Published: 02/09/2004, Volume II4, No. 5921 Page 22 23
The mayor of London's senior adviser on health has lots to say about structures and partnerships - but who should really be tackling the capital's health inequalities and its many other problems?
It has to be a good omen. On my way to London's City Hall I chance upon the rarest of people, a taxi-driver with a good word to say about mayor Ken Livingstone. Normally the mere mention of his name would fill the air with abuse but today I am told how much he's done to clean up the capital.
The good mood continues.On a late summer morning, the ultra-modern headquarters of the Greater London Assembly basks beside the Thames. Tower Bridge lies behind, the skyscrapers of the financial district crowd the opposite bank. The whole place looks shiny and new.
The mayor's dream of bringing the Olympics here in 2012 does not seem so far-fetched.
But the mood of optimism does not last. I am here to talk to Neale Coleman, one of the mayor's senior advisers, whose wide portfolio includes economic regeneration and planning as well as health.He is also the mayor's representative on the London Health Commission, the independent body set up by Mr Livingstone to bring together the city's main influencers on health policy from the NHS, local government and the voluntary sector.
Mr Coleman's challenge is a stiff one. As Mr Livingstone enters his second term, London's health appears in poor shape.
A report in July by the London Health Observatory identified growing health inequalities in the capital. It declared: 'Those primary care trusts with the greatest inequalities are also those with the worst health status and [if current trends are maintained] their relative position will continue to worsen.'
July's star ratings were also not a good advert for the city's primary care. Of the 12 PCTs in England with no stars, half were in London.
One of Mr Coleman's main concerns about health strategy in the capital is that PCTs and the borough councils they mirror are just too small.He does not argue with coterminosity but says that 'on future service planning, you need to look at sub-regional level at least.'
Is that not the job of strategic health authorities? 'Well, quite.
They should be powerful organisations but they do not have the budgets. They seem slightly funny creatures to have emerged from the last re-organisation.'
However, Mr Coleman says he and his boss oppose any further wholesale reshuffling of the NHS deckchairs.
'Ken has been in politics long enough to know that continual reorganisation of health has been very damaging. But if you had larger boroughs you could have larger PCTs, with the advantages of staffing and planning. I wonder, when I look at the relationship between PCTs and some of the acute providers, is it really in balance? It doesn't seem so and it doesn't seem like a change for the better.'
Mr Coleman believes the dominance of the acute sector, together with the complexity of health issues faced by London PCTs, are two of the key reasons behind their poor star ratings performance.
'I am not going to knock star ratings', he says - before doing just that.
'They are a snapshot and a very selective way of assessing organisations.'He points out that 'London's acute sector has many hospitals with three stars'while there are no three-star PCTs and concludes: 'I do not think That is necessarily a clear picture of what's going on.'
The mayor has been wary of being seen to tell the NHS what to do - on the contrary, he has ensured the LHC subjects all his plans to health impact assessments.
Mr Coleman is equally cautious: 'We shouldn't set ourselves up to boss the health service around - it seems there are a quite a lot of people employed to do that as it is.'
However the LHC, with its many patrons but no boss, has been more free to criticise where necessary.
This year's annual report is critical of the health inequalities faced by the city's black and ethnic minority population.
This is a huge issue: 80 per cent of the 516,000 people expected to join the capital's working population by 2016 will be from BME communities.
The report suggests that local targets are the best way to reduce inequality. It says: 'Better use should be made of community intelligence to increase understanding of communityled responses to health' - which is a polite way of saying that sometimes the NHS does not have a clue about how to engage with local people.
Mr Coleman believes the best way to change that is for health issues to be encompassed within wider engagement on community regeneration. This is also the focus of the 'London works for better health' programme set up by the commission in the summer.
It is perhaps ironic that, while the report highlights the role of unemployment in creating health problems, London is more reliant than any other city in England on recruiting its health professionals from overseas.
According to a recent King's Fund report, 14 per cent of nurses in the city qualified outside the UK, compared to a national average of 4 per cent.
In his first term, the mayor gave a high profile to encouraging the financial sector to improve its recruitment from local areas with high BME populations and Mr Coleman says he now wants to give the same kind of attention to healthcare: 'The health sector should be doing more and we want to work with them and put some money in, ' he says.
'It is absurd that so much effort and energy is expended on sending people to the four corners of the globe to find staff for UK hospitals.
'At least a commensurate amount should be done to recruit locally.'
Regional power shift: will London lose out in battle to wrest control from Whitehall?
The next few years are likely to see a shift in power away from Whitehall and down to regional level.
A draft bill has already been promised, which will give new regional assemblies strategic powers over housing, planning, transport, fire and rescue.But many in local government believe the new bodies will not stay away from areas like health, education and social care.
However, the bill specifically excludes the GLA: the irony is that the push towards regional assemblies masterminded by deputy prime minister John Prescott could leave the capital with the weakest mayor of the lot.
Mr Coleman is concerned that London should not get left behind in the move to regional government.
He contributed an essay to a New Local Government Network report earlier this year. In it, he protested against the government line that London would not get the same unified control over areas like housing and community regeneration as the other assemblies.
His concern is that splitting the responsibility to develop social policy strategy for the capital between the GLA and the government's London office is confusing and inefficient: 'In many cases it is about giving lead responsibility, and crucially, responsibility for distributing funds, to the mayor and the GLA rather than a government office.
'There is an ongoing tension in the extent to which powers over staffing and funding can be retained by government offices when you have an elected regional government setting broad strategy across areas like transport, planning and economic development.'
He believes the government office should give up its responsibility and funding in areas like public health and neighbourhood renewal: 'When you have the London Development Agency [which falls within the mayor's remit] with money for economic regeneration and a separate [government-controlled] body for neighbourhood renewal funding, inevitably they do not join up properly.
'Certainly on health, there are already good contacts between the LDA and local health organisations and the LDA is increasing its focus on the subject.'
He points to work on developing a drugs and alcohol strategy: 'That has been a good piece of work... [but It doesn't have] the commissioning and funding powers to support it.'