Do we need more democracy in health?

The NHS is a massive political football, kicked around by politicians and commentators as if it was one single thing. It is also the site of countless political battle grounds, between medical professionals, officials, managers, companies, charities, patients, the public and representative groups of all these interests in health. There will always be political battles over health, from national arguments over social factors, prevention and funding for services, to local arguments over the quality of care, food and treatment in a particular service.

This short presentation raises some questions about making health more democratic, at all levels. While the local level is most important, the national level sets the strategic framework and rules (the system conditions), so it focuses on the national level first with a proposal for a national stakeholder forum alongside the Health Select Committee of Parliament, because ultimately Parliament has the democratic authority and legitimacy to decide the rules.

This discussion is particularly relevant in the context of NHS’s England’s exploration of a “Civil Society Assembly” for the NHS.

There are enormous pressures on the NHS, both financial and political. The question is where and how these pressures will be dealt with, and how much of a say the public will have in the process, as patients, tax-payers and citizens. The following is one attempt at posing the question: comments welcome.

1.Public service, funded by taxes
2.Ownership of strategic framework – repeated reorganisation of the structure reflects the failure of the political system to come to terms with the NHS.  We.   need to get public agreement for the strategic direction, principles and framework for the NHS.  We have a constitution which was imposed rather than developed and owned through  public involvement, which also means it is relatively easy to change
3.NHS failures to hear patients
4.Too big for scrutiny by Parliament.  An economy as big as that of Turkey
5.Reconcile conflicting interests
6.Take difficult decisions
7.Produce better decisions for health
What do we mean by democracy in health?

What do we mean by democracy in health?

Stakeholder representation is about ensuring that everyone affected by something should have a say in the decision. So people with learning disabilities, special needs or chronic illnesses should also be able to take part in discussions and decisions that affect them as well as everyone else

Who has  voice & power in health?

Who has voice & power in health?

The new regime is top-down, CLICK
with patients and the public at the bottom, and the Secretary of the State at the top, accountable to Parliament.
In effect, an elected dictatorship or form of “democratic centralism”
I suggest we need to introduce democracy at three levels – services, local area and nationally.
First put patients & public at the top – I suggest doing this through a National Health stakeholder Forum

Set up Locally elected forums, either part of Local Authorities or extended Health and Well-being Board, with decision-making powers over all services including health
Then representative Boards for each Service as far as possible, including representatives of users and local communities

This may seem very tame, but it represents a very radical step which will be resisted by the Department for Health, NHS & Parliament
For this reason I propose it as a way of strengthening the role of Parliament and the Select Committee system
We could set up a stake holder forum, which I’d like to see become a ‘Parliament for Health’

Parliament for Health

There are various possible models for how membership is elected: one is that they would come up through HealthWatch, Patient Participation Groups and other local health forums and representative bodies.

Another model is to have a process for organisations to be recognised as constituent bodies and members of each section would initially be elected through those bodies, with representation reserved for different groups. In due course all members could be subject to elected by the public on the basis of EU constituencies, but still nominated by the constituent bodies.

Co-chairs of the forum would be members of Parliament, perhaps from either House. The whole forum would elect three or four co-chairs, with a stipulation that no party could have more than one co-chair.

The work of the Forum could be conducted in different ways, including participatory local or regional forums, working groups, online forums

Parliament for Health Powers:

1.Propose priorities for health
2.Hold NHS Board and strategic health bodies to account
3.Promote dialogue on critical issues
4.Recommend priorities for research and development
5.Run public consultations on health matters
6.Scrutinise WHO, Council of Health Ministers, etc;
7.Pre-legislative scrutiny of bills
8.Scrutinise and revise legislation through a “public reading stage”
9.Consensus building, where appropriate;
10.Advise on implementation;
11.Monitor implementation of policies affecting health;
12.Review and evaluate impact of legislation.
Local Health and Well-being Boards:

Health and wellbeing board

The big difference is that apart from Councillors, the Health & Wellbeing Boards are appointed and members of a Parliament for Health would be elected through their constituency groups


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  1. rotzeichen says:

    This whole article is premised by the assumption that the NHS is a failed project.

