It has long been SHA policy that greater democratic accountability should be introduced into our health care system.  The NHS has never had any form of effective accountability.

Since there are already elected and democratically accountable local authorities which deal with most local public services it has been our view that health care should be added to their responsibilities – thus ‘integrating’ with social care and then to public health, housing, environmental health, planning, economic development and other services.  It has never been suggested that we have a separate elected body just to deal with health care (as was tried unsuccessfully in Scotland) as this just perpetuates division.  Leaving the NHS as the only public service outside the local authorities’ settlement is simply unacceptable fragmentation.

There remains strong support for the NATIONAL nature of the system and for both health and social care – having national frameworks which define entitlement and assessment, national terms and conditions for staff (and strong regulation over terms and conditions of staff in non-public care suppliers), one NICE and one system for system oversight and regulation.

Whilst WHAT is decided nationally the HOW is determined locally at whatever level makes most sense.

This does inevitably lead to local variation but that has always been the case – rural vs urban being an obvious example.  Our policy is for local decision making over the distribution of services, over local funding arrangements and priorities – decisions made through the democratic processes. Nothing in this allows any area to opt out of its statutory responsibilities and we would favour some strong and swift mechanism to resolve and disputes, again locally.  This is in contrast to the NHS where everything is effectively decided remotely without any accountability or transparently.

It is possible to make the necessary changes, over a long period, by following the approach adopted by Andy Burnham, through the existing organisations. This does maintain the separate nature of the multitude of health care providers and some ‘commissioning’ or planning as a separate function; obviously health care providers would not be managed by local authorities.

The obvious risk is that local authorities will be subject to funding cuts then blamed when services deteriorate.  They will look at outsourcing options as they did so disastrously with social care.  The solution as spelt out again by Andy Burnham is ‘preferred provider’, repeal of the Health & Social Care Act and specific procurement guidance applicable to all care services.

Progressively moving local decision making away from the traditional NHS bureaucracy is going to be contested every step of the way by those whose strong vested interests have shaped how the system works at present.  But unless we genuinely embrace the idea of democratic accountability we are not going to get integration of all public services focused on improving wellbeing and addressing the huge issues around the determinants of poor health, of inequality, exclusion and unacceptable variation which have been endemic in the NHS since its inception.

Whilst democracy has its risks the alternatives have more.


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  1. This is just meaningless Neo-Liberal claptrap and has nothing to do efficiency or a better health care system.

    Neo-Liberals always talk in terms of setting the framework and freeing people from government interference, Neo-Liberals also never admit to being Neo-Liberal.

    Socialists understand the meaning of democratic government and this is not it.

  2. Robert Jones says:

    Mmmph. Look, there’s a really big snag here, and that’s the nature of local government. We’re not all governed by metropolitan authorities which can afford the best staff (even if they don’t always employ them). Just as you can’t assess structures by reference to the Isle of Wight, which I infest, you also can’t judge them by what might be possible in Manchester – and that inevitably means there will be fragmentation across the field.

    To take the Isle of Wight as an example, though; we have one unitary authority, a County Council. The last (Tory) administration so mismanaged it that responsibility for children’s social services and education has been taken away from the council and is managed from Hampshire. There is no realistic possibility of devolving power from the Isle of Wight Council, because all we’ve got apart from that are parish and town councils which have neither the powers nor the capacity to manage anything more complicated than the village pond. I don’t want these people, ANY of them, running the NHS – they are patently not good enough to manage their existing services, never mind anything so complex as health provision.

    You may argue that the island is a poor example because of its numerous administrative (and financial) weaknesses, but a look over the rest of England is hardly going to reassure you that the ability exists in local government generally to do a much better job than our Gawd-‘elp-us local authority (which is presently engaged is slicing services into the bone): and you may describe local government as “accountable and democratic” – that depends on so many factors, but even if it were actually true, it doesn’t make local government competent.

    I don’t question the SHA’s motives and to that extent disagree with Mervyn Hyde, but I do question the judgement behind this model, which seems to me to take FAR too much for granted in its rose-tinted view of this country’s local government structures, staffing, and oversight.

  3. Martin Rathfelder says:

    Devo Manc is not perfection- it’s, at best, only a step down the road. And maybe it wouldn’t work well in the rest of the country. But that doesn’t seem like a good argument for not giving it a try.

  4. Mark Burton says:

    It’s worth remembering that Bevan’s original preference was to bring health under local government. Local government was then too weak (and v often too Tory) to take that on, hence the 1948 NHS structures. I favour local government control of the NHS but am sceptical about its capacity, especially after 30+ years of attack by neoliberal governments.
    I don’t see how the introduction of democratic governance can work in the absence of a new social settlement that rebuilds society, community and democracy. It will just be tinkering that leaves elected members managing cuts (sorry, efficiencies). And if you think the Manchester proposal is about democratic control read the Memo of Understanding on the AGMA website. So far as I can see this is a joint board type of arrangement. But its plan to pool budgets could mean big trouble in the absence of appropriate funding as we saw with one of the country’s few Care Trusts, under much more favorable fiscal conditions, Manchester’s Mental Health and Social Care Trust. Yes, here in Manchester.

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