Sunday, June 4, 2006

Localism in the NHS: Reducing the Democratic Deficit

This is a chapter which I co-wrote with Daniel Hannan MEP for a new book which is now available on amazon called The Future of the NHS edited by Dr Michelle Tempest.

"Election is a better principle than selection. No Minister can feel satisfied that he is making the right selection over so wide a field."
Aneurin Bevan

When the people of Kidderminster objected to the closure of facilities at their local hospital they started a campaign. Such was the strength of feeling that not only did they gather together supporters but they transformed themselves into a political fighting force. Eventually this led them to winning a majority of their local council seats and even the local parliamentary constituency of Wyre Forest. However, despite all of these efforts, they remained disenfranchised. They were unable to exert any direct control over the decision-making process which remained entirely in the hands of the Secretary of State for Health.

This illustrates one of the major challenges for the NHS in the years to come: reducing what has become known as the democratic deficit. It is perhaps ironic given the noble and seemingly democratic ideals upon which it was founded: fair access to health care for all, regardless of wealth.

However, it is also perhaps representative of a deeper malaise in the provision of public services which has become increasingly centralised. Politicians and mandarins in Whitehall issue directives to teachers setting out every detail from the curriculum to class sizes. So, too, with the NHS which is driven by the need to meet a limited number of targets set by central government rather than a goal of fulfilling the disparate health requirements of local communities. Whilst well-intentioned, such centralised decision-making over such an enormous organisation often leads to unintended consequences. A good example of this occurred in the last general election when it transpired that a government directive that all patients must see their GP within 48 hours hadn’t resulted in the desired effect of having appointment times being pushed forward. Instead, patients wanting to book more in advance were told that they would have to call back nearer the time.

The centralisation of decision-making in government has also been accompanied by a rise in two particular entities in the bureaucratic structure: that of the expert and the manager. Increasingly, when there is a difficult decision to be made, government ministers will side-step the issue and set up a commission to look into the matter or a quango to actually make the decision. This is also well-intentioned but takes important decisions even further away from the people who they affect. It also often shrouds what are in fact political decisions under the veil of expertise. In effect it simply abrogates responsibility to others who are less accountable.

So, too, with the rise of the manager. The professionals who deliver public services have been separated from its organisation even at some of the lowest levels. This function has been taken instead by managers. Few would suggest that there is no need for managers or that they do not have the best interests of the various public services at heart. However, again it has led to decision-making being taken away from the local level and moved more to the centre.

These developments have led people to become disillusioned both with politicians and very often with the provision of the services they control. We suggest is that those who run the NHS return to first principles and aim to reform it with two particular principles in mind:

1. decisions should be made as closely as possible to the people they affect; and
2. those people should have as much say in those decisions as possible.

In effect: localism.

The following merely provides a number of suggestions and illustrations as to how this may better be achieved and is not in any way meant as a comprehensive review of all the possibilities.

Patient choice
One of the biggest problems facing the NHS is that despite the undeniable good intentions behind it, it has produced what the Prime Minister has called a “deeply unequal” system where the rich opt out and the least well-off sometimes receive the worst health care. One way of tackling this issue is to try and give patients as much choice as possible in the services available to them, the ultimate devolution of power.

This is now being provided in a limited form with every patient needing a hospital referral being given the right to a choice of at least four. The target for elective treatments is that by 2008 the patient will be able to choose from any hospital in England that can provide care to NHS quality and price.

However, it is to be hoped that this does not end up becoming a choice in name only with no diversity in the services which are offered. In particular, it is hoped that private provision of state care will be allowed to flourish. Private companies should be allowed to bid to provide patients with the care they need and ultimately the funding to provide that care.

Further, whilst it is recognised that informed choices will be more difficult to be made in areas such as mental health care, it is hoped that the principle of giving patients the power to choose the service provider is extended to as many services as is is practicable to do.

In answer to the argument that such measures may ultimately result in unfairness with some patients being giving more choice than others, the answer is simple. The unfairness is that which exists at present due to the one-size-fits-all system. For example, figures show that patients are twice as likely to die in the worst performing hospital in England as they are in the best. Increased choice will reduce unfairness by catering to the particular needs of particular communities recognising that inner city populations have very different health care needs to rural areas. By embracing pluralism, standards will be driven up for all.

Diversity of provision
Inextricably linked to providing patients with as much choice as possible is the need to liberate the NHS from the top-down approach of a state monopoly obtaining services only from itself. This can be replaced by a flourishing market attuned to local conditions and needs. If private and not-for-profit organisations can provide the same or a better service for less cost there is no reason why they should be restricted in doing so. This currently accounts for only about 10% of electives and overall around 1% of the total NHS budget.

Private providers should be encouraged to bid for as many services as possible and there should be little or no limit on the amount of services they provide. The move from a command to a mixed economy will help to stimulate competition and vitality within the health sector. This in turn will produce innovation and improvements in productivity which will be essential in the years to come in helping to meet ever-increasing health expectations.

Elected bodies
In addition to the democratic effect of increased patient choice, the structure of the NHS itself should also be democratised. The most significant body within the present structure is the primary care trust (PCT) which commissions the majority of NHS services. They make the decisions as to what resources are given to primary care and in what form and also what resources are allocated to secondary care such as hospitals.

