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    Democratic control of NHS

    Please note that the following is just rough notes, and should be supplemented by viewing the video of the event;

    26/9/2016 Democratic Accountability in the NHS
    Chair Chris Bain

    Dr Brian Fisher: Vice President of the Socialist Health Association: Brian firmly believes that patients should have full access to data about them and that this will enhance safety and care.

    Andrew Gwynn MP: was appointed to the Shadow Health team by Ed Miliband, and was reappointed in September 2015.

    Dr Ivan Bennett: sits on the GM Clinical Senate and is a Non-Executive Director at the Central Manchester University NHS Foundation Trust with an interest in Patient Experience and is ‘Freedom to speak out” guardian

    Estephanie Dunn: regional director for the Royal College of Nursing’s North West region.

    Chris Hopson: Chief Executive NHS Providers


    The streetfighting in the LP about democracy has no echoes on the left in the NHS. The left appears to have almost no interest in enabling patients and communities to shape their care and their NHS.
    Communities have huge commitment and love for the NHS. In Lewisham we had 25000 people on the streets to save our A+E. And the same is happening up and down the country in face of the govt’s austerity and dismantling of the NHS.
    But policy discussions on the left rarely consider how that energy and intelligence can be hard-wired into our plans for the NHS. We talk endlessly about privatisation and restructuring and the powers of the SoS. If we want a thoughtful, responsive and personal health and care service, we need to pay as much attention to how individual patients and communities can become part of the decision-making in the heart of the NHS.
    I am shocked and angry that the debate remains at the level of “Let’s bring back CHCs”. Yes, we need such formal structures, but this remains a totally inadequate policy programme for accountability and transparency.
    We need to offer a vision of health and involvement that enhances care, improves health and makes sure that NHS and LA organisations are responsive to the communities they serve.

    We now have good evidence that health improves when people can:

    • CONNECT with others
    • CONTROL more of their lives

    So, to integrate accountability and transparency throughout the NHS we need to ensure that these relationships and support for them are built and sustained by every NHS worker and every NHS structure. Here are 2 ways that illustrate what I mean and about which I have personal experience.


    IT offers huge scope for improving the responsiveness of the NHS to individuals and communities. I am co-director of a company that makes all this possible, as part of the NHS now.

    • Feedback
    • Links with community groups through social prescribing
    • Record access +
      • All integrated
      • PHR
      • Understanding and control


    Experience from across the world, backed by good evidence, shows that by building face to face social networks between people through processes such as community development, huge changes can happen – to people’s lives, to professionals’ lives and to the lives of communities. By supporting communities and their own assets to develop their own agenda for change and then working with statutory agencies to meet the issues that matter to them, we can:

    • Improve health
    • Improve the responsiveness of the statutory sector
    • Help tackle Health Inequalities
    • Improve individual health behaviours

    AND it appears to be a good investment. 1:4

    We need Community Development Workerss throughout communities linked to the NHS and Local Authorities, and probably housing as well.


    They are being implemented now. The LP and the left has a huge legacy of community action and social movements. The right wing is hijacking these right now. This should be our agenda. We can offer real and powerful ways that push the boundaries of accountability and transparency – let’s do that together.

    Andrew Gwynn MP:

    Parliamentary accountability for healthcare was though the Secretary of State for Health, and it is a disaster this link has been broken. Jeremy Hunt can now say it has nothing to do with him as its NHS business, but by the same token he can’t claim at the same time to be the voice for patients. When patients want to complain they should be able to take it up with the Secretary of State for Health.

    The agenda for the devolution of health in Manchester was developed from spring 2016. We must be careful. there may be some positives, but there are also some risks. Manchester’s’ 6-billion-pound health budget can help forge new relationships and plan better, more patient centred services, but there is still a funding gap. By 2021 that gap is projected to be £1.7 billion, and there are endemic health inequalities in the region. Is devo being set up to fail? Manchester is one of the first care and health integrated regions. Thameside local hospital and clinical Commissioning group work with a single aim and budget. So is national accountability reclaimed at a local level? We need more MPs aware of what is going on and Local authorities to hold the integrated care organisations to account. Too many councillors just nod through decisions therefore we must upscale the capabilities of councillors and hold them to account. Local Authorities are well placed to meet the challenge, but they must invest in training and their capabilities to hold the NHS bodies to account.

    Empowering the patient: The NHS does things to you. With new technology we can genuinely empower patients to be far more involved locally. STPs have planned health and care to meet budgetary needs, but now there is an opportunity to meet health and care needs. Health cuts backs have been to the detriment of tackling health inequalities, Life expectancy in Denton South is 10 years less than Denton North, therefore we need to empower patients to ensure we determine the social needs of an individual – inoculations, housing, environment and wellbeing. We need to develop a wellbeing strategy to narrow inequalities. However we devise accountability we must retain the N in NHS. We can deliver locally, for local needs but the N is crucial. There must be no postcode lotteries. Best practice should be picked on and developed nationally. Accountability must be strengthened to restore the powers of the Secretary of State for Health. We need accountability in Parliament, Councillors, neighbourhoods and local communities.

    Chris Bain: We should also emphasise the S for Service in the NHS – not a privatised S for system.

    Estephanie Dunn:

    I put patients at the heart of whatever I do. We came early to the idea of devolution, but there was no conversation with nurses around concerns with service quality and sustainability. Details about how funding will work were not laid down. We now have the added challenge of economic uncertainty. A lot of the investment was going to come from the EU. It is crucial that the people on the ground change their behaviours, but the numbers of nurses, doctors and other health professionals is reduced, the numbers and role of school nurses is reduced at a time when safeguarding is needed more than ever, due to bullying, suicide, deprivation and people are disengaging. There is an increasing number of women in single parent households who are disadvantaged. Activated patients take more responsibility for their health and we need to re-educate society how this will work. People need to take more control, but there must be a safety net. When people feel disadvantaged and dis-empowered they don’t take care of themselves. They use social tranquillisers like drink, smoking illegal drugs, overeating and poor diets. The change will not happen overnight after generations of disadvantage. There is a lack of awareness as to how the body works. A massive education programme is needed. 80% of the local population in Manchester didn’t understand how devolution works. There should be “nothing about us without us”. We need to be held to account not by the Local authority, but by the people. They should know we now have a system with insufficient resources – we lack the numbers needed of doctors, nurses, and other healthcare staff.

    Ivan Benett:

    I have an interest in the patient experience. What say do patients have in the service they receive? There is some demonstration of accountability in the NHS, but not a lot. The Health and Wellbeing Board in Manchester works well, and is a positive force for change. The Health and Wellbeing Board has a say in strategy for the city. The Health Scrutiny Committee reviews and scrutinises health services and acts as a consultative body to local health providers when they have a duty to consult. It is not responsive to patient’s needs.

