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HOW TO USE OUR GUIDANCE
(You can follow our step by step guidance below on this webpage of download/open the guidance in a separate Word document here.)
- Unfortunately we cannot reply to every question but have focused on three main areas of service cuts: Health Visitors, Community Nutrition & Physical Activity Service and Substance Misuse Service
- COUNCIL ONLINE CONSULTATION CAN BE ACCESSED ONLINE HERE:
- NB We have filled out the guidance as members of the public (ie not as service users or as health professionals.
HOW TO ANSWER
- Because the consultations are particularly difficult to answer for members of the public we provide both brief answers AND informative text that provides a rationale for the answer.
- Council questions are in blue
- For Save Lewisham Hospital Campaign brief sample answers see our boxed text in red.
- For longer explanations of each point please see the text provided in italics, sometimes on drop down box – which you can draw on if you wish.
Please remember, responses to the consultation MUST be in by 7TH November 2018
SECTION 1: HEALTH VISITORS
The Council aims to cut 196,306 (2.6%) from the Health Visiting service
WHO ARE HEALTH VISITORS AND WHAT DO THEY DO
Introduction from the Save Lewisham Hospital Campaign
Health Visitors are registered nurses/midwives who have additional training in community public health nursing. They provide a professional public health service based on best evidence of what works for individuals, families, groups and communities; thereby enhancing health and reducing health inequalities. This is achieved through a proactive, universal service for all children 0-5 years and for vulnerable populations targeted according to need.
Pre-school children and their families are a key focus. Families from all walks of life may need support for specific issues that affect their children’s health and development. The actual service provided to each particular family will vary according to a personalised assessment of their own needs and evidence of what will work for them.
Health Visitors work with parents with new babies, offering support and informed research-based advice from the ante-natal period until the child starts school at 5 years. In Lewisham Health Visitors are aligned to GP practices and visit all the families registered with those practices.
A Health Visitor has a minimum of 5 contacts with a family, via the Healthy child Programme, when concerns about a child’s development or a depressed mother can be spotted early.
- Antenatal contact
- When a baby is between 7-14 days
- 6-8 week visit
- 7-11 month developmental review
- 2-2 ½ year review
In Lewisham Health Visitors have achieved UNICEF Baby Friendly Level 3 Accreditation and they run breastfeeding support hubs daily in the borough. They also run child health clinics and a programme called the Freedom Project for women who have suffered domestic abuse. They run a post natal support group for women at risk of post natal depression. The Care Quality Commission in 2017 rated Lewisham’s Community Children’s Services as ‘Outstanding’
Consultation Responses to Council proposals for cuts to the Health Visitor budget
The following sample responses offer information and guidance for those responding to the consultation questions as a Personal-Member of the public.
Question 1 Council says
What do you think are the most important outcomes for the health visiting service? (Please pick up to five options)
The Save Lewisham Hospital Campaign says
We suggest that you choose ALL of these points.
Reply ‘All of these areas are important and it is counterproductive to choose one option rather than another.’
Additional comments from Save Lewisham Hospital Campaign
- Reducing infant mortality
Infant mortality is the death of a child under one year. Premature birth is the biggest contributor to infant mortality as well as adverse factors around the time of birth. Childhood illnesses and accidents are also a cause and Health Visitors have a role in preventative work. - Reducing low birthweight of term babies
This is multi-factoral and factors such as maternal smoking, poverty, ill health and complications of pregnancy can affect birth weight - Reducing smoking at delivery
Many services contribute to this and Lewisham public health did a lot of work to encourage early booking for ante-natal care and offering an ‘opt out’ smoking cessation service and this has reduced smoking in pregnancy and around the time of birth. Smoking around the time of birth increases a baby’s risk of Sudden Infant Death Syndrome and respiratory illnesses and smoking in pregnancy increases complications for mother and baby and contributes to a lower birth weight. The work that Health Visitors do with families contributes to this outcome. - Improving breastfeeding initiation
Health Visitors contribute to this outcome through their ante-natal contact with women and their hard work and dedication won them UNICEF baby friendly level 3 accreditation in 2016. They run breastfeeding hubs every day in the borough where pregnant women can go to learn breastfeeding skills from lactating mothers. - Increasing breastfeeding prevalence at 6-8 weeks
Health visitors contribute to this outcome through their contact with women in their own home and in Child Health Clinics. All Health Visitors in Lewisham have UNICEF training and Lewisham has one of the highest rates of breastfeeding in England. - Improving child development at 2 -2 ½ years
The first 1000 days of a child’s life (conception to age 2 years) are considered the most critical time of development for a child’s future wellbeing and the Health Visitor is the professional most involved with a child at this time. Lewisham has a high ‘school readiness’ rate at 79% above the national average of 71% but still means that 1:5 Lewisham children are not school ready and would benefit from more intervention in the early years. Allen (2011) made the scientific and economic case for early intervention to prevent longer term social and health difficulties for children and families and to reduce the expenditure on late intervention. - Reducing the number of children in poverty
27% of Lewisham s children live in poverty which is a tragic figure in modern day London. Health Visitors cannot change this on their own but can lobby and protest against austerity measures that affect the families that they visit.