The major difficulty with these bodies is that they contain no directly elected representatives. Further, there is nothing to stop its current membership of, for example, GPs, simply allocating resources in a way that suits themselves without sufficient reference to the local needs of patients and of hospitals and other services.

One possible route is simply to make PCTs more representative with hospital and community doctors being added along with private providers and also members of the community. However, other than the public representatives, each of the other groups would at least have an interest in simply arguing for more resources to be allocated their own way.

Given the significance of the decisions which the trusts make in terms of resource allocation, the authors advocate that PCTs should be abolished in their present form and replaced by an independent Commissioning Body. This could take one of two forms. One might be a panel of experts or managers who could listen to all the arguments and then make the decisions. However, not only is this wholly undemocratic, it also falls foul of the difficulties set out above which occur when panels of experts start making political decisions.

The preferred option is that the commissioning body should consist of directly elected representatives. These would be under a duty to consult all stakeholders as to how resources should be allocated. These would include GPs, hospital and community doctors, private sector providers of health care and patients. Local people should then be trusted to make the decisions that most suit their own communities having been provided with the best possible advice from the professionals, thus invigorating community involvement in health care.

Unfortunately, the only elected representatives so far introduced into the NHS have been to foundation hospitals which would seem to be a case of putting the cart before the horse. It is the commissioners rather than the providers of health care that most need accountability if local people are truly to be empowered.

The means of providing the elected representatives is connected to another reform necessary for making people feel closer to the decision-making process. At present the structure of the NHS is so complicated that even those who work within it hardly understand how all the funding streams tie together. A big reason for this is the ad hoc nature in which the NHS has developed, often rolling from one crisis or reform to another without any principle underlying it.

The whole structure needs to be revisited and simplified down to as few layers as possible. It would be hoped that primary care trusts and other health organisations could be given boundaries that coincide not only with each other but also with local authorities. This would facilitate the provision of directly elected representatives in that the new commissioning bodies could then consist of locally elected councillors. This would tap into the already vibrant local party politics and help further to politicise the electorate over deciding the future of their own health care services.

It should be noted that ironically this would truly be bringing the NHS back to its roots since the original plans contemplated much local government involvement. However, in order to appease the medical profession, when the NHS was finally introduced the primary care administration of the NHS had the least amount of local democratic accountability.

Increased local powers
One issue which the introduction of elected representatives to Foundation Hospitals has highlighted is the need clearly to define the powers and responsibilities of those who are elected. Commissioning bodies should have their functions clearly delineated from the start.

The introduction of directly elected representatives not only invigorates an organisation but it also empowers it through the extra legitimacy. With this democratic safeguard, there is no reason why decisions which are currently made centrally should not be made at the more local level of the new commissioning body. It is therefore hoped that their responsibilities would be wide.

A good example of a power which could be devolved is that in relation to the guidelines issued by the National Institute of Clinical Excellence (NICE). These were introduced to try and end the so-called postcode lottery in NHS prescribing and enforce the same rules across the board. However, this suffers from a number of problems. First, it fails to respond to local needs. Second, it again disguises what is a political decision (cost/benefit analysis) as something solely for the realm of experts. This false distinction was highlighted recently over the use of Herceptin for early breast cancer which led to legal action and the Health Minister taking the unusual step of in effect overruling NICE arguably for political expediency.

We believe that NICE should be abolished. A Parliamentary Select Committee should deal with the making of recommendations for drugs and conduct detailed consultation. The experts involved with the Institute (who themselves are to be applauded) would be able to give their advice and opinions and then the politicians could produce a report spelling out all the costs and the benefits and making recommendations. The newly formed Commissioning Bodies could make their own decisions in the light of this advice in consultation once again with all their local stakeholders. The irony is that many experts might welcome being able to return to their traditional role of providing medical guidance and opinions without being forced to make what are in effect political decisions.

An example of a policy which could be scrapped following the introduction of the Commissioning Bodies would be the use of national targets. The priorities for each particular area could be decided in advance by the locally elected body following full consultation. In fact, this is the sort of issue which the local representatives would probably have addressed in their manifestos.

Empowering professionals
The other way of ensuring decisions are made as closely as possible to the people they affect is by bringing doctors and other health care professionals back into the decision-making process.

The first way to do this is through a formal role in the consultation with the Commissioning Bodies. Doctors have been subjected to growing numbers of national standards frameworks. These hinder their clinical autonomy and their ability to provide for the needs of specific patients. It is hoped that decisions on issues such as this can now be made at a local level initially by the Commissioning Bodies and then implemented by the doctors.

In addition to the limitations which have come from centralised planning, doctors and others have also had many of their policy and operational powers given to managers. Whilst the policy-making decisions which managers currently take should be devolved to the Commissioning Bodies, other more day to day decisions on resource allocation should be returned to the doctors and others who previously made the decisions. Those managers who remain should be left with at most truly administrative responsibilities.

Almost sixty years after its foundation, the NHS is in need of invigorating and entrusting back to the people it serves. Through a mixture of patient choice, diverse providers, democratic accountability and re-empowering of the professions, it is hoped that a new flame of civic pride will be lit which will guide the institution through its next sixty years.
Daniel Hannan is an MEP and one of the 22 authors of ‘Direct Democracy: An Agenda for a New Model Party’ published by, 2005. Tim Kevan is a barrister at 1 Temple Gardens.

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