    The Clinical Commissioning Group is thought to have more power than it does. It is made up of GPs, and is accountable to group practices. If they don’t want to do something, then they don’t. Patient Participation Groups. PPGs can speak, but they are not really listened to – they are a kind of add on. CCGs hold the secondary care budget as well as the prescribing budget.

    We need better input from people. Group practices are not a part of the health service and have no more accountability than a greengrocer. Most just pay lip service and they should be doing much more. Acute Trusts are more reasonable. The public can have a role and can influence. By becoming a Governor, you can hold the board to account. Governors can appoint and dismiss the chair and non-executive directors. To sum up there are a number of gaps in accountability.

    Chris Hopson:

    The NHS budget is £120 Billion, around 1/6th or 1/7th of GDP. It provides a vital national service. The NHS is the one thing that stands out making us proud to be British. Since the NHS has so much of public funding then the Secretary of State for Health should be capable of scrutiny by Parliament. The NHS has 1.3 million staff, so we are dealing with a complex structure. However there is the implication that the Secretary of State should make all the decisions. Too many roads lead to the Secretary of State’s office, and he has been meddling. Initially Alan Milburn thought he should be solely accountable but later he felt it was too complex and there should be local accountability. A key role of local government is as commissioners of care. There is a need to support local people better. Clinical Commissioning Groups have an important role to play, along with Foundation Trusts.

    It is an important model. The system is under huge amounts of pressure and clear governance is needed. Who do we hold to account if things go wrong? A single unitary board, acting as a whole seems the most practical model.


    Corrie Lowrie: I felt that as a governor I was just there for window dressing. Too much money was wasted on booklets to tell people “how good they were”. Nobody has mentioned the elephant in the room – privatisation, or the people who don’t want to share their medical notes. Nobody asked me if I wanted to be devolved. The amount of money going into private companies is not mentioned at all in the Socialist Health Association, nor are the numbers of private health organisations hiding behind the NHS banner. A sugar tax would be more effective in supporting people to live healthy lives than these private companies with their interest in profit, and Milburn owns a private health company. If we had true democracy then we should let the public know how the NHS is being sold off, and the government is Americanising it. I hate to see all this “manage your own health” rhetoric. It is an empty slogan.

    Mike Hobbs: consultant psychiatrist; Public and patient engagement forums are not engaging and are not well heard. How do we engage with the community and at the level of the people who use the services? Healthwatch is still very patchy and the budget is stripped out. Local authorities are increasingly taking on the role of commissioning in health and social care, but they are not very accountable.


    The NHS needs to go back to basic principles. An integrated health and care system would strip out the waste of tendering and break down the commissioning split. I don’t agree with the free market approach, it is inadequately challenged through democracy. Andy Burnham has been looking at how to bring the care system back into the public sector. Local authorities cannot put sufficient packages into place as numbers and quality are not adequate. The NHS is looking at how to bring care provision in house. Care is integral to the NHS. Some decisions Parliament has made are detrimental to the public NHS, and the Shadow Health team are working on how to put “Public” back in the NHS. But it is not just the public who are in the dark. I sometimes only get to hear things via my opposite numbers. Shadow Health Ministers are cut out of any discussions. Devo is an opportunity, but also a risk. Not only does the government cut our grant, but then Hunt ignores the good stuff and concentrates on the bad bits cause by his governments funding gap…he puts the blame on Labour, Manchester.

    There is a difference between organisations which must put profits and shareholders first and for example, hospices. The hospice movement has made a fundamental contribution. It is not profit making, and there is an appropriate role for non-profit making organisations.

    Taking responsibility and looking after yourself; People should get support to do that, but they must also get the support they need if more specialist healthcare is needed.

    There is an opportunity to make it better with formal democratic involvement. The NHS is undemocratic. Parliament under the Health and Social Care Act is becoming less and less accountable, due to among other things the STPs. There are informal ways in which communities can make a difference in shaping care locally. Become a member of a Trust, and PPGs can be really active.

    Katy Gardner: Already councillors are too overworked and underfunded. They must be really on the ball or they will be run by council officials. The SHA has a role to play in upskilling councillors – you don’t know what you don’t know.

    Derek Timmins: Talking about elephants in the room, think of Kaiser Permanente. It is a nightmare. We are five minutes to midnight to the breakup of the NHS. It has the second lowest funding in Europe. This is a political choice and political ideology. As for public accountability. Look at the case of Cheshire sexual health. The contract was awarded to Crewe. The councillors raised objections, the chair of the clinical commissioning groups raised objections. Everyone thought the weight of opposition was such that the day had been won, but the chairman pushed it through on a nod (his nod). To fight such huge injustices is beyond most peoples’ capabilities.

    Patient Participation groups. The patient voice has been disenfranchised to be replaced with that of transactional costs, lawyers, management consultants and accountants. Locally we see increasingly the phenomenon of revolving doors, for which I blame the influence of MPs. There is a huge democratic deficit. One last point on conflicts of interest. Conflicts of interest are all too often simply not declared. MPs are supposed to represent us. They need to get their act together, and we need to get ours together and make sure they do. It’s down to our representatives doing their job better.

    Jos Bell: There is a lot of consultation work around child and family services, but evaluating projects is now a token gesture. Shaping a Healthier Future;  Imperial College Healthcare NHS Trust closed two A&Es and there was a massive spike in the demand on A&E services in the one A&E department left. It became the worst in the country. They want to demolish Charing Cross hospital. Meetings are held in secret and doors guarded by security staff. They wouldn’t even let the MP in. There is a massive funding deficit. STP plans are barely known. We could swing a Tory majority to a Labour one by making these issues known about the NHS. Councils could start by refusing to sign off STPs or Shaping a Healthier Future. Councillors are told they won’t get public funding if they don’t sign up, but STPs are not a good thing. They might have potential, but not given the lack of funding and lack of staff. 90 minutes is the average length of time for a serious ambulance call out.

    Brian Fisher:
    STPs are another example of magical thinking. There are heroic assumptions but in practice the NHS will just experience cuts and privatisation as a result. The laws for tendering are still in place. Hunt is still in place as nobody else wanted to do it, and the press liked the Milburn version not the Burnham version. We are up against it. We have some fantastic MPs but there is a Tory majority. See ministerial appointments e.g. Phillip Dunne

    Chris Bain:
    Thank you for a fantastic discussion. We must work on ideas on how to engage the wider community, and hold up a mirror to where things need to be done differently. There are huge challenges, especially around private sector involvement, a world where they would rather have an empty bed than be commissioned at a loss. We also need to deal with the poor quality of care and somehow make things work again. I had hoped there would be more positivity. We must find a simple and easy to operate system which does not come at the expense of the running of a complex system like the NHS.

