Feature

On whose say so?

The latest round of structural changes to the NHS make new ideas about how to involve people in the shape and running of their local health services more vital than ever, explains Alyson Morley

More people care about health and health services than any other political issue.¹ What is more, public opinion research shows that this has been the case for decades and, most likely, will continue to be for many years to come. But people have almost no say over the way their local health services are run.

Far from making good his promise to ‘sweep away the quango state’,² prime minister Tony Blair has presided over a period in which the last vestiges of democratic accountability in health — local councillors serving on community health councils — have been swept away to be replaced by a huge expansion of health-related quangos.

The list appears endless, with new acronyms appearing on what seems to be a weekly basis. We now have CHI (soon to be CHAI) and CSCI, NPSA, NICE, CPPIH, the Audit Commission and the NHS foundation trusts independent regulator at national level, and PALS, ICAS, PPI forums, local network providers, primary care trusts, NHS trusts and foundation trusts at local level.

All of which, no doubt, are striving to improve health services and make them more patient-centred: but that is not the point. The NHS has never seemed more remote and bewildering to local people. How can we reconnect this much-loved institution with local people? Certainly not by creating more quangos. If only 15 per cent of the population were aware of CHCs,³ what hope do they have of understanding the respective roles and responsibilities of the different counterparts of the new patient and public involvement structures?

The government’s assurances that the creation of foundation hospitals heralds a new dawn of democratic accountability rings hollow with those of us who have had the chance to examine the governance structures in any detail (see pages 12-14). What we discover is that the ‘members’ who ‘own’ the foundation hospital will not only be a narrow, self-selecting group but that they will also be far removed from the real holders of power.

If any good has come out of the furious debate provoked by foundation hospitals, it is the consideration of what a truly democratic health service would look like.

We cannot rely on past structures to show us the way forward — part of the problem stems from the way in which the NHS developed. Often, it is caricatured as a Soviet-style, monolithic, centralist public service that sprang fully formed from the pages of a central government plan. The reality is completely different. Our hospitals developed from the pre-existing hotchpotch of private, charitable and public hospitals, which largely operated as autonomous institutions. The same is true of primary care: it has always been an uneasy mixture of self-employed practitioners, the private sector and local public servants.

Before the structural reorganisation of 1974, local authorities were responsible for public health and community health so there was at least some democratic accountability in parts of the health service. But since then all subsequent reforms have eroded what little democratic engagement there was.

Health ministers of all political persuasions seem to find structural change irresistible. Reforms and modernisations sound far-sighted, dynamic and radical in government press releases. The reality is often costly, time-intensive and deeply demoralising for staff, without necessarily delivering any real benefits to patients.

That is why the options outlined in our recent publication People Power and Health: A Green Paper on Democratising the NHS seek to build on existing democratic structures. We do not simply want to extend the reach of local councillors, although there is good reason why they should be involved in strategic planning for health improvement. We want to create a new role for local people in the health services. As elected representatives — not a self-selecting few looking after the business interests of a single health institution — they would be accountable to local people and have the flexibility and autonomy to set their own priorities, milestones and targets.

We believe it is entirely appropriate for central government to retain control of long-term outcome targets, to be responsible for the fair allocation of resources to improve health and to set quality standards for services. But beyond that, its influence in the planning, prioritisation and delivery of local services should cease.

We have called this document a green paper because we want to encourage discussion and generate ideas about how best to achieve real democracy and public involvement in the NHS. You may not agree with all the options outlined; you may have alternative proposals. We welcome all contributions to this important debate, which should feature prominently in the party manifestos in the run-up to the next general election.

People Power and Health: A Green Paper on Democratising the NHS is available from the Democratic Health Network, 22 Upper Woburn Place, London WC1H 0TB, price £5. It can also be freely downloaded from www.dhn.org.uk.