or to develop a required product. As such they rarely have the luxury of following their noses in research, just because it looks interesting.

Government funding
Sometimes there is a case for blue sky research directly funded by government, but probably, given budgetary constraints and the constant need to be immediately answerable to the electorate, not often.

The right way to support (most) blue-sky research is through the universities' wider funding and large science-led corporations.

Such investment will, if directed wisely, bring reward in the longer term, when investors can as a result make the evidence-based case for government to invest in developing the applications of their new-found knowledge.

Innovation (small) 80x101.jpg England's Northern Universities are upset that the Biomedical Research Centres (BRCs) of excellence are all in the 'Golden Triangle' of Oxford, Cambridge and London. 'Added value' economic impact has been sidelined. With intimations of southern advantage and selective assessment perspectives, is this a re-run of the 4GLS synchrotron debate on location in the 'north' or 'south'?

Prof Alan Gilbert, Vice-Chancellor of Manchester University, is championing medical science in England's northern universities, after his institution was not selected as a comprehensive biomedical research centre of excellence (BRC). This accolade, worth 8-figure sums to each institution, has been awarded only to universities in Oxford, Cambridge and London.

Once again, the Golden Triangle has triumphed over everywhere else in England.

And once again the southern economy hots up as northern sensitivities are similarly inflamed.

Who decides?
The decision to support only Golden Triangle universities was made by the Department of Health / NHS National Institute for Health Research (NIRH) high command, on the basis of assessment by a panel of experts working outside England of the international excellence of medical science in the competing universities.

This panel does not seem to have laid much emphasis on the impact of macro-investment in the knowledge economy on regional economies as such.

History repeats itself
So here we go again.

More science money is being invested where money has already gone. Comparatively less is made available where investment has historically been more difficult to obtain.

When the big debates about synchrotron investment in the North of England were conducted, the medical science people were hardly to be seen. The Wellcome Trust, a major player in bio-medical research, was widely regarded as unhelpful to those making the northern case, and even some northern university medical scientists did not support it.

Yet investment (usually of government money) in scientific institutions with capacity and established further potential is critical to wider long-term prospects for the UK economy.

Biggest impact, greatest added-value
Prof Gilbert says that universities must not 'ask favours because we have been disadvantaged historically'. But in fighting his case he could look at the Daresbury (4GLS) - Rutherford Appleton (Diamond) synchrotron debates to see that the issues may be slightly different.

It is not 'asking favours' if those of us, the public whose money is being spent, demand equity in terms of investment opportunities for top-level science.

Wider perspectives
The NHS is a very closed institution which has not, historically, been good at acknowledging it is now an important part of the wider knowledge economy.

Patient care is the aspect of this huge organisation which most members of the public experience, but that should be a fundamental 'given'. It cannot provide refuge from the fact that, medically or otherwise, international science knows no silos.

Excellence in context
Nor can a rightful emphasis on patient experience permit us to forget, as collectively holders of the public purse, that any public investment needs to work in as many different ways as possible.

As the growing success of the U.K.'s 'northern' Darebury Laboratories has shown, internationally excellent science, public benefit across the nation and added-value regional development can evolve hand in hand, if enough decision-makers have the vision and courage to ensure that this will happen.



In Praise Of Politics

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Election Night (tables, small) 05.4.26 057.jpg The benefits of modern democracy which we in the U.K. enjoy are diminished by the media when they invite us to confuse the real thing with synthetic 'political entertainment' concocted by those who then 'report' it. At a time when cyncism about politics is rife, people need to know about the realities of political involvement, so they can make informed judgements about whom they wish to support.

LouiseEllmanAdoptionMtg05.4.15c.jpg I’ve just returned from the Labour Party conference in Manchester. Personally, I was impressed. The Prime Minister and Chancellor each spoke with great authority and conviction about what politics means to and for them, and I think it would be fair to say their orations resonated clearly with what the large majority of those attending believe and were looking to be affirmed.

My belief is that the Labour Party, whatever its blips and foibles, stands for a way of life which is fair, progressive and ambitious for everyone’s future. Other major parties in the U.K. can make their own case, but there is no doubt that those who seriously subscribe to these alternative credos also believe that their politic represents a way of life which makes sense to some people. I am content to acknowledge this - and where necessary to ‘take them on’, as Tony Blair urged in his speech. No doubt willingness to contest the political territory would apply in reverse for other parties, too.