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    Videos of our meeting in Liverpool on 26th September

    Dr Brian Fisher,

    Andrew Gwynne MP

    Dr Ivan Benett

    Estephanie Dunn, Royal College of Nursing

    Chris Hopson, Chief Executive NHS Providers


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    With Sustainability and Transformation Plans (STPs) aimed at delivering multi-billion savings, being carried out secretly in 44 areas nationwide, this is a seminal moment for the NHS. Leaders need to engage the public in addressing the country’s health and social care crisis; come clean about what STPs can realistically deliver; and acknowledge that in some areas STPs could actually be asking the wrong questions.

    Nine months ago NHS England announced that every health and social care system would produce a STP, the first drafts of which have now been submitted to NHS England. On one of August’s quieter news days they made major news, with STPs flagged as the means health bosses would save billions by closing hospitals and other services.

    Let’s be clear. The principle of the STP is sound. After the disastrous destruction of planning arising from the Coalition’s 2012 Health and Social Care Act, the notion of bringing together providers and commissioners within a recognisable geographical area is a good one. STPs offer opportunities to explore options and collectively find solutions to various health and social care challenges. They also give the chance to join up health and social care, and involve local authorities much more – potentially key in an era of wider devolution.

    So what’s the drawback? More money will be needed and transparency is key. STPs are being undertaken in the context of the greatest financial squeeze ever experienced by the NHS, and between them they have to deliver at least £20bn of savings. It’s fanciful to think they can do this without hard choices being made by the government about what the NHS will now stop doing.

    And the plans are being drafted in secret as the STP’s geographical footprints have no statutory basis, no clear governance or decision-making processes or obvious way for members of the public – or indeed their local Members of Parliament – to know what they contain.

    Public engagement

    Like other MPs my focus is on my own constituency. For Bristol South residents the STP is formed of Bristol, North Somerset and South Gloucestershire CCGs, a recognisable planning area (BNSSG) based on hospital catchments but covering three local authorities very different in their political and social demographic.

    In 2004 the same geographical area joined together to produce the Bristol Health Services Plan. Then it comprised four Primary Care Trusts and the two acute Trusts. These six NHS bodies described the need for changes to ‘transform and modernise’ local health services largely by moving services closer to home, improving quality of care, bringing together specialist hospital services and improving the quality of old hospital buildings.

    After scores of public meetings and a wide range of engagement with the public a plan was produced, agreed by all six Trusts and overseen by a joint scrutiny panel of the three local authorities. It resulted in the closure of one hospital, the building of a new large acute one, new community hospitals, GP surgeries and rationalising of other estate. Most of the promise was delivered.

    What hasn’t been achieved since these agreements is the delivery of the assumptions that underpinned the plans in terms of how many beds would be needed, how long people would stay in hospital, and the substantial increase in community services including urgent care centres to reduce pressure on A & E. And that means that 12 years on largely the same population, in the same geography, with the same health and care needs, will now be getting a new Plan, its STP.

    What will it reveal when we eventually see it? My own view locally is not very much. Old sites have been closed and old buildings replaced with newer more efficient ones. One hospital has a £50m annual deficit and there could be an additional £30 – 50m deficit in the wider BNSSG system.

    Where can BNSSG find £80 – 100m worth of further savings? It doesn’t take an accounting genius to work out it can only be done by cutting staff, continuing the pay freeze, dissuading people from attending A&E, crude rationing of services to cut demand, reduction in attendances and admissions to hospital, and the recurring talk of prevention. None of these have worked before.

    GP recruitment

    It’s worth stating that in Bristol South the major NHS issue residents face is the sustainability of primary care – getting a GP appointment, for example. GP recruitment to south Bristol, with its high levels of health inequality, has long needed support, and sadly in the current world of NHS England organisation and GPs having the pick of more convenient or lucrative placements it is hard to see prospects of improvement. This problem cannot be solved by reducing hospital activity to save money. So from the perspective of my Bristol South residents, the STP is missing the point.

    What will happen next? We can speculate but many who know the NHS predict:
    • Government will finally bow to the inevitable and fund health systems that shout loudest or are in the most favoured locations.
    • Staffing problems across all disciplines will continue to worsen with services gradually becoming unsustainable.
    • Waiting times and lists will increase and targets will disappear.
    • The NHS Constitution, which specifies our right to treatment within set times, will be watered down or voted away by the Tories’ huge English majority in Parliament.
    • People who can afford it will choose private treatment so slowly a two tier system evolves.

    Involving taxpayers in finding solutions

    Make no mistake, in some areas major changes will be necessary. But the only chance NHS leaders have of securing public confidence going forward is involving taxpayers at the earliest possible stage, as we did in BNSSG 12 years ago, so they appreciate the challenge and help produce the solution.

    In the absence of NHS leaders proactively involving the public, what can those who care about our NHS do to bring influence? Firstly, pressure must be applied to local leaders and NHS England to publish STPs, as I’m doing locally.

    Other options, in the absence of a change of Government and or immediate Government policy, are:
    • Lobbying local and national NHS bodies
    • Attending Trust board and CCG governing body meetings
    • Reading the public papers. Actually very little is secret – sometimes it is just hard to piece together.
    • Demanding your £350m. Don’t let the Brexiters off the hook. In Bristol South 47% people voted out in the EU Referendum.
    • Asserting your rights as laid out in the NHS Constitution and Handbook.

    But it takes time, energy and capacity to take on large institutions. Busy people shouldn’t have to, especially when they are vulnerable as any patient is likely to be. Getting good quality healthcare, and the ticking timebomb of the scandal and silent misery of access to social care are prominent in the minds of the people we seek to represent.

    So this is where the Labour Party should come in, speaking up on their behalf. Labour should be campaigning, ensuring people know their rights, enshrined in law by the last Labour Government under the NHS Constitution, and supporting the people who are being denied treatment.

    Labour should welcome the way place-based planning can draw people together to find solutions, as a potential means to resolve some of problems caused by the Health and Social Care Act.

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    I want to make an extended argument this morning about the importance of governance and accountability in the provider sector. And then explore what we need to do to safeguard that governance and accountability as we add a needed focus on local systems to our current focus on individual providers.

    It’s worth starting by reflecting on why governance and accountability matter in our world.

