Tim Kevan: Gordon Brown, the NHS, and the democratic deficit

Tim Kevan is a barrister and was a contributor to a recently published book entitled ‘The Future of the NHS’ edited by Dr Michelle Tempest and published by xpl Publishing.  He was national chairman of the Conservative Students from 1993 to 1994.

First it was Gordon Brown and now it’s David Cameron.  Everyone wants to set the NHS free, to take it out of politician’s hands. The idea is that this will restore faith in politicians ironically by taking the day to day decision-making away from them and allowing it to be run by professionals uninterested by short term political gain.  This approach is partially supported by a recent You Gov which followed the publication of a book The Future of the NHS which showed a two to one majority in favour of the government withdrawing from the NHS.   

However, what both the Chancellor and David Cameron seem to have missed is that the frustration with the NHS in its present form is based upon ever more distant decision-making from the people those decisions affect and his solution will only serve to exacerbate this problem.  It reflects the very real democratic deficit which exists in the NHS.  For example, when the people of Kidderminster objected to the closure of facilities at their local hospital they started a campaign which eventually led them to winning a majority of their local council seats and even the local parliamentary constituency.  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.  The introduction of an independent body is hardly going to empower people such as those from Kidderminster.  Instead, it will take decision-making one step further away.   

One solution to this problem is to introduce democracy directly into the NHS.  This could immediately be done by changing the structure of the NHS and in particular primary care trusts and other health organisations so that their boundaries coincide with local authorities.  Once this has been done, decision-making power can be handed over to locally elected politicians who can respond directly to the needs of local communities, failing which they will be accountable at the ballot box.  This would not only invigorate the NHS but it would also empower the PCTs and health authorities through the extra legitimacy.   

On a wider level, it is to be hoped that this is not the direction in which the Cameron Conservatives intend to go more generally.  It was also reported only recently that the country now has 882 different independent governmental bodies or quangoes, each of them not only taking power further away from the people but costing those people a total of £124 billion for the privilege.  If the Conservative Party wants a radical proposal for their first day in office, perhaps they could promise to abolish all quangos in their present form within 2 years and instead to hand over the regulatory functions to locally and nationally elected bodies.

Comments

[Serf]

If we have to abandon the patient's passport, which would have put power in the hands of individuals, then local accountability is the next best solution. National independence is the worst.

[deborah]

YES to abolishing quangos. I'd vote for that one.

[voreas06]

I was disappointed to hear that Cameron wanted to go down the de-politicised independent body route, with a regulator. I think your idea of making trusts locally accountable is excellent, and would be the perfect example of localism and I dare say very popular. Obviously both prevention and procurement would probably be best kept centralised.
On another point I think that those who call for choice and competition are not looking at the reality of what can be achieved without a massive hospital building programme which would be wasteful. also I just do not believe that the profit motive is the best way to achieve the best healthcare, therefore I think any reduction in costs needs to be made through efficiencies, and either performance related pay and a customer feedback system or local accountability seem like much better routes for good healthcare and value for money.

[Jonathan Mackie]

Not sure how replacing one set of buearucrats with others albeit at a local level will improve the NHS.

Decision making would still be one removed from the actual consumer of services and therefore unresponsive to consumer needs.

I think we really need to look at embracing a more social insurance based model, which would truely empower the patient. The state could be a guarantor or service quality, but it does not need to provide services.

[Jon Gale]

Local Authority based trusts would merely exchange interfering national politicians for interfering local politicians - how is that any better?

The problem is that 'acountable' politicians will try and fiddle the health service in populist ways to protect their seats, but (even if well intentioned) dont really know what they are doing. Medical professionals should run hospitals not meddling amateurs.

[Klamm]

The bottom line is that there is a taxpayers deficit and a lack of comsumer power. There is no link between those who fund the NHS and the service they get given to them.

Even handing it over local politicians would not solve the problem, because whilst the democratic link would be closer, the taxpayers deficit would still be there.

The question that really has to be asked is why are there no waiting lists in France and Germany when they spend the same proportion of GDP on their health service?