Political debate about the future
The Labour Party national conference is one of the largest and without a doubt one of the most inclusive conferences in Europe. Women and men, first-time attenders and cabinet ministers, delegates of all ages, ethnicities, faiths and walks of life, meet in the course of that event as equals to bring their richly diverse experience and expertise to the issues of the day.

And the same applies to the democratic political process in the U.K. on a wider scale.

Election2005CampaignMK&JN,Sudley1.jpg The critical point is this. Where citizens are prepared to give their time and other personal resources to engaging in debate about the future of our country (and that of the globe), they should be respected for having the courage and conviction to do so.

Of course there are caveats to this general position. When opposing parties permit the debate to become unpleasantly personal, or when they step outside the boundaries of decency (as for instance the British National Party does frequently) they diminish fundamentally the democratic process and thereby lose the right to respect and engagement in that process.

Synthetic ‘news’
So what do we make of the media coverage this week?

Frankly, it has not so far been consistently of the best. I have no problem about considered critiques, or even criticism, of the political offer – that’s what politics is about – but I have plenty of reservations about lead stories concerning what Cherie might or might not have muttered to herself, or about the future prospects of John Reid and Gordon Brown, following the synthetic televised gruelling of a supposedly ‘representative’ (and, for its purpose, woefully small) focus group.

This is the media making the news, not reporting it…. Not an unusual occurrence, but one which does not deserve the headline reporting these matters were given. There are serious issues at stake, and the wider public needs to know about them. Such trivial issues are entertaining, but they don’t take us very far in understanding what the underlying politics is all about.

Politics as commitment
Election2005CampaignOffice(chaps).jpg Perhaps this needs to be said loud and clear: Many people are involved in politics with no expectation of personal reward. Most professional politicians go the extra mile and more (if they don’t, they deserve the abrupt termination of their political careers which is likely to follow).

Politics on the ground comprises hours of envelope stuffing and telephone calls; it requires rainy Saturday mornings in surgeries in what are now called challenging contexts; it involves knocking on the doors of not-always-appreciative strangers; it requires digging into one’s own pocket far more than filling it. And, critically, it demands the courage and conviction to stand up and say what one believes, and to take the reputational consequences.

And, most of all, decent politics at every level is underpinned by hope for the future – the belief that people can be persuaded to one’s view of what could be.

Politics as entitlement
I disagree fundamentally with the politics of the right, but I agree that sometimes the questions posed by right-wing politicians are valuable pointers to important issues which require resolution. I also accept that, within the bounds of decency and respect for other decent people (a requirement of us all), those who promote such right-wing positions have an entitlement to do so.

Political debate from the beginning of time has been the fairest way to decide who has the best ideas about what should happen, and who should be given the power to make that come about.

News, Politics or Entertainment?
If the media want to tell stories about what Cherie might have said to herself, or about a synthetic, manufactured event around the future of Gordon and John, no-one should stop them, self-serving of media pundits and distracting from serious debate though these stories are. Indeed, perhaps we are all complicit in this, at least insofar as the media would say we read this stuff and don’t challenge it.

But let’s at least ask that spurious ‘political’ stories be reported under the heading of Entertainment, not News; and let’s try to ensure that proper political reporting is delivered in ways which mark it out as Politics properly defined.

Politics is a difficult and sometimes even dangerous game; it needs, and democracy itself needs, the best people and the best efforts we can muster – and this in turn requires a modicum of underlying respect for those who still choose to make the effort.

Hope not cynicism
Election Night (Lpool MPs) [smaller] 05.4.26 051.jpg If there were a better way to run modern societies than democratic politics, someone would have invented it by now. At a time when the victory of cynicism over respect for engagement in the political process has probably never been greater, we, the public, damage ourselves as well as the politicians if we don’t insist at some level that politics is fundamentally about hope for the future; and that political media-created 'entertainment' and democratic politics are different things.

World Health Day

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'Working together for health' is this year's slogan for World Health Day (today).

The World Health Organisation (WHO) quite rightly asks that we take time just for one day in the year to think about what 'Health' actually means. So today, 7 April 2006, is World Health Day.