    They matter because:

    • Providers are spending £70 billion of taxpayers money, 9% of all public spending;
    • The services providers deliver are central to the communities they serve;
    • In each of those communities, providers are one of the largest local employers and often the largest public sector employer;
    • An NHS provider is one of the few organisations in our national life where treatment, care or support for ourselves and our loved ones can irrevocably and profoundly change our lives – for the better, and sometimes, sadly, for the worse;
    • And healthcare is also a high risk part of our national life where providers need to reduce avoidable mortality and avoidable errors and where it is right that they should give appropriate account when things do go wrong. And this is an environment where things can, do and, to a certain extent, probably always will, go wrong given the level of risk involved.

    How providers have developed effective governance and accountability mechanisms

    I’m struck, as a relative newcomer to the NHS, by how much time and effort NHS foundation trusts and trusts have invested in developing effective corporate governance and ensuring appropriate accountability for what they do. And, by and large, how effective and well developed governance and accountability mechanisms in the provider sector now are.

    The time and effort that has gone, for example, into creating effective unitary boards that confer identical rights and liabilities on executives and independent non-executives.  This means executive directors can be challenged by both their peers and independent non-executive directors as part of the continuing business of the board.  This allows boards to hold the executive effectively to account as part and parcel of its regular work, rather than as a bolt-on, which is often the case in other governance models.

    The investment in an extensive set of Board sub committees that spend appropriate time scrutinising and assuring the detail of what is going on at ward and service level. The robust and rigorous quality assurance frameworks that look at patient experience and service quality. The effort invested in engaging and supporting frontline staff, to encourage them to raise issues of concern candidly in a spirit of improvement, not blame.  The gathering and scrutiny of extensive data to see what is happening at patient level, for example rigorous interrogation of HSMR and SHMI data to assess avoidable mortality. The time invested in assessing, managing and mitigating the ever present risk across what are very large and complex organisations.

    For Foundation Trusts, the development of a whole new governance model of members and governors to ensure that the board is accountable and responsive to its local community. For all providers, the time invested in meeting the requirements of a wide ranging set of accountabilities: to commissioners; to regulators and system managers like NHS Improvement and the CQC; to local health and wellbeing boards and scrutiny committees; and, in the case of FTs, to parliament itself.

    I deliberately rehearse the list at length because I think it’s important everyone in the service understands just how much time and effort has been and is being expended to ensure that governance and accountability in the provider sector are effective and fit for purpose.

    Adding a local system focus to the focus on individual institutions

    All of this activity has, of course, been focussed on individual provider institutions. That’s not entirely surprising given the emphasis the policy framework has placed on provider autonomy, patient choice, and appropriate competition between providers. The individual provider has been the lynchpin, the focal point, the centrepiece of the system, with a matching degree of focus on the individual CCG.

    But we are now heading for a different policy framework with a different set of emphases. A framework where the local system, not the individual provider, is the focal point. Where secondary care, primary care and social care are much more integrated. Where competition between providers is replaced by collaboration between them, across a wider geographic footprint. Where the organisational focus is on accountable care organisations, MCPs, PACS, federated provider boards and Devo governance mechanisms covering whole regions rather than individual providers and CCGs.

    We are pursuing this direction of travel at high speed. The Five Year Forward View set out the vision. The STP process is designed to create the strategic plans. The vanguards and Devo Manc are piloting ways of getting there. The 2016/17 planning guidance set out the early steps everyone has to follow. And the new NHSI oversight framework includes a whole domain, one of five, to assess how providers are enabling strategic change at a local system level.

    More than that, all kinds of new ideas are now floating around. Combined authorities as a potential new organisational form. System control totals as a new way of allocating money. Acute bed days per thousand head of population as a new way of measuring performance. The STP process as a new way of overriding individual provider veto of plans that other providers support.

    We mustn’t leave governance and accountability behind in the rush to local systems

    The problem I want to highlight today is that I think we’re in danger of leaving the governance and accountability behind. In the words of one chief executive, whilst the vision, the strategy, the planning and, increasingly, the proposed delivery are hurtling towards the world of local systems, governance and accountability are still stuck in the world of individual institutions.

    I think this carries significant risk.

    If we are to move to new care models, if we are to adopt new integrated organisational forms, if we are to deliver services effectively across a wider geographic footprint we have to ensure that the governance of service delivery and the accountability for that service delivery remain robust and effective.

    This means maintaining our investment in good corporate governance by organisations but developing a more robust approach to governance between organisations and being clearer on lines of accountability at the local system level.

    And although the current narrative emerging from the centre sometimes implies that we are moving from an individual institutional focus to a local system focus, the reality is that we need both. It’s not an either/or. We have to find ways of making governance and accountability for individual institutions and local systems complementary not mutually exclusive.

    Worrying about governance and accountability isn’t pedantry

    I know that some in the centre think that raising these issues is being pedantic, legalistic or is a way of blocking change. It isn’t. Good governance and clear accountability allow risk to be managed and mitigated. They need to be developed thoughtfully at times of peace to enable us to manage effectively in times of trouble.

    We all understand the need for that local system focus. That’s why so many providers are leading vanguards. That’s why, in most places, providers are the key driving force behind the STP process. And that’s why providers are at the front of developing new organisational forms be it the Royal Free developing a provider chain, Salford developing an accountable care organisation or Southern Healthcare developing an MCP with its local GP federation.

    Important questions that must be answered in adding a local system focus

    But many of you are now asking questions about governance and accountability in these emerging structures that need urgent answers:

    • What happens if an STP footprint develops plans that require an individual provider to sacrifice its individual interests for the greater good of the local system as a whole – how is that reconciled to the provider Board’s, its NEDs’ and its Governors’ statutory duties?
    • What happens if some parts of an STP agree to a plan but others don’t? How far and when is it reasonable for the interests of an individual provider to be trumped by the needs of a wider local system?
    • How much and what delivery will be put through STP footprints when?
    • How will accountability actually work if money and delivery is allocated, managed or measured at the level of a local system rather than an individual institution?

    These are just a few questions from a more extensive list. Urgent work is now needed to
    develop robust answers to them.

    If this work isn’t done there is a danger that while providers are prepared to plan at an STP footprint level, because it’s just a plan, they won’t be prepared to deliver services, handle money, agree to service reconfiguration, or be held to account for performance at that local system level. In other words, we can’t do what we now need to do without some concentrated work on how governance and accountability will function with this new, additional, focus on local systems.