We should change to their models not stick to one that the Soviet Union would have been proud of. Even if it watered down like the proposals.

You only have to read Cancer Ward by Aleksandr Solzhenitsyn about a Soviet hospital in the 50's to see the NHS in 2006 is no better.

[James Maskell]

Jonathan Mackie, any form of social insurance is out of the question now. Lansley said so in yesterdays speech...

[Jonathan Mackie]

James - What has Lansley's speech go to do with my views?

The public are ripe and eager for change in health care provision. There is no need for the Government to be the provider of health, provided it remains free at the point of use.

State provided health care, as in any service is low quality, lacks market signals, inefficently allocates resources etc etc.

[voreas06]

I think Local accountability is very different as it may be possible for example to stop local A&E wards from closing. If local elected officials jobs are on the line then they are more likely to respond. I do however agree that it doesn't give everyone in the trust a stake in patient satisfaction, and the only solution to that as I see it is to make people on the frontline directly accountable through PRP with a customer service element. I don't think you are going to get an improvement in Service until you trust people and remove several layers of ego-driven empire building wasteful management.

[Jonathan Mackie]

Voreas06 - performance related pay doesn't will make no difference to the priorities of the NHS. It may improve the experience of the user and possibly end the "get lost" mentality that sometimes exists in public services, but that is about it.

The whole model of healthcare needs restructuring, around the priorities of the consumer. If we have local worthies determining health care it will lead to inefficent demogogory when resources are being allocated.

[voreas06]

Jonathan Mackie: The whole model of healthcare needs restructuring, around the priorities of the consumer.

Whilst you are right PRP aimed at frontline staff alone cannot restructure a local trust if everyone's pay in the trust started to be influenced by customer satisfaction ratings it would soon change it's priorities. If a chief exec of a trust or a cleaner in a trust is paid more if all areas he/she has control of are achieving a high rating then they are more likely to ensure that happens.
I think the alternative based on choice is not realistic, for things like A&E and Maternity there is never likely to be a choice(therefore you pay monopoly prices), and even if you had six hospitals to choose from they will be reducing costs to a minimum which is not what you want when you are relying on them for possibly your life. Not to mention how much wateful infrastructure that will need within a town/city.

[Angelo Basu]

The French system sounds from the link below like an ideal one for localising Conservatives.

http://www.civitas.org.uk/pubs/bb2France.php

[Klamm]

Well said Angelo

The key issue to remember is why are there no waiting lists in France and Germany when they spend the same proportion of GDP on their health services?

[David Sergeant]

In the past I have been a robust supporter of stability before tax cuts and accepting the EU, but, I am very twitchy about the Cameron view on the NHS. I don't see how it can be "a great achievement of the century". It seems to me to be an organisational shambles that wastes vast amounts of money and gives one of the worst health services in the western world.

Moving to an insurance type system like every other western country seems seems inevitable and esential if we want some element of consumer power and efficiency.

However, trying to guess the thinking behind the Cameron approach (we're all reduced to guessing!), firstly, there is no way an insurance based system could be introduced within a government term so there is no point in an opposition talking about it. Anyway, it would frighten the voters. Secondly there is a possible "third way" (!) that seemed to work rather well with fund holding GPs and, as I understand it, a NuLab version that could be sorted is in place. Third, perhaps, given the size, the difficulties and voters viewpoint, it is possible that a Tory government could make a public sector service work properly, surely one could be made to do its job! Oh yes, fourth, what the country in general and public services in particular need after the lunacy of the last 10 years is a period of stability and that's what one expects from a Conservative government.

[sjm]

The NHS is not just about hospitals, it's about GPs, community nursing, teaching, training and research. Given that the overwhelming majority of councillors I have met in the past 20 years are greedy, self-centred morons, the notion of them running the Health Service is a sick joke.

The German Health Service is in serious trouble, so should not be touted as an example.

