The current system is far from perfect, but for the past 20 years the NHS has included members of the public as non-executive directors on the boards of primary care trusts, strategic health authorities and their various fore-runners. This system means that currently the lay Board members have a significant role in governance and strategic planning. The government is proposing to abolish all Non Executive Directors and introduce unaccountable GP consortia boards with no obligation to appoint lay members. In addition the secretary of state has made it clear that he no longer wishes to be accountable for the performance of the NHS. This will in future be the responsibility of the NHS commissioning board.
GPs will continue to be encouraged to involve patients in their own healthcare, and Consortia will try to engage with people about services, but this is not the same as democratic accountability. There is a difference between engagement and decision-making, between having the right to be consulted and having genuine power to make change. Engagement is about discussion and deliberation rather than the exercising of power.
While a patient who is unhappy with their GP is able to move to another doctor, it is unclear if in the future they will be able to move between consortia. For example, if a patient lives within a consortium that denies IVF after the age of 32 will they be able to move to one that has a higher age limit? If a patient is unable to move between consortia when unhappy it will make a mockery of the claims that patient demand will drive provision.
At a recent discussion on consortia Johnny Marshal, chairman of the National Association of Primary Care – a man considered to be the brains behind the reforms – claimed that accountability issues were keeping him awake at night. He also stated that he wanted to keep politics out of the NHS – at both the national and local level.
Marshal is wrong about the role of politics in the NHS. The NHS can never be free of politics, nor should it be. How the country provides healthcare is an area of legitimate concern and debate. Differing views exist and these views need to be aired and considered within the political arena. It is essential that setting health policy and health priorities remain at the heart of political debate, rather than veering toward the position where healthcare becomes a personal and private issue based solely on individual decisions, and not on what is best for communities.
Marshal is also mistaken — the current reforms move public health into politically led and accountable Local authorities, so some parts of the NHS will find themselves under local political scrutiny.
Moving public health to local government means that if a member of the public has a concern about the provision of preventative services such as screening or healthy eating and exercise programmes then they will be able to take that concern up with an elected representative at their council. That councillor can then approach the health and wellbeing board or the portfolio holder and demand an answer or action. But if the issue is with hip replacements or diabetic services then there will be no elected representative who has any direct responsibility. If the Secretary of State is no longer responsible for anything apart from macro level health policy and health protection then what will be the point of taking up an issue with your local MP? The standard answer from ministers will be that it is a matter for someone else. This was recently illustrated when Andrew Lansley told a young boy in Southampton who was concerned about the possible closure of the local paediatric heart unit to ‘go and tell that to the person making the decision’. This was a shocking response and one that demonstrated not just the government’s reluctance to be held accountable but their determination to distance themselves as far as possible from the contentious decisions about healthcare which their ideological approach is forcing.
If Labour is serious about supporting localism then it must address issues of accountability. There is no benefit in having local services and local priorities if those making the decisions are not accountable to the local community who are affected by those decisions.
There are two ways to improve local accountability of the NHS: firstly to directly elect public members of the GP consortia boards. Public representatives would have a mandate from the local population and would take that mandate to every meeting they attended. Importantly, the public would also get to pass judgement on the performance of the consortia and the elected representatives at the ballot box. As well as improving accountability this would also improve communications with the public as the elected members of the consortia board would have an interest in talking to their electorate and responding to their concerns. Elections could be arranged to take account of the need for continuity and if desired could be contested by individuals standing on politically neutral platforms.
The second route would be via local councils. Councillors are already considered competent enough to manage social services, and will soon be adding large chunks of public health to their portfolio, so why not give the health and wellbeing boards the right to instigate powerful enquiries into the performance of consortia and, crucially, have the final sanction of recommending the removal of a failing consortium?
For as long as the NHS remains a public service surely it must also be accountable to the public.