This year's strapline is 'working together for health'. Reduction in child mortality, improvements in maternal health and combatting HIV / AIDS, malaria and other diseases are amongst the Millennium Development Goals ** which all Member States are signed up to meet by the year 2015.

[** The other five goals are eradication of extreme poverty and hunger, universal primary education, promotion of gender equality and the empowerment of women, environmental sustainability and a global parnership for development.]

A time to reflect?
But here we are in Britain, one of the half-dozen most wealthy countries in the world, and even we don't get it right on all counts. There is plenty to worry about in the health of our nation; but it cannot be said, as of some other countries, that anyone 'has' to starve or die of cold, lack of clean water or because of any of the other horrendous experiences of people in other parts of the world. In the U.K. we have choices, and we have resources, which really do mean this never has to happen.

I say this neither (I hope) to make inappropriate comparisons - poverty in health or anything else in the U.K. is relative; poverty elsewhere is grimly absolute - nor to offer bland pronouncements about what we 'ought' to do to reduce such awful suffering in other areas of the globe.

What I seek to understand more clearly is how we can think in a more joined-up way.

Only connect...
We in Britain, like those in other first world countries, mostly know that how we treat our bodies and what we do to promote sustainability are critical both for ourselves and to what happens to people elsewhere, as well as people here. We know too that responsibility for this lies with us personally and as parents, as well as with 'the government', or 'them'.

There's a message here. It's at base very simple. The fundamental question is, how do we deliver action?

If World Health Day does nothing else, perhaps it encourages us to reflect how, across the globe, we are all interconnected and interdependent. The 'links' are there, on the internet and, even more importantly, in our hearts and minds.

The U.K. Science and Innovation Framework 2004-2014 has taken on new significance with the recent Budget. Scientists, economists and the regeneration arm of government need to make common cause if the proposals to reshape particle physics (PPARC), medical research (MRC) and links between business and innovation are to achieve the promise which they appear in many ways to offer.

The Government, we gather, would like to elaborate its ten year plan for science, the Science and Innovation Investment Framework 2004-2014: Next Steps, by bringing together the Particle Physics and Astronomy Council (PPARC) and the Council for the Central Laboratories of the Research Councils (CCLRC).

The proposal emerging from the Department of Trade and Industry and the Department for Education and Skills is that these two august bodies be merged as a new body, the Large Facilities Council (LFC). The LRC would have a budget of half a billion GBP a year for current CCLRC work and that part of PPARC's work which concerns large investments. Other, grant awarding, parts of PPARC would merge with the Engineering and Physical Sciences Research Council (EPSRC).

The physicists are not happy
It would be fair to say that this proposal has not been greeted enthusiastically by everyone in the science community. To quote one astronomy blog:
This move would place astronomy and particle physics research in direct competition with the rest of the physical sciences for money. I would expect this to mean that it will be harder to get a particular research project funded, as the competition for the limited funds is greatly increased. It will also mean that the new EPSRC will have to develop a plan / road-map for the whole of engineering, physics and astronomy; a pretty huge field. Can one funding council do this alone while maintaining the breadth and depth of research in the UK?

Nor perhaps are the medics
Another of the Next Steps proposals is that the Department of Health's research and development budget should be merged with that of the Medical Research Council to bring together all public research in health and medicine in the U.K, with a budget of some billion GBP. Inevitably, there will be questions asked about whether this size of investment can be feasibly managed. (There are possible parallels, not least in the particle physics world, where Cern's much admired Large Hadron Collider (LHC) is funded by 20 European states, using the talents of 6,400 scientists from all corners of the globe.)

The wider contexts
These ideas are not, however, developing in a vacuum. Side by side with the recasting of the budgetary alignments are proposals to set targets for increasing numbers of school students, and to increase business investment and involvement in research and development. These are difficult objectives to challenge, except perhaps in the sense that 'more not less' might be the cry.

It's important to acknowledge all the levels at which these various concerns and considerations apply. There are fears for vulnerable / invisible research, there are fears about the status of academic institutions and research bodies, and there are the natural fears of scientists that their jobs maybe at risk. As we know from other change initiatives, these concerns cannot simply be dismissed.

Benefits of a new kind?
We should however try to factor in a number of newer perspectives as we consider these proposals. I have argued elsewhere that support for large-scale or 'Big Science' in the North West of England would have been easier to secure, had there not been a stand-off between those medical scientists funded by the NHS and those funded by other bodies.