- Improving school readiness
Health visitors are crucial in helping prepare children for school child to engage in and benefit from early learning experiences that best promote the child’s success. Health visitors carry out development reviews and refer where appropriate. They have a wide local knowledge so that families can access services targeted at under 5s. See previous answer to 2-2 ½ year development.Field (2010) concluded that the first 5 years of a child’s life are the most critical to a child’s life chances
- Reducing under 18 conceptions
Health Visitors can affect this by the early intervention that they do with children under 5. Education is the best preventer of teenage pregnancy and the worldwide drop in teenage conceptions is linked to better rights and education for young women. Having aspirations and hope of a better future affects the choices young women make about their fertility - Reducing excess weight in 4-5 year olds
Lewisham has a very high rate of obese Year 6 children at 24.8% (England value 19.1%).
So, early intervention regarding weaning and diet is very important but needs to be done alongside a change in the food industry and a reduction in fast cheap food outlets that appeal to poorer families - Reducing hospital admissions caused by unintentional and deliberate injuries in children
These two outcomes are very different: unintentional injuries are mostly the result of an accident – all accidents are preventable but often out of parental control. The deliberate harm of a child is a very complex and serious event. Health Visitors contribute vastly to keeping children safe from harm and safeguarding children is at the core of their work. Munro (2011) reviewed child protection work and emphasised the importance of early intervention stating that preventative services could do more to reduce abuse and neglect than reactive services - Improving population vaccination coverage
GPs now have the contract and responsibility for childhood vaccinations but Health Visitors can contribute to the uptake by discussing the benefits with parents. - Disease prevention through screening and immunisation programmes
Health Visitors do not have a budget or responsibility for this but can contribute to the uptake of screening by discussing with parents and encouraging uptake. - Reducing tooth decay in children under five
This is a challenge for Health Visitors due to the food industry prioritising profits ahead of health, but they can have a positive impact with their contact with parents. Reducing tooth decay is part of the development reviews carried out at one and two years of age by health visitors.
Question 2 Council says
Are there any other outcomes that you feel the Health Visiting Service should be working towards?
Save Lewisham Hospital Campaign says:
If fully staffed there is one Health Visitor for every 542 children under five in Lewisham whereas the recommended ratio is 1:250. This ratio is unacceptable. With the current level of vacances the ratio is 1:700+ nearly three times the recommended level.
Health visitors do a remarkable job and it would be impossible to add to their workload without greatly increasing their numbers. They offer a service to all families but visit more often the children who are in greatest need. We need more Health Visitors not less.
See text below for range of activities already carried out by Health Visitors that are not listed in Question 1.
Further comments on this question from the Save Lewisham Hospital Campaign:
- There are currently 42 Whole Time Equivalent (WTE) Health Visitors and 22 800 children aged 0-4 years. The Health Visitors Association recommends a ratio of 1: 250 The Laming Report –following the death of Victoria Climbie –recommended no more than one Health Visitor for 400 children. In 1934 the ratio was one Health Visitor to every 250 children.
- Lewisham has one of the highest rates of domestic abuse in England and women are at increased risk in pregnancy and the first year after giving birth. This is when women will have the most contact with a Health Visitor whose role in identifying and intervening when families are affected by domestic abuse is vital.
- Perinatal mental health problems such as postnatal depression (PND) affect over 1000 women every year in Lewisham. Health Visitors support this group of women and offer extra listening home visits and run a specialist postnatal support group for them to promote attachment – which can be adversely affected by PND. This work is vital as perinatal mental ill health has a huge impact on women and their families.
- Health Visitors also work with refugees, homeless families, teenage parents, families affected by physical ill health, substance misuse issues and other vulnerabilities.
- As the Public Health Consultant for Lewisham, Danny Ruta, stated in 2015 ‘Children are the future of any community. Their health and welfare, and their present and future happiness, ought to be the most important focus for the activity of any society. Pregnancy and early childhood, particularly the period that is now known as the first thousand days of life, are critical in determining an individual’s future health and well being.’
Question 3
Do you think that the proposal to cut funding will affect individuals and the community in the following ways?
