WORKSHOP TWO: LOCAL DEMOCRATIC ACCOUNTABILITY
Andrea Jones, Chair of Trafford MBC Scrutiny Committee: The old style local government of the 20th century - decision-making was done by committee. Political parties dominated local government and made decisions. Many local authorities were one party states and there was no real scrutiny of the decision making processes.
The new arrangements offer choices - many councils are going for the cabinet and scrutiny model. Decision-making will be undertaken by the executive and it will be scrutinised by other councillors, an exciting way forward. Scrutiny committees will have the power to call in decisions before they are made, and can make recommendations and review long term policy. Scrutiny committees will not be whipped and therefore they will be non political. They will not have pre-meetings and will be able to select their own chair. Scrutiny will require very different skills, and people are only just beginning to learn how to do it. There will be a new learning process around a huge agenda. If local authorities also have to scrutinise the NHS, they will need assistance and expertise to help them, for example, professional advice and involvement of former CHCs.
Paul Walker, SHA Vice President: Paul has been appointed and anointed throughout his professional life. This was wrong and inappropriate.
Just after the split between commissioning and providing, he believed that the commissioning role should have been given to local government. Then he retired and became a councillor in Bristol. He was the health lead, and they set up scrutiny arrangements before it became statutory. He found his experience of local democracy off putting. Most councillors do not read their papers anyway, so to give them a huge new area of work will be purely tokenistic. He has therefore moved away from the notion of involving councillors.
He remembers the start of CHCs, which everyone thought was a super idea. However, they are very variable and very under resourced. Then he served for four years on a CHC. He still thinks they are a good idea and that they should not be abolished but resourced properly. They should not be the pygmies dealing with a behemoth. There is a need to keep what we have and develop it.
What form should democracy take? Health authorities and NHS Trusts should be elected on a health ticket, attached to CHCs? Should health be democratically accountable at every level - national, regional and local? Yes, but then there will be the issue that the system will retain postcode prescribing. The NHS can either be a monolithic organisation directed from the centre, or one where there is discretion and democratic decision making. Paul personally could live with postcode prescribing. He now works in Wales, where there is no NHS Plan as yet. They are to keep their CHCs. Also, they still have independent as well as party councillors.
Maggie Mansell, Croydon Councillor: Councillors have had to rethink processes as well as structures and to ask questions that were not asked under the old system. Maggie loves the idea of elected health councillors, but it is unlikely to be a runner. There is no reason why a CHC together with elected councillors could not be a sub-committee of the Council and be the specialist health scrutiny sub committee, along with members from the voluntary sector and the patients' forums.
What will they be scrutinising? They can ask for information from council officers and from health service officers, which will require health and local authority co-operation. They should also meet more than twice a year.
Guy Routh, NHS Consultants' Association: Guy supports democracy at all levels, but that alone will do nothing to change NHS culture. The assumption is ex..ing (?) to NEDs and work out how we get it through NEDs. The same would happen with elected health councillors - so we need more openness in the NHS. What is democracy? Also, there are difficult decisions in health around the availability of resources. He agrees CHCs should develop a supporting role but with proper training, resources and genuine involvement
Michael Varman, PCG Chair: Michael is preparing for PCT status in a powerful partnership with the City Council and the three PCGs to change health care in Nottingham, whether the local NHS wants its or not. They have a very unhealthy population compared with the neighbouring constituency. The key issue is that unless the population owns its own health, nothing will change. There will be three locally accountable organisations within the PCT, working closely with local government and drawing NEDs from each locality if possible, who will be accountable to that patch. The snag is that the population does not access what will benefit them. For example, there are twice as many heart problems in the area with half as much treatment when compared with the neighbouring constituency.
How to engage the population in health decisions? On joint walkabouts problems are raised, but they are not about health care but about community safety, housing, pollution etc. The government lays down targets via national priorities for health care, and also for local government. They may not be the same, but they have to turn these concerns into a response in the HImP, e.g. from concerns about crime to ensuring more use and take up of drug services. So democracy is needed, but we also need to work out how the population gets to own its own health.
Shirley Goodwin, Public Health Director: Local accountability will be important in the larger Health Authorities. Shirley is looking at Section 31 flexibilities in the Health Act to share the public health function between health and the local authorities.
If the responsibility for public health were returned to local government, would that not partly answer the question around the need for democratic accountability? Giving commissioning and the responsibility for public health to local government could assist local people to own both their own health and their local council. This could also lead to a better turnout in local elections and more interest in the electoral process.
Julia Knight, PCG lay member: Julia is disappointed at the government tenor of democracy. CHCs could become scrutiny committees. There is a lot to say about building on the work of good CHCs, and bringing the poorer ones up to scratch. But councillor members of CHCs are not always the best. They have no time to do the work and some are unable to separate their CHC role from their party political role. Elected local health boards would be a good idea.