The regeneration agenda does not, as of course Gordon Brown and his colleagues would argue, stand apart from the agenda for Big Science. The real challenge, however, is to manage the necessary transitions in a way which values and promotes the knowledge economy and those who work within it, rather than leaving them behind, bewildered and resentful about the proposals which are now emerging.

Never has there been a greater need, if we are all to benefit, for the scientists, the economists, the regeneration specialists and the politicians to talk amongst themselves. This, fundamentally, is what the current consultation period on Next Steps must be about.

The NHS is experiencing another wave of 'reconfiguration', with a focus particularly on NHS Trusts and who runs them. But has there really been a shift from public sector thinking to the modern management of a complex part of the knowledge economy? On present evidence, opportunities to encapsulate hard-won insights into the organisational aspects of the health service are probably being lost.

The wholesale reconfiguration of the National Health Service, and particularly of Strategic Health Authorities and Primary Care Trusts, is now well underway. Public consultation finishes this week, and already some appointments are being progressed actively, albeit on a provisional basis.

This is probably not the place to go into the ins and outs of the basic argument - the bigger debate about the health economy is being conducted across the country and in Whitehall. What engages me more particularly is the essentially non-political issue of how much recognition is being given to the management of knowledge across this vast swathe of our public sector activity.

Is 'institutional memory' sufficiently acknowledged?
Whilst nealy all normal NHS employees are guaranteed jobs for a period following the intended reconfigurations, this arrangement does not extend to non-executive board positions. Indeed, the intention is now being taken forward to appoint new non-exec. posts not only through competition between existing post-holders, but with appointments being opened up to all comers - at a time when already many current non-executives will fall by the wayside anyway.

Yet non-executive directorships are the very roles which are intended to hold to account, and support, executive directors in their work. The risk is therefore that experience built up amongst non-execs. over the past few years since NHS Trusts have come into being is about to be lost, almost as soon as it has been developed.

This raises serious questions about how institutional memory and expertise amongst NHS non-executive directors is to be safeguarded. Where's the knowledge management?

Public sector or significant knowledge economy?
Little visible effort seems so far been made to bring together in recognisable form all the aspects of high-level experience and skill which will take forward this current wave of NHS reconfiguration. Just as at last there is an emerging real understanding by non-executive directors of their crucial role, the chances are that it is to be lost again.

This is a quite separate issue from that of the general merits (or otherwise) of current moves to reshape the NHS. That debate is critical, but it is not the one we are addressing now. What we have here is a public sector health service which still sees itself as run on the basis of aspiration, rather than as a serious element of the knowledge economy, with all that implies for the management of skills, resources and the like. The preservation of institutional memory is a management, not a poltical, issue.

Introduce all the changes in structure that you wish, but alongside these must be a clear and formal recognition and management of the knowledge and skills, of themselves, within the health service. This is what modern management of complex organisations is fundamentally about, and it has to apply as much in the management of the health service as it does in any commercially-led set up.

Trying to bring (appropriate) 'business' attitudes into the health service is fine - though there are probably plenty of high-level people already there who have good ideas about this. But for success in the immediate future NHS organisations will need to protect and formalise their institutional knowledge right now; and the arrangements in place at present for moving on don't make that easy.

The 'health economy' is much discussed but little defined idea. Within local health-care provision it carries an assumed status which it is perhaps now time to challenge. We don't in everyday parlance between managers talk of an 'education economy'; so why a 'health economy'? Many of us would defend very strongly the concept of essential health care free at the point of delivery, but the idea of a closed specialist health economy may not be the best strategic vehicle to ensure delivery of such modern, responsive and effective health care.

There's a fair amount of excitement around the changes in the National Health Service these days. Big shifts are about to occur in the shape, goegraphical and structural, of Primary Care Trusts, Stratgeic Health Authorities and much else. And in amongst all the other deliberations there is much reference to the 'health economy'.

What is the 'health economy'?
Now is probably not the best time to go into the pluses and minuses of the strategic plans for the various strands of the NHS; feelings are running high and there's a lot to sort out yet. But it may well be a good time to ask, just what is the 'health economy'?