- Worse healthy life expectancy
- Higher infant mortality
- More hospital admissions
- Lower school readiness
- Increase in waiting times for services
- Lower breastfeeding rates
- Lower uptake of immunisations
- Lack of qualified/experienced staff
- Increase in health related issues/morbidity
- Higher levels of children with excess weight at 4-5 years
We could also add to this list: ‘Greater difficulty of attracting and recruiting staff’.
Save Lewisham Hospital Campaign says
The service cannot be delivered for less money or less health visitors – it is already being delivered on a shoestring budget and it is shameful that children in poverty-stricken England in 1934 had more Health Visitors than modern day Lewisham
As stated above there is one Health Visitor in Lewisham may have responsibility for over 700 children, whereas the recommended ratio is 1:250. Health visitors do a remarkable job and it would be impossible to add to their workload without greatly increasing their numbers. They offer a service to all families but visit more often the children who are in greatest need. We need more Health Visitors not less.
Question 4 Council says:
Do you have any other ideas about how we could deliver this service differently in order to achieve the same reduction in funding?
Save Lewisham Hospital Campaign says:
Save Lewisham Hospital Campaign says:
Prevention is better than cure – it is better for the child and their family and better for the NHS and society. Preventative health care is an investment and saves money in the long run – but more importantly it saves suffering and improves people’s lives.
Council: Please provide any further comments
Save Lewisham Hospital Campaign says:
The blame for this budget reduction lies with Theresa May’s government. Conservative austerity policies adversely affects the poorest and most vulnerable members of society. The current government treat most of us with contempt and are not providing society with the health service that we need and deserve.
Lewisham Council should protest this government imposed budget cut and join with other councils to demand adequate and fair funding for public health service, if necessarily taking the government to court.
SECTION 2: THE COMMUNITY NUTRITION & PHYSICAL ACTIVITY SERVICE PROPOSED BUDGET REDUCTION
The Council proposes to cut £10,000 (5.8%) reduction in funding for the Community Nutrition and Physical Activity service delivered by GCDA (Greenwich Co-operative Development Agency). 6.3.1
‘This borough-wide service supports communities to become healthier and more resilient through delivery of initiatives such as cookery courses, physical activity sessions and the healthy walks programme, to working with food businesses to make their food healthier. The community development approach supports individuals, groups and organisations to promote healthy lifestyles and the service offers support, training and mentoring for community groups and organisations to deliver local healthy eating and physical activity initiatives.’ Council document 6.3
Question 1 Council says:
Do you currently use or have you ever used the Community Nutrition & Physical Activity service?
Save Lewisham Hospital Campaign says:
Please fill out as appropriate to yourself
Question 2 Council says:
How important do you think each of the following objectives are for the Community Nutrition & Physical Activity service?
- Developing a model that enables healthy eating and physical activity interventions to be more widely available in the community
- Improving the skills and resilience of local residents by delivering sessions aimed at the individual
- Supporting a local environment that makes it easier to choose healthy diets and active lifestyles
- Working in partnership so that community development is coordinated at a local neighbourhood level
- Supporting the recruitment and training of local volunteers
- Supporting communities to develop and deliver local healthy eating and physical activity initiatives.
Save Lewisham Hospital Campaign says:
All of these objectives are very important in helping to prevent ill health and maintain good health particularly among the most vulnerable sections of Lewisham’s population. Physical and mental health are inextricably linked. It is often the case that those with the worst mental health experience poor physical health and those with poor physical health experience higher rates of poor mental health such as anxiety, depression and social isolation (Public Health and Mental Wellbeing, 2016 Lewisham Council)
These cuts lead to more expensive health consequences later.
Additional comments from Save Lewisham Hospital Campaign
Life expectancy is 6.1 years lower for men and 5.1 years lower for women in the most deprived areas of Lewisham than in the least deprived (Lewisham Health Profile 2017 Public Health England). Lifestyle and behaviour change are a priority for Lewisham so cutting this budget will have a negative impact on people’s health. Prevention is cost effective so cutting the service will have an impact on resources needed for intervention.
Question 3 Council says:
How far do you agree with the following statements:
- We should make cuts by reducing services aimed at the individual
- We should make cuts by reducing services aimed at the community
Save Lewisham Hospital Campaign says:
We do not agree with either statement as both are important interventions. Individuals do not live in isolation and their health has an impact on their family, the health economy and themselves. What an individual learns from a health intervention can be passed on to others and have a greater impact. Community services enable more people to access help so should not be cut.
This service operates on a very small budget and we do not think that any money can be saved without having a negative impact on the people who need its support.
This question is very unfair without a clear balance of impact from either approach.
SECTION 3: BUDGET CUT TO SUBSTANCE AND ALCOHOL MISUSE COMMUNITY SERVICES
The Council plans to cut £127,000 (3%) in funding for substance misuse.
‘The main services are delivered by Change, Grow, Live (GCL) and Blenheim CDP. Both provide a range of interventions targeted at patients and family members suffering from substance misuse. 6.4.1 CGL run the main complex needs service in the borough which assesses and triages all those presenting with a substance misuse or alcohol need. Service users receive a systematic assessments for an appropriate pharmacological therapy for opiate dependence and commencement of dose titration within 24 hours of presentation. In addition to this there are a range of specialist elements within the service designed to meet specific needs.’(Para 6.4)
Question 1 Council says
Do you think it is likely that the proposal to cut funding will affect individuals and the community in the following ways:
Save Lewisham Hospital Campaign says:
Tick ‘Extremely likely’ to everything
Additional comments from SLHC:
Reducing the amount of money that is spent on substance misuse is likely to mean fewer staff employed in local services, or fewer people being funded for detox/rehab, or fewer specialists for complex populations. This will mean reduced productivity of services which would mean people remaining unwell in the community for longer – leading to worse outcomes in all the areas listed above. The continued cuts to the substance misuse budget over the last decade have had a negative effect, so it is impossible that further cuts will reverse this negative effect, rather it will worsen.
It is worth noting what Simon Stevens, Chief Executive of NHS England told the House of Commons Health Select Committee:
“An area where you get very quick payback, or indeed a worsening of the situation if those services are not there, for example, is drug and alcohol services and sexual health services. If those services diminish, that shows up as extra demand in more expensive parts of the National Health Service within 12 months, not within 10 years.”
Question 2: Council says:
Do you think that this proposal will affect particular individuals more than others?
Save Lewisham Hospital Campaign says:
Tick yes
Additional comments from the Save Lewisham Hospital Campaign:
Without seeing the specification set out by Lewisham Council for 2019/20, or any proposals from bidders, it is difficult to know exactly how the services will change and which individuals will suffer more. To that end, this question is somewhat misleading.
The likely populations that could suffer are:
- Volunteers – Greater pressure often gets placed on volunteers when money is tighter, because there is no money to get enough paid staff. Bearing in mind that many volunteers are in recovery, the effect of this stress can be great and even be a factor in relapse. Any volunteer who relapses because of work-related stress is a tragedy and a symbol of the false economy of squeezing the budget.
- People who fall short of thresholds for inpatient care, yet are clearly in distress and need more help – Panels decide who gets rehab and who doesn’t. With less money, there will be fewer people who get rehab or inpatient detox. Based on that, all the people who do not receive funding for inpatient care from 2019, yet would have received it if they had presented in earlier years, will be more affected by cuts.
- People who do not readily fit the false dichotomy of a ‘complex’ and ‘non-complex’ service user. Those who have done frontline work with people who need help, in any capacity, realise that we are all complex in some way. By defining people otherwise, as non-complex, services restrict treatment options and doom many chaotic individuals into only ever being offered one option, which does not work for them. What happens in such cases is that people repeat an ineffective treatment or else go looking for help in A&E, which costs the local health economy more mone. Denied help, many people defined as ‘non-complex’ later meet your definition as ‘complec’in a worse state.
- People who used to receive a specialist worker, such as an older person or carer, get swept away by the cuts.
- Every service user is at risk. The example of Lifeline showed it is possible that a large amount of people could be affected when an organisation fails to provide a service for some time. Lifeline went bankrupt by pretending they could deliver what councils asked for, despite the money on offer being patently insufficient. It is worth remembering that CRI closed their doors to Lewisham’s service users a decade ago, when they failed to include premises or a database in their winning tender, then tried to start the service with neither.
- In Lewisham, it is worth noting that CGL provide an insufficient inreach service to the hospital yet NICE guidelines say a 7 day a week alcohol care team in the hosptial could be expected to deliver savings of £448,000 per annum, based on a DGH population of 250,000. This equates to £179,000 per 100,000 population. (it is worth noting that a CQUIN is on offer to the hospital if they provide a minimum service of detection and intervention). The fact such a service is not possible on the amount of money Lewisham Council spends on substance misuse suggests there is not much capacity to make further cuts without risking significant increased harm.
Question 3 Council says:
Is there any way that you or your organisation can contribute in helping to alleviate the impact of this proposal?Save
The Save Lewisham Hospital Campaign says:
You need to answer this yourself as it is applies to you
Question 4 Council says:
Do you have any other ideas about we could deliver this service differently in order to achieve the same reduction in funding?
Save Lewisham Hospital says:
We say no – but you may have your own views if it applies to you.
Council: Please provide any further comments:
Save Lewisham Hospital Campaign says:
The deterioration in council budgets has reached a level that needs to be treated as an emergency, so the council should use their reserves to off-set this funding shortfall and put more pressure on Teresa May’s government to end austerity.
