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.

Daniel Hannan MEP and Tim Kevan: Localism in the NHS - reducing the democratic deficit

Daniel Hannan is a Conservative MEP and regular ConservativeHome contributor.  Tim Kevan has been a barrister for just under 10 years and was national chairman of the Conservative Students from 1993 to 1994.

As we celebrate the 60th anniversary of the passing of the original legislation for the NHS and the institution stumbles from one crisis to another, a timely poll has been carried out by YouGov which shows a two to one majority in favour of the government withdrawing from the NHS.  This poll highlights one of the major challenges for the NHS in the years to come:  reducing the democratic deficit. 

Unfortunately, the only elected representatives so far introduced into the NHS have been to foundation hospitals which would seem to be a case of putting the cart before the horse.  It is the commissioners in the primary care trusts (PCTs) rather than the providers of health care that most need accountability if local people are truly to be empowered.  They make the decisions as to what resources are given to primary care and in what form and also what resources are allocated to secondary care such as hospitals.  The major difficulty with these bodies is that they contain no directly elected representatives.  Further, there is nothing to stop its current membership of, for example, GPs, simply allocating resources in a way that suits themselves without sufficient reference to the local needs of patients and of hospitals and other services.

Given the significance of the decisions which the trusts make in terms of resource allocation, we suggest that PCTs should be abolished in their present form and replaced by an independent Commissioning Body consisting of directly elected representatives.  These would be under a duty to consult all stakeholders as to how resources should be allocated.  These would include GPs, hospital and community doctors, private sector providers of health care and patients.  National targets and centralised decision making could then be left behind in favour of local people being trusted to make the decisions that most suit their own communities thus invigorating community involvement in health care.

Alongside this, we also suggest that the whole structure of the NHS needs to be revisited and simplified down to as few layers as possible.  It would be hoped that primary care trusts and other health organisations could be given boundaries that coincide not only with each other but also with local authorities.  This would facilitate the provision of directly elected representatives in that the new commissioning bodies could then consist of locally elected councillors.  With this democratic safeguard, there is no reason why decisions which are currently made centrally should not be made at the more local level of the new commissioning body.  This could include, for example, decisions as to which drugs to make available with the National Institute of Clinical Excellence simply taking an advisory role.  Further, national targets could be abolished in favour of this devolution of power.

The You Gov poll is therefore a timely reminder that the NHS is in need of invigorating and entrusting back to the people it serves in order that a new flame of civic pride will be lit which will guide the institution through its next sixty years.

Daniel Hannan MEP and Tim Kevan are contributors to a new book published this week entitled ‘The Future of the NHS’ edited by Dr Michelle Tempest and published by xpl Publishing.

Related links: Ten point briefing on localism and Dr John Crippen recommends A fair contribution at the point of entry to the NHS.