    Principles for answering the key questions on governance and accountability

    How do we go about answering these questions and doing this work? I would like to finish by suggesting three principles:

    Co-production between local and national
    The first is that any work must be co-produced by the centre and local institutions. Too much of the existing policy structure has been developed by the department and its arms length bodies without appropriate consultation with frontline organisations. Front line organisations have the statutory responsibility for local delivery and they have to make the framework developed by the centre work on the ground. It is vital that skills and expertise are pooled. Particularly when much of the expertise, knowledge and skill on governance and accountability resides in provider boards and other local organisations. It doesn’t sit at the centre.

    Compliance with the law
    Secondly, the answers we develop must have a sound and explicit legal basis.  While we all understand the wish to avoid primary legislation, we simply cannot pretend that the 2012 Act does not exist.  In a complex and risk laden sector like health care, front line boards must have the protection of a governance and accountability framework that is compliant with the law. We all know that when things go wrong, which is likely to happen more frequently if we are experimenting with new ways of working and as the overall strategic environment deteriorates, the first recourse is the law. What were the legal responsibilities and have they been met? Our system leaders need to acknowledge that provider board directors have duties set out in statute that cannot be wished away or ignored. If we don’t have a legally compliant framework we are exposing our senior leaders to unacceptable risk. And when we do the difficult things we know we have to do, like reconfigure services, they will simply fall apart in our hands at the first legal challenge if they are not legally robust.

    Replicate what works at individual institutional level
    Thirdly, the principles of good governance we have already developed at individual institutional level should be reflected in the governance we now need to develop at a local system level. These include appropriate autonomy from the centre; clear lines of accountability, including to local communities; appropriately robust and detailed assurance and risk management systems and processes; and a degree of independent challenge from a non executive function. A number of you have rightly pointed to these as significant issues in the current STP planning process governance. Chairs and NEDs, for example, have been unclear about the role they should be playing here.

    The role that NHS Providers will play

    NHS Providers as an organisation will play its part in this important debate. We’ll continue to raise these issues at system level, even if they make us unpopular. We will develop provider sector thinking in this area as we will do with a separate session with Chairs at the end of today’s conference. We will discuss these issues in the relevant networks. We’ll incorporate these themes into the emerging Board Development Programme we have agreed to create with NHS Improvement. And we will continue to share good practice and emerging thinking on paper as we have done in the joint publication on lessons and tips from new care models that we are launching today with Hempsons and which you will find on your chairs.

    This was first published on the NHS Providers site

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    North West Leicestershire is about to publish its Local Plan. An inch thick, this pedestrian document tells us that this Council will co-ordinate a wide range of other organisations to ensure infrastructure is provided at the right time and in the right place to absorb the impact of new housing developments and provide for the health needs of people moving into the area.

    The best predictor of future behaviour is past behaviour.

    At a recent Policy Development Group, a cross-party committee of elected Members pursued the fate of £1.3M of developer contributions for health that remained unspent, some of it at risk of being paid back.

    Lacking a root cause analysis local GPs, NHS England and Council planners were involved in a blame game. The tangle of red tape, risked developers laughing at the public sector as they re-pocket money returned with interest.

    Teasing this mess apart has allowed some funds to escape the log-jam and NHS England we are now spending some s106 money on Long Lane Surgery in Coalville and on a surgery in Measham. But I am not taken in by this snippet of good news. Nor do I trust in future solutions such as moving to a Community Infrastructure Levy. My GP informants still describe a legal system that makes easing this money out of the bureaucracy so difficult that most clinicians give up.

    Remaining focused on funding GP premises, when so much else is pushing healthcare into the abyss, is almost certainly not enough. A Local Plan with vision would look beyond the immediate needs of service providers, such as GPs to the wider determinants of public health.

    Loneliness is a killer. Thanks to the developer-centric demands of the National Planning Policy Framework, the Council’s plans for cultural facilities in Policy IF2 grudgingly allow their expansion if the community can prove an increase in demand.

    After the closure of the iconic Snibston Discovery Museum perhaps I should not complain that the Plan appears to major instead on preventing existing community buildings from being demolished.

    My colleagues in public health should be pleased to see that the Plan does have a detailed section on transport infrastructure. The Royal College of Physicians reports that there are 40000 deaths a year due to poor air quality mostly from exacerbations of asthma and COPD. We know that we have road junctions that repeatedly breach air quality guidelines including the Copt Oak and Broom Leys junctions.

    According to the RAC North West Leicestershire along with neighbours South Derbyshire are in the top 10 Districts where working people are obliged to use their private car to go to work.

    It is axiomatic that wealthier communities are healthier communities. Ensuring people in North West Leicestershire can access properly paid employment has to be a key public health strategy.

    In supporting this Plan going forward for consultation, I am therefore particularly pleased to support Policy IF5 in which North West Leicestershire, in direct contrast to the County Council, commits itself to supporting the provision of public transport on the Leicester to Burton line.

    Providing East-West connectivity and putting the former mining town Coalville of back on the railway map, as HS2 looks increasingly unaffordable, it would be good to get national support for this important public health intervention.

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    The House of Lords is a large unelected body commanding little legitimacy.


    1. Make it a smaller elected body.


    1. Abolish it


    Either of them would ensure that Parliament consisted exclusively of full time politicians owing their place to party political processes.

    This is hardly empowering.  This is not the mood of our times.


    A Second Chamber which consists entirely of people who are NOT FULL TIME POLITICIANS.

    • That doesn’t mean that they can’t be elected.
    • It doesn’t mean that they can’t be part-time politicians.
    • It does mean that they must live a life in which Parliament is a small part – a voluntary form of public service, rather than a job.


    500 seats each shared by 24 people (12,000 people in total) attending for 8 hours a fortnight would create a Chamber that could meet for 16 hours a day (8am to midnight) six days a week


    This proposal is compatible with any of the electoral methods proposed – you just elect more people. However the considerable increase in the numbers to be elected does open up new opportunities.


    The following is an electoral method which takes advantage of the much larger number of people involved in a part time chamber to combine some of the competing electoral proposals.

    As just one possibility

    Out of 12,000 people sharing 500 seats we could have

    A fifth (2,400 people sharing 100 seats) elected by the method advocated by Billy Bragg, seats allocated to political parties in proportion to the votes they receive

    • Political parties receiving more than 1% of the vote would receive a number of seats proportionate to the number of votes.

    • For a transitional period the party’s life peers would have a claim on these seats but no new political life peers would have this right.

    • After the transition

      • up to a quarter of the seats would be nominated by the party,

      • up to a quarter would be indirectly elected by the party’s elected representatives and governing bodies,

      • at least a quarter would be elected by the party’s members and

      • at least a quarter would be elected by the entire electorate in a geographical single member constituency (a sort of open primary but after the General Election not before it)

    • Each party group would make its own arrangements to rotate attendance

    A fifth (2,400 people sharing 100 seats) elected by STV with quota to link national and local government. This is the Senate of Regions and Nations idea made more local still (taken down to district level) and linked to the idea of election by STV with quota

    • Electing 2,400 people means 1 representative per 27,000 people (about 23,000 electors).

    • This means that it is possible to use district councils as constituencies and still have multi-member seats in which STV can work.

    • Those elected could serve on the council as well as in the House of Lords – the title alderman could perhaps be revived.

    • In two tier areas they could serve on both the district council and the county council – indeed in large counties they might entirely replace county councillors.

    • In devolved nations some arrangement could be made, appropriate to the situation of the individual nation, to involve them in the national parliament. For example they could share a number of seats in the national parliament on the same 8 hours a fortnight basis as they use in the House of Lords

    • Some arrangement could also be made to involve them in devolved arrangements in regions

    • They could therefore knit together the different levels of elected authority.

    • They would form themselves into groups to arrange the rotation of attendance. The LGA would arrange the rotation of those who could not find a group

    One tenth (1200 people sharing 50 seats) to consist of faith representatives

    • Elected by multi-faith partnerships

    • The established churches in England and Scotland could organise these partnerships and the rotation of attendance but have no other special role.

    A fifth (2,400 people sharing 100 seats) to consist of a citizen’s jury (1,200 people sharing 50 seats) and its expert advisers (1,200 people sharing 50 seats)

    • Each month 90 jurors would be chosen by lot to serve for one year and 10 would be chosen by the National Jury, from amongst those due to leave it in the next three months, to have their term extended by a further year

    • The National Jury would appoint 1,200 experts to support it in its work. Half of these would be filled by 24 places (one seat) reserved for experts appointed from each of the major professions (Health, Finance, Law, Engineering, Architecture & Planning, Other Professions), scientific disciplines (Physical Sciences, Biological Sciences, Geographical & Environmental Sciences, Social Sciences, Applied Sciences, Other Disciplines) and bodies of knowledge of especial relevance to the work of a legislature (Economics, Public Finance, Public Health, History, Politics & Social Policy, Statistics & Interpretation of Evidence, Constitutional & Public Law, Human Rights, Ethics, Government & Public Administration, Politics & Political Philosophy, Policy Application of Science, Behavioural Sciences). The remaining 25 seats (600 individuals) could be appointed from any area of expertise or achievement.

    • For a transitional period existing non-political life peers would slot into expert places to maintain continuity and to reduce the number of appointments that need to be made at the outset.

    • An elected Secretariat of the National Jury, elected by the jurors, would arrange the rotation of attendance

    One tenth (2400 people sharing 50 seats) to consist of youth representatives

    • Members in this category would attend once a month rather than once a fortnight to minimise disruption of education so 50 seats would be shared by 2400 people not 1200.

    • Half the seats would be filled by the members of the UK Youth Parliament and by former members for one term of office after leaving. The Youth Parliament would arrange the rotation of attendance.

    • The other half would be filled by student representatives. Seats would be divided proportionally between student unions who would arrange the elections by STV with quota. NUS would arrange the rotation of attendance

    One tenth (50 seats, each shared by a number of people) to be filled by representatives of organisations chosen by the people.

    • Any organisation could stand other than a political party, an organisation with a political test of membership, an organisation formed primarily to influence a particular party, or a public body under the control of Ministers

    • To stand organisations would need either 100,000 members or 100,000 nominators (or a mixture of the two e.g. 60,000 members and 40,000 nominators who are not members)

    • Trade union and charity law would be amended so trade unions could stand whether or not they have a political fund and charities could stand

    • Voters would vote for 20 organisations. The 50 with the largest number of votes would appoint a group of people to rotate one seat

    • Elections could take place concurrently with the European elections.

    One tenth (50 seats, each shared by a large number of people) to be filled by representatives of the major interest groups of the realm.

    • An Assembly would be created for each major interest group of the realm

    • Membership would be based on standing, achievement, representative function, office or election by a larger group and as far as possible would be automatic or by election not a special appointment

    • These Assemblies could be based on relationships to the economy (Land & Title, Capital, Labour, Management, Consumers), professions (Health, Finance, Law, Engineering, Architecture & Planning, Other Professions), bodies of knowledge (Science, Social Sciences, Applied Sciences, Other Disciplines, Universities, Schools), cultural movements (Arts, Media, Sport), honours (Life Peers, Other Crown Honours) types of public service (Administration, Advocacy & Dissent, Charities)

    • Each Assembly would meet monthly and identify two delegates to attend each meeting of the Chamber

    As an optional extra, arrangements could also be made to allow the public to vote electronically, having watched the debate on television. Individuals unable to watch at the right time but wishing to participate could do so by appointing proxies.

    This is an additional possibility. If 25,000 public votes equated to 1 vote in the House of Lords (rounded up for the option which obtained the most votes and down for the other) then the public vote would overtake the vote in the House when more than 12,500,000 people participated. A new participatory politics would emerge around the campaign to secure proxies.


    Business planning would need to be done at least a month ahead to allow members to make appropriate arrangements. Saturday afternoons could be reserved for urgent business which could not be planned a month in advance.

    Speaker and officers It would be necessary to have a panel of deputy speakers and also to elect an Executive Committee to oversee organisational arrangements. Groups of members would also need whips and officers to arrange rosters or coordinate procedures. These members would be able to attend even when not rostered, although they would only be able to vote when rostered.

    Existing life peers Political life peers (those appointed specifically as working peers and those who have held elected office or served as Ministers) would slot in as members of the delegation from their party. Special arrangements would be made for those whose party has ceased to exist or has ceased to be entitled to seats – two seats would be shared between these members. Crossbenchers would slot in as expert advisers to the National Jury. Individuals who have not been appointed specifically as working peers or held elected office or served as Ministers, but who have taken a party whip would be individually considered by the National Jury who would decide whether to appoint them as advisers or to treat them as political peers – those treated as political peers would join their party delegation.

    New life peers In future life peerages would be an honour rather than a legislative appointment, although an Assembly of Life Peers would be one of the assemblies entitled to send two representatives to each meeting of the Chamber.

    Participation by members who are not rostered Normally members who have good reasons for attending should be rostered to attend but it is possible to think of circumstances where this might not be possible, especially for members in small groups where several might have a reason to attend or where a member holds a dissenting opinion. To deal with this, the Speaker of the House of Lords should have power to invite an unrostered member to attend in a non-voting capacity if that member has business on the agenda or a specific and particular contribution to make or is a member of a committee which is meeting.