[matt wright]

This is a very interesting thread and a very important debate. Generally I like the approach to localism and would tend to favour it where possible but I can see some obvious problems with some services and certain models as mentioned in the article. What is going to happen when Blankshire County offers x life saving service and Exampleshire County doesn't. Its the postcode lottery problem again! The public won't be interestyed in replies like, "oh well we gave local powers for Blankshire to do what they want", the public will just say, "what sort of Govt has let this happen etc". I think where possible we ought to favour devolving as close to the consumer as possible. That too can have problems in the real world.

Matt

[Bald Eagle]

I tend to agree that allowing local authorities to run hospitals, or indeed, other forms of healthcare, directly will just move political interference from the centre to local politics.

This has the advantage that it can make the healthcare service more responsive to local needs. This is certainly positive but in order to achieve this we need not subject healthcare providers to local authority control, only set them free of central control, even if they are centrally funded.

However, if you believe in a diversity of providers of healthcare, then there is no reason why a local authority should not run a local hospital or other healthcare provider. If it turns out that the local authority does it well then this form of managment works well then it will spread and if not, not.

The point of a diversity of providers is to find and then replicate those parts of the system that work. By allowing diversity in the system we can run many small 'experiments' in the best way to provide healthcare and keep the best ways. As the author points out, there are advantages to local authority control. But we shouldn't subject the whole system to one form of management as we do not know in advance, in such a complicated system, whether it will be best one or even a good one.

[Angelo Basu]

Provided that the way that funding comes from central government is fair and objective (ie no diversion to ensure that local hospitals in areas where the government is defending marginal constituencies) local control and decision-making will not be damaged by invidious comparisons with other areas. Places like Kidderminster have shown that concern about local health services is capable of transcending party allegiance so why shouldn't the rest of the country be expected to take a similar stance if it cares enough about the issue?

Putting the power into local hands on the basis of elections for such key local services can work- Jamie Oliver has also shown this with the way in which he mobilised the people of Lincolnshire to address the issue of school catering rather than merely acquiescing in the choices of local politicians who have a wider range of concerns and the ability to blame Central Government rather than take responsibility themselves.

If this still results in poor service in an area, the only people to blame will be the people in that area itself. Let people make their own mistakes and live by their consequences.

[Simon Chapman]

Grantham Hospital is one of those whose A&E services are under real threat. This is causing local fury and fear in equal measure.

Much of the anger stems from the fact that the United Lincolnshire Hospitals NHS Trust ("fair" on quality of services, "weak" on use of resources in today's tables) is totally unaccountable for the decisions that it is making.

The Conservative NHS Bill won't address this. Giving local authorities the power to commission local services would. That's the sort of accountability we should be looking at.

[Simon Chapman]

From today's Reform news review:

The Economist comments on NHS independence proposals: “In practice, however, it will be difficult to divorce the NHS from political control …. Even if it were realistic to make the NHS independent, this may not be the right time. The health service is at last moving in the right direction – towards greater choice and competition – but only because of the impetus for reform that has been driven by Mr Blair. An independent NHS board would find it much more difficult to force the pace of change” (Economist, p.29).

[Beverli Rhodes 7 July Bombing Survivor]

The health service is at last moving in the right direction – towards greater choice and competition perhaps but where does that leave the man in the street? Just with a different puppet dancing to the tines of the puppet master(or muppet as the case is here)

One of the key gripes of the 7th July bombings survivors is the waiting lists, the endless mountain of paper in order to get treatment for injuries sustained due to a bomb - a bomb whilst on the way to work, work where we have paid our taxes! There no waiting lists in France and Germany when they spend the same proportion of GDP on their health services Why not here?

Personally I would like to see a superior service offered within the NHS but that is unlikely in my lifetime.

I notice that some posts suggest private medical insurance - not one survivors yes Ill say it again NOT ONE SURVIVOR was treated or even offered treatment on their PRIVATE medical insurance for injuries sustained in the 7th July bombings. Why? Well all private medical policies have extended exclusion clauses that specifically cover non-payment for acts of terrorism. Private medical insures find ways out of paying for medical treatments.

Its time to find another way. Dont cry - just pay.

[Dave B]

I think devolving health/NHS to local government is a super idea :-)