There was also a row inside Cabinet about the structure of the NHS. Herbert Morrison, with his background in the London County Council (LCC) wanted a localised, municipal structure. Aneurin Bevan wanted a centralised state-controlled monopoly, like British Railways or the national coal board (NCB). Bevan was a product of his times: he believed socialism meant state control, and entered the government in 1945 surrounded by nationalised agencies and bodies. During the war, the hotch-potch of private, voluntary, state and municipal hospitals and medical services had been brought together into a co-ordinated service to cope with mass civilian casualties and war-wounded. The NHS, with the sound of bedpans falling to the floor in Tredegar being heard in Whitehall, was the logical next step.
Bevan won the argument, and healthcare in the UK was nationalised at a stroke.
There are two historical weaknesses in the structure of the NHS. The first is that its centralised character has not tackled regional disparities in health. People in the northern cities were living shorter, sicker lives than people in the southern counties. The NHS did not tackle health inequalities, and today we are still playing catch-up. The second issue is the lack of democratic control. Ministers are not responsible for what goes on in hospitals. But the public has no say either. Just consider how hard it is to navigate the complaints procedure, or what happens when there is a major failure as at Stafford Hospital. The public are on the outside, looking in. It is left to the professionals to run the service.
In New Zealand, the Labour Government in 2000 experimented with elected health boards as a means of directing resources where they were needed most. Chris Ham at Birmingham University wrote a piece a few years ago which said a
‘lesson from New Zealand is the value of local people involved in health boards. The two-thirds of members elected by the public are chosen every three years, with elections held at the same time as those for local authorities. Turnout is around 40%, and most candidates stand as independents. New Zealand’s system has the twin virtues of engaging the community directly and avoiding the risks of over-centralisation to which the NHS is so prone. There is a greater willingness to deal with the challenges of the health system at a local level, instead of pulling these challenges in to the government in Wellington.’
As a special adviser, I argued for elected health boards for the NHS. I met with Chris Ham to discuss his study-tour of New Zealand. The model I suggested was one third NHS professionals and experts, appointed by the Health Secretary, one third councillors, sent from local authorities, and one third directly-elected representatives of the local population. That model would allow direct, and indirect democratic involvement at the level of the PCT, but avoid the danger of ‘capture’ by the BNP or any other single group. It would have been for the NHS, and also good for local democracy too. The idea was strangled at birth by the Labour government’s centralising tendency, which was a shame. Even a line in a speech floating the idea at the Labour conference was removed at the last minute.
I was reminded of all this this week, when I was making a presentation at the Royal College of Nursing (RCN). Looking at the health section in the Coalition Government’s Agreement, hastily put together during the negotiations after the general election, there it was:
‘We will ensure that there is a stronger voice for patients locally through directly elected individuals on the boards of their local primary care trust (PCT). The remainder of the PCT’s board will be appointed by the relevant local authority or authorities, and the Chief Executive and principal officers will be appointed by the Secretary of State on the advice of the new independent NHS board. This will ensure the right balance between
locally accountable individuals and technical expertise.’
I hope that this is one pledge that the Conservative-led coalition delivers on. Labour should sign up to it, not oppose it in Parliament, and prepare Labour candidates to stand in every Primary Care Trust area on a platform of defending the NHS.
While local engagement in the NHS is positive, I worry that it would too easily become politicised. We shouldn’t be battling on party lines when it comes to healthcare delivery – that must be done in parliament and councils. The decisions PCTs make must be based soley on patient need, not what will look good in the local paper and lead to re-election. I met the head of Wiltshire PCT during the election and he feared elected boards would mean he would lose the remarkable mix of experienced appointees he currently relies on. They simply wouldn’t stand for election and didn’t see themselves as part of a political process.
The challenge for the NHS must be to engage more closely with local communities, but not allow individual or party agendas to dominate overall strategy. Why not instead have community health forums which allow all patients to feed thoughts into a local group. This group would then have a representative who was a honourary PCT member and fed back to the board.
This would make the whole process much more dynamic, as people would always have a forum to directly interact with and the process is completely non-political, but patient-focused. This would also be more accountable than electing an individual every few years and would avoid unnecessary conflict within the PCT. I can’t see that having more politicians running the NHS is going to improve it in any way.
It’s really about being held to account. PCTs are unanswerable to the public yet totally funded by that public and we are talking hundreds of £Ms. Non Executive Directors do not represent the public. In High Wycombe recently 40000 signatures were ignored by the PCT and the PCT repeatedly stays away from public meetings to discuss NHS issues.
If it’s “Our NHS” then could we please have a say in how locally it delivers services?
Not much point worrying about “PCTs” when all the money/action is coming via GPs! The most intractable group of “independent contractors” who are answerablle to exactly no one! They will have to create 00s of unelected mini quangos to handle the moolah……………what a shambles!
To appointed to any health authority an experience in business is required which promptly disqualifies the vast bulk of the interested population. The only way forward is to transfer all PCTs to local government. If that means more than one local council becomes responsible so be it, it is not insurmountable politically or administratively. Also, I am always a bit wary of wanting to take the politics out of things. Isn’t this what Tories used to say when they lost control of anything?