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    We thought we had a political narrative on the shape of the NHS. David Cameron famously slams “pointless reorganisations” in 2011 but foolishly allows Andrew Lansley to run amok with his Health and Social Care Act in 2012. Jeremy Hunt is then brought in to steady the ship – Lansley having been deemed politically toxic – and we all settle down to making the 2012 structures work as best we can. Yet now we have a new kid on the block – George Osborne, chancellor of the exchequer – shaking up the NHS in revolutionary ways and with no scrutiny or transparency. What’s going on?

    The starting point is Osborne’s surprise decision to devolve the £6bn NHS budget of Greater Manchester to a combined authority of the constituent local councils pending the arrival of a directly elected mayor in 2017 – a huge leap from the previous “city deals” that were confined to matters like planning and transport. The chancellor said this deal “set a trail for the rest of the country to follow” and, in responding to his recent arbitrary deadline for devolution bids, several combined local authorities have taken him at his word – Cornwall, Gloucestershire, Liverpool and London, among others, have all tabled bids to control their NHS funding.

    This potentially amounts to an administrative revolution in the NHS that makes former shadow health secretary Andy Burnham’s pre-election proposals for stronger health and wellbeing boards look decidedly tame. The cities and local government devolution bill wending its way through parliament would, for example, give the secretary of state for communities and local government the power to transfer the functions and properties of other public bodies to these incipient, unelected combined local authorities. As things stand there is no exemption for NHS bodies from this clause.

    We really need to start asking some serious questions about this silent administrative revolution:

    What is the purpose?

    Apart from some vague ideas about integrated care and service transformation, no clear reason for these changes has been expressed or debated. Indeed, since the various deals are undertaken as secret bilateral negotiations between central government and regional political elites, there is not even the opportunity to scrutinise and challenge whatever assumptions are being made.

    Where are the providers?

    Even in the case of Greater Manchester – the golden boy of devolution – the deal has been a secretive top-down arrangement between regional commissioners, national NHS agencies and the treasury. GP leaders in Manchester have described the announcement of the devolved NHS budget as “a total shock”, while third sector and independent providers of social care (accounting for almost all of it) have been completely sidelined. History tells us that top-down reforms alone rarely result in sustainable change at the frontline.

    Where are the citizens?

    In principle it would be reasonable to assume that devolution is something to do with empowering citizens of regions and localities, but democratic governance is absent. The public will be mystified at the multiplicity of directly unelected bodies like combined authorities and joint commission bodies running their affairs, and in due course greater control will be in the hands of a single directly elected mayor. The latter will certainly help to pinpoint responsibility but heroic leadership is a flawed model of governance. Already there is a wave of resistance in Greater Manchester by a range of activist groups, trade unions, MPs and the third sector. What sort of devolution deal has no seat at the table for citizens?

    Where is the money?

    It is far from clear who will hold the purse strings in a devolved NHS, how overspends will be addressed and how the boundary between free healthcare and means-tested social care will be negotiated. There will be no additional funding and the chancellor and health secretary will be only too happy to lay responsibility for rationing at the door of the devolved authorities. In this way a Tory government with a mission to run down the role of the state will have effectively removed the ‘N’ from the NHS and paved the way for a balkanised healthcare system across the entire UK. Politically contentious decisions on clinical thresholds for accessing services and support will no longer land in the lap of Westminster politicians.

    Devolution to English regions is a clever political tactic – nobody is really against it, the rest of the UK already has it in varying degrees, Labour has been left flat-footed and regional political elites are keen to grab whatever powers and responsibilities are on offer. It may well, in principle, be a good idea to regionalise the NHS – there are arguments for and against. The problem we have is that this debate is not taking place. The NHS and local government is being transformed at pace and scale, yet most people have no awareness of this, have had no consultation and even less involvement. Lansley’s NHS bill was famously paused in order to reflect and gather fresh evidence. Maybe it’s time to do the same with the cities and local government devolution bill?