This is a very particular notion, and possibly not a very helpful one. In the U.K. at least it seems mostly to refer the range of business and economic activities which fall within the scope of government-led medical attention. Nonetheless, it is by no means as easy as one might imagine to find a definition of what the health economy actually is, as opposed to simply references to it in the contexts of other health-related activity. 'Health professions', 'health care' or 'health economics', yes, there are many formal references and links; but 'health economy'.... if you know of a good weblink or text book, please tell us!

A constraining concept
Perhaps it's time to stop using this term at all. With the newer ways of delivering health care (even though this is still more likely to be 'illness and medical care', rather than 'well-being and health promotion care') the interface between different types of providers is becoming more blurred. The intention of the NHS to provide essential care free at the point of delivery remains, whoever is giving it, but the economic links are of necessity becoming far more complex.

New opportunities
There are many ways in which a more fluid concept of health-related activity might widen the scope for responsive delivery. We don't hear about the 'education economy', 'arts economy' or 'science economy' as every day notions; they're all part of, for instance, a much bigger knowledge economy. Perhaps less talk of the 'health economy' will open up more visible opportunities for local social enterprise and business engagement in flexible and client-responsive health care provision; and that in turn may perhaps also help local investment and regeneration in a much broader way.

The messages of health promotion are universal; but are they coming over sufficiently effectively to the person in the street?

There are a number of things which anyone can do to enhance their chances of good health - don't smoke, don't drink too much, get some exercise and eat sensibly are the main bits of advice; and we could add to that, try to live in a physically healthy environment, make sure you have your immunisations, check ups and the like, and give your kids a good start in life (breastfeed, cuddle and talk to them, etc).

Not really rocket science, is it?

Why local priorities?
Given these universal priorities, the way healthy living is often promoted sometimes puzzles me. The messages are simple, and can I suspect be targeted quite straightforwardly where they have most effect. So why the huge plethora of leaflets, people and campaigns?

Of course some individuals will always want more than the generic message, and that's good - if they know, they'll probably tell others - but I suspect that the huge amount of 'individually packed' info which comes into play at the level of single primary care trusts is sometimes more confusing than helpful.

There are of course some priorities which apply more to certain places and people than others - smoking and unhealthy eating are two examples - but the wider the campaign, the more effect it will have.

Health promotion is often marketing
Perhaps I've got it wrong, but marketing is a specialist activity, and lots of health promotion boils down to marketing. And marketing often seems to work best when the message is simple.

By all means have more info ready in the wings, but perhaps more visible messages from the 'centre' would be helpful too. It's beginning to happen, but it's not yet connected for everyone.

PFI contracts are again in the news, as the London Underground Northern line grinds to a halt and no-one knows who to hold accountable. But what does this also tell us about private (and social entreprise) service provision which is bought in by NHS and Foundation Health Trusts? Private sector buy-in contracts need careful thought if they are to deliver what is expected, no more, no less. So who is going to provide this legal scrutiny?

''No-one, it seems, is in charge.... London Underground needs a simple line of control and responsibility and does not have it.... In truth the problem is not the involvement of profit-making companies in the underground, but the terms on which they are involved and at present these are failing badly.' Thus runs the Guardian's second editorial today.

Just two days ago (this website, NHS Contracts and Foundation Hospitals: Who has the Legal Expertise?) I predicted that issues around PFI would continue to run, and that the problems which have plagued PFI contracts would in all probablity also plague new Health Service arrangements. It didn't take long to see that unfortunately there is indeed mileage in this prediction.

The NHS is now taking financial management very serously indeed. How long will it be before there is similar attention to matters contractual? Significant external commercial partnerships are a fairly new development in the NHS, which has almost always previously provided its own in-house services.

Much has been made of the political implications of private service providers being involved in the NHS, but I wonder whether the same reservations would be applied to social enterprise involvement? If the answer is No, social entreprise involvement is alright, but private sector provision is not, then perhaps we have our eyes at least partly on the wrong ball if we simply dismiss the idea of buy-in as such?

Given the complexities of modern technolgies and economies, does it matter where the service comes from, as long as it's good, in budget, well-delivered and properly accountable and managed?

It's the management and accountability issues which are critical - and it's here that NHS and Foundation Trusts need to think very carefully. They are accountable, and they need to manage.

There are an awful lot of smart city lawyers out there. We must be sure some of them are on the public service side when it comes to negotiating health provision contractual arrangements.

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