Feature

All those in favour of Hutton?

The Hutton commission’s recent proposals on democratising the NHS are a good start, says Martin Rathfelder

The NHS is probably the largest organisation in Europe which remains relatively isolated from the pressures of the market, but it suffers from the problems which plagued other nationalised industries. It is a centralised command economy, with little genuine democratic involvement or participation. Despite many expensive local consultation exercises, all important decision making actually happens in Whitehall. The agenda is set in a constant stream of guidance, linked to performance targets, which pours out of the Department of Health and is modified locally only because the service cannot possibly deliver all of the centrally prescribed agenda.

Gisela Stuart, parliamentary under secretary of state, said in the Department of Health paper on patient and public involvement in the new NHS: ‘Working effectively in partnership with patients can…be of great benefit to the NHS. It delivers better results for individual patients and better health for the population.’

But the involvement of patients at present is entirely individualised. We are patients – not citizens – the mechanism is clinical governance and the questions in which we are to be involved are about monitoring services. The agenda is determined clinically: clinical governance is not a system for determining what services should be provided, unless decisions can be made on a technical basis – and we are a long way from that. And the important decisions relate to health, not just to the treatment of illness.

The Hutton Commission has little to say about democratic involvement in public health issues. The theory is that health improvement programmes are led by both health and local authorities, but it remains to be seen whether this can be made to work.

We agree with the Hutton Commission that the NHS needs a more explicit purpose. Both political parties behave as if the main aim of the NHS is to administer as much treatment as possible to as many people as possible. This may be good for political point scoring but it creates impossible expectations and ignores the fact that medical treatment is not good in itself. Most people would prefer to retain their health with as little medical intervention as possible.

The overall objectives of a socialist NHS should be to create a system which reduces social and geographical inequalities in health, provides equal and good access to services, is publicly funded, democratic and responsive, free at the point of use, effective and efficient, ensures equal opportunities, and is a good employer. The NHS should work with local and national agencies to create a healthier environment and to eliminate poverty in order to reduce health inequalities. Hutton’s proposed constitution imposes the principle that the NHS should be universally available to all, regardless of means, ethnic origin, gender, age, sex, sexuality or any other difference. This appears to be an attempt to outlaw discussion of rationing, when what is required is an explicit policy of rationing which imposes a democratic perspective in the place of the prejudices of doctors.

We could improve health by tackling its social, economic and environmental determinants and at the same time improve democratic accountability within the NHS if we involved local government in locality commissioning of health and social services. There are difficulties in this approach, but they could be tackled by locating the right decisions at the right levels.

We believe that five levels of accountability are required:

• The secretary of state must account to Parliament for the central direction of the NHS;
• Elected regional government should replace the regional offices of the NHS and take over strategic functions. They should have a developmental and regulatory function (including NHS providers) and plan and commission specialist health services and capital investment;
• Local NHS commissioning and planning should become a local government function and derive democratic accountability from its locally elected members. There might need to be some further changes to local government to enable this to work, particularly over the boundaries between health and traditional local authority functions;
• Hospitals, community services and primary care trusts should be run by boards which include representatives of local government, health professionals, user groups, staff and other interest groups. Providers will be part of the NHS and accountable both upwards through the regional government and to their local commissioning authorities;
• CHCs should be strengthened by developing their statutory right to obtain information and providing a regulatory role. Hutton’s recommendations in this area are generally sound. CHCs must develop links with neighbourhoods so that local organisations and people can become involved.

A bottom up approach starts with people and integrates them into a social/political hierarchy from individual to their family and social network, the neighbourhood, local area, region, nation state and international/global connectivity. Empowering individuals and strengthening communities lie at the heart of Health for All policies. These personal and community levels allow for participatory and informal democratic input into recognisable democratic structures.

The proposals of the Hutton Commission to set up a written constitution for the NHS may not be the best way forward, but deserve serious consideration if Labour is go into the next election with clear ideas on how local decision making in the NHS can be given real legitimacy.