    This was first published by the Guardian

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    What is the best we can hope for from the new Government – whoever is in charge? I have three hopes. First, greater commitment to the real purpose of the NHS – equity. Second, less structural reform, and more real innovation. Third, the emergence of alternative voices and perspectives – from communities, from the groups facing disadvantage and from the professions themselves. Overall I would like the NHS to see itself as a community – not as an organisation – a community that takes social justice seriously.
    In A Better Plan for the NHS, Health and Care Ed Miliband and Andy Burnham say “The NHS is our country’s most precious institution and Labour’s proudest achievement.” This is strong stuff, but it is understandable that the NHS holds this place in the hearts of many. Before his death, my granddad wrote his memoirs – the memoirs of a working-class man from Manchester – he describes coming home from the war:
    “We had a National Health Service by now. It was introduced by the Labour Government who swept to victory after the war was finished. This was a great innovation. Free medical attention, dental and ophthalmic treatment and free medicine, no more doctors’ bills to worry about… The British people like the system…”
    This is surely at the heart of what makes the NHS great – free health care – no discrimination between the rich and the poor – equity. Yet, when we compare the principle of equity with the reality of the NHS – in its incarnated form – there are so many paradoxes:
    • The creeping return of charging, means-testing and privatisation.
    • The huge income inequalities – some have truly had their mouths stuffed with gold.
    • The institutionalisation imposed on disabled people and people with mental health problems.
    • The enormous centralised bureaucracy at the heart of the NHS.
    • The elitism and detachment from community and democratic accountability.
    • The exploitation of our wealth to draw medical expertise away from developing countries.
    The real NHS is a little less loveable than the ideal NHS. So, of course, the temptation is to ‘reform’ the NHS; but this is so dangerous.
    One of the most interesting consequences of the British healthcare system is its centralisation in Whitehall with political control handed each term to one (or usually more) Secretaries of State. Each one then discovers that almost everything good about the NHS is far too complex and detailed for them to do anything about. So politicians find there is next to nothing of meaning that they can do – so in order to be appearing to be doing something they must do big things without meaning – hence structural reform.
    Over the life of the NHS we have seen two waves of meaningless structural reform. The first wave from 1945-1990 was bureaucratic reform – dividing and re-dividing the NHS into districts, regions, units etc. The second wave began in 1990, and we are still in it now, and it is market reform – creating phony market mechanisms, commissioning systems, contracts and increasing privatisation. If we cannot end this wave then we may eventually see the collapse of the NHS.
    When I think of this process the image that always comes to mind is of a child playing with an expensive and complex toy, and a tired parent saying, “Now, stop fiddling with that – or you’ll break it!” However I do not blame politicians for this problem. In a sense we are the parents, but we keep giving control of the NHS to one individual because that’s the way we think democratic control must work. This goes back to the founding story of the NHS – we treat it as if it was founded by politicians and we hope that it is safe in their hands (or we fear that it isn’t). We forget the decades of work to create the NHS done by communities, campaigners and activists, work which the Socialist Health Association documents so well.
    So, the big question, going forward is whether we can turn away from meaningless bureaucratic controls, and phony market systems, and instead find our way onto a better path. There is nothing inevitable about this – we have just lived through the worst Government in over 75 years – who seem to have set about destroying the welfare state – and there is  good chance they will get in again. Alternatively the Labour Party is trying to position itself as close to the Conservatives as it can get away with, in the hope of winning back power.
    It is a dispiriting scene; but there are some rays of hope, and with hard work these could be magnified into something stronger.
    1. We could take the principle of equity more seriously
    As it stands champions of the NHS stand upon the highest peak of the welfare state and watch as the rising waters of injustice swallow up the social security system and social care. It is hard to be optimistic. But, we could wake up and realise that it is not the NHS that matters – but justice itself. We could recognise that the principle of equity both needs better protection and a wider scope. For instance, I’d like to see a movement to unite behind a constitution – not for the NHS – but for the welfare state as a whole; and not some meaningless policy document – but fundamental legislation to underpin the whole system.
    One emerging opportunity is the renewed effort to ‘integrate’ of health and social care. Eventually we will find (again) that integration is the wrong way to frame the challenge. However we will find that there is a much more important distinction to be made, between circumstances where individual budgeting is useful, and where it is not. It will turn out that the line between these two circumstances will be drawn quite deeply within the NHS. Figuring out where personalisation should begin and where it should end will turn out to be one of the key policy questions.
    Now this could be a disaster. For it could allow the excessive means-testing of social care to creep into the NHS by the back door. Hence, many resist the extension of ‘personalisation’ into the NHS. However, what if, instead of resisting individual budgets – advocates of justice attacked the root problem – means-testing itself. If the NHS is good – why do we allow severe means-testing of social care? There is no moral case for social care means-testing. Society only needs one system of means-testing – it’s called taxation. There is nothing fair about taxing disabled people and older people and calling it a ‘community care contribution’. This is just an extra tax that targets disabled people. Instead of resisting personalisation advocates of justice within the NHS could make common cause with those of us opposed to social care means-testing.
    We could go even further and ask questions about the benefit system, income distribution in health care, the pharmacy industry or regional injustices. Equity is a powerful and positive concept – and if we really care about it then we should be prepared to ask tough questions about where it applies and how to make it work.
    2. We could declare commissioning dead and look for real innovation instead
    I don’t know whether anyone will be brave enough to declare commissioning dead, but there remains no evidence that it has created any significant improvements and perhaps it would be useful to challenge the whole concept. Certainly, the last set of structural reforms, despite the rhetoric, have largely moved more power and control to Whitehall – leaving a rather complex structure of local Well-being Boards and Clinical Commissioning Groups (CCGs) with only minimal influence over the real system.
    However, while this may not be ideal in the long-run, I think it may be best to leave these structures alone, for they contain within them some positive possibilities. While power has not shifted to local clinicians or to local government, they are both at least now able to be part of a real conversation about local health services. This is real progress and it opens the door to further innovation.
    Real innovation does’t come from Whitehall and it doesn’t come from commissioners. It comes from communities and it comes from practitioners themselves. The NHS will truly flourish when people can find room to develop new ways of working. Innovation – which must be essential to the on-going health of the NHS – is a creative people-led process and it needs a permissive environment which is not frightened by local differences, experimentation and the odd failure.
    One area where much more innovation is possible is in mental health services. Today the mental health system is coming under increased scrutiny for good reason – not just because it has been severely cut – but also because it is fundamentally flawed. It has invested in the very things that don’t promote good mental health. Increasingly self-advocates and families are finding ways to develop better forms of support. For instance, the People Focused Group in Doncaster has demonstrated that mental health is advanced more by peer support than professional services. Such groups are finding allies within CCGs precisely because clinicians understand the frailties of the current system better than anyone. These kinds of people-professional alliances will be essential to restoring the NHS to health.
    3. We could welcome more diversity and greater connection to local communities
    Increasingly the NHS needs to look beyond the confines of services and of organisations. We need to identify and build upon the capacities of our communities and we need to be able to build new alliances. For instance, WomenCentre in Calderdale and Kirklees had generated multiple benefits for local women and families – health benefits and other social benefits – in ways that are much more efficient than typical models of public service. However the organisation is not a ‘service’ to be commissioned; it is a community – women supporting women. If the NHS is to thrive it needs to be able to listen to and respect this kind of perspective.
    The NHS needs to learn that its commitment to justice can’t just be a matter of organisational form or the repeated use of the formula ‘free at the point of use’. A real commitment to justice means taking seriously how you work as an individual, how you work with others and how you work to improve things in the wider community.
    Perhaps the most important challenge – however crazy it might seem – is to stop looking to politicians for the answers. Politicians are not the answer, and they are not the problem. They are mostly good people trying to do the right thing. (Sorry – I know that will be heresy for some.) However, they work within the confines of the feasible – and it is we who define what is feasible.
    If professionals, advocates and local leaders come together to define better solutions then politicians will open the doors to let change happen. But, if we sit in our silos and complain then we will find that policy is dictated by the assumptions of the powerful, the wealthy and by commercial interests. The NHS is in our hands – but if we choose not to think, not to act, not to get organised – then we will find ourselves… well we will find ourselves precisely where we are: in trouble.
    The NHS can be a community. It can be a place where people take justice seriously. If, as individuals, we begin to act as if we can make a difference, as if we are not just cogs in a system, then we may be astounded at what we can achieve.
    These are only some weak rays of hope. Whether they turn into anything more depends on us.
    I know nothing about writing blogs – but I know what I don’t want for the NHS in Manchester;
    1.  I do not want the NHS to be “devolved” to a bunch of Council Leaders with no clinical knowledge whatsoever of healthcare, treating patients and saving lives.
    2.  I do not want accountability and responsibility for the “National” Health Service to be “devolved” from the Health Secretary to a cabal of “unelected”  Quangos like Monitor and NHS England (and its 9,”Commissioning Support Units”?) stuffed full of their “free-market” acolytes, “privateers”, “McKinseyites,” Accountants, and Management Consultants – hell bent on using the NHS as a “cash-cow” to line their own pockets!
    (Note: A recent FOI request by “Private Eye” to NHS England about its spending on “Management Consultants” whilst slashing health budgets was rejected on the grounds of “commercial confidentiality