Democracy is difficult, but we must start somewhere. To do otherwise will be patronising. People have a right to know what is being done with their taxes.
Catriona Morton, GP: Catriona has no local democratic involvement. She would probably be one of the resources. When they discuss issues like CHD, alcohol, and mental health issues, the patients want the same things, for example, local alcohol services, prescribing of Zyban, CVD clinics.
The local community want to improve their health and have a consensus of what is needed. They achieve better results at primary care level than at hospitals, but they need more resources, more appointments, earlier appointments, more GPs. Patients think the health centre is the focus for accountability and when they are told to go to the patients' forums, they are not interested.
Maureen Smith, Occupational Therapist, Surrey. Maureen raised the USA town meetings model, where they have annual elections on everything, including major budgets such as education. Solutions are often identified at town meetings, and the closest model here is the CHC. However, there is a danger of voter fatigue.
Nursing care at home will not work because it is not resourced sufficiently, yet nursing homes are disappearing. These adversely affect members of a hidden vulnerable group.
Ian Syme: They have two social services departments, one City Council, and one health authority, all of them underfunded. Stoke Health Watch members attend board meetings of every body and ask questions. Health is at last becoming more open, but is still very defensive.
We should be aiming for perfect information from perfect data, from both the health authority and the local authority. The cabinet system is not truly democratic. We can't ask questions at local authority meetings, although we can at health authority meetings.
Dave Parry, man in the street: The esoteric language is not understood and must be modified as a part of the culture shift. Wyre Forest was very officer led. Then the hospital issue emerged, and 19 of 42 councillors are now Health Concern councillors. Some medicos fell by the wayside but another adjusted his language and dialogue. Now there is an up to 48% turnout in local elections. The GP has an important role to translate medical jargon, unlike consultants and the health authority.
Donald Roy, Wandsworth CHC Chair: Donald agrees that the extension of the Access to Public Bodies Act was very effective. But it is hard work using lay CHC members. These lay members sit as of right at each PCG, Trust and health authority board meeting and are not bound by collective decision-making. The abolition of CHCs means that in future there may not be the people at each board doing the monitoring. The local press do not have the staff resources, and do not understand the issues.
In Tory authorities like Wandsworth, we face the situation where councillors on the CHC serve their Group and/or are there to discredit the CHC. They asked the local authority to work together with the CHC on scrutiny, but were told that the existing structures are sufficient. PCGs and CHC have shared a common agenda around public involvement and community development. However, the local authority does not share it, and has often been positively opposed to it.
Jane Haworth: The council members on her CHC are superb. Democracy, yes, but which democracy? Much is based on the unitary model, so what happens in the shire counties? Who should come together in that partnership? If it is left to the health authorities, there will be no agreement. We need to look at the trust catchment areas and draw in people from each local authority. The public also has a responsibility to try and keep themselves informed.
Fiona Campbell, Democratic Health Network: Who are CHCs accountable to? Who elects them? How about direct election to CHCs, or to whichever body calls CHCs to account?
Geeta Patel: Geeta is a founder member of a diabetes self help group. They cannot leave the issue to health services, which are primarily directed and delivered to white people, although four times as many black people have diabetes. PCGs and PCTs are new organisations and have an ambitious programme to carry out the health agenda of local communities. HAZs act as the leader on the public participation work stream. A lot of people feel totally disconnected from the democratic process as they have no experience of it. Her group also did a gender audit of those decision-making bodies in Wolverhampton that did not hold themselves to be accountable.
Woman, 1974 CHC founder member: CHCs had speaking rights in 1974, then a period without them, and now have them again. She has doubts about scrutiny panels. They will have a different role from the CHC. Scrutiny takes place after the event, CHC scrutiny takes place before decisions are made.
Judith Blakeman, KCW CHC Chair and K+C councillor: We have not yet touched on the role of the ILAFs. Perhaps these could be elected, with effective statutory powers of scrutiny over the larger health authority economies?
Gordon Worrall, S. Birmingham CHC: Gordon believes in an independent patient watchdog, whatever it is called, but it should have the word patient in the title.
Local authorities should be the body to be consulted on strategic issues, not CHCs, which have only an indirect system of election and appointment. Under the old system, the attendance and performance of councillors on the health authorities was generally poor. Election is not feasible in the short term under this government, so for local authority scrutiny, there is a very strong case to co-opt people from the CHCs. Local authorities should welcome this as an additional source of expertise and experience.
An example: in Birmingham there were proposals for social services cuts due to under funding. The money was then given to the local authority by the health authority. The health authority had been given the extra money by the government for winter pressures.
Could CHCs be an intermediary body? Are they no longer needed? Should we look again at how to involve service users more effectively?
Workshop1 Participation
Workshop 3 Two sorts of accountability
Workshop 4 Delivering an effective service