    That is of course wholly untrue, the NHS even with the market intervention introduced by New Labour, was still the finest most comprehensive and cheapest system in the world.

    The idea that the NHS is broke, is down to Neo-Liberal propaganda and the bogus statistics of Professor Jarman.

    Example: I would defy any one to point out to me where one death is mentioned in the Francis report. There is none, except a reference to the possibility of one patient.

    The reason we are having the difficulties we are experiencing now is solely down to underfunding, creating low staff levels and fewer doctors are being trained, this is not by accident but by design to make the NHS fail so that it can be privatised with impunity. New Labour now Blue Labour are guilty of that agenda.

    What this socialist health association should be doing is challenging the so called leadership of this party to properly fund the NHS and expand it not privatise it.

    Their recent insipid declaration of council run joined up care is a sham and will mean the councils acting as outsourcing agents to the private sector. Andy Burnham is a sham.

    I have in a past post here, outlined what kind of institutions could be set up as NHS care residencies which would have grounds and residents surrounding hospice facilities; which could give maximum freedom for the elderly; whilst having hospice facilities when they need all round the clock care, without moving them out of the surroundings they choose to live and die in.

    The NHS is being and was undermined by New Labour who have exactly the same agenda as the Tories. New?blue Labour are Tories who are in the pockets of the Bankers.

    There is no deficit problem, they know it but persist with the Bankers Neo-Liberal agenda.
    Professor Mark Blyth explains the financial crisis and why the Bankers do it.

    Mark Blyth – Austerity history of a dangerous idea:

  2. carol dimon says:

    NHS alone ought notv to be addressed when considering poor care; it occurs in any sector. Low funding/ staff levels are not sole reasons but yes, are a major factor. One recommendation is to encourage Govt to “listen to the voices” ie not major players with vested interests. Healthwatch is not as independnet as you think- see book “The Commodity of care”.

  3. Martin Rathfelder says:

    I don’t think Titus regards the NHS as a failure, but its record of democracy, particularly at local level is not impressive. We don’t defend the NHS effectively by pretending it’s beyond improvement.

    1. rotzeichen says:

      Therein lies the problem, “We don’t defend the NHS by pretending it’s beyond improvement,”
      You are in fact attacking the NHS not defending it, I have produced statistics provided by OECD , which categorically states that in real terms the NHS ‘was’ the finest health care system at the cheapest cost per head of population. Whilst no other system, government sponsored or private is as comprehensive or cost efficient.

      I cannot believe you do not understand that, in fact I think you know that, so why are you attacking something as precious as our NHS when the private sector is clearly worse?

      You are repeating Brian Jarman’s statistics as though they they are fact, when Keogh has already said these statistics have been discredited and he will not be using them in his reports in the future. Are you really just trying to make the privatisation case for the next Labour government rather than a genuine case for real improvement, which would of course mean real funding.

      I have no doubt that you have seen this video of Dr Lucy Reynold’s who makes the case beyond doubt as to what the real agenda is towards our NHS.


      I would very much appreciate your comments on her video

      As a little rider I have also included Michael Moore Link :

      The NHS is suffering from underfunding, understaffing, fewer doctors are being trained, hence the problems with A&E.

      I know from anecdotal information provided to me by ambulance staff that the private sector dumps patients back on to the NHS when they get it wrong, and more frequently than just the odd mishap.

      Perhaps you remember the implant debacle !!!!!

      1. Martin Rathfelder says:

        You are mistaken to suggest that we “are repeating Brian Jarman’s statistics as though they they are fact”. We have published half a dozen articles demolishing the stuff about excess deaths. The latest was

        But we think to defend the NHS we need to do more than denounce its enemies. We need to ensure it continues to improve. That includes recognising its weaknesses and proposing ways in which they could be improved..

  4. I don’t say or even imply that the NHS is a failure, but I do think our current system of democratic governence (such as it is), has failed to protect the NHS and the health of the nation, as reflected by the persistence of health inequalities (cf Mariott and Black Reports), as well as the recurrent top-down restructuring of health services with little public support for successive changes. There is a problem with the democratic deficit in health and other sectors, including finance. A stronger democracy, at all levels, would not have allowed the poor care we have seen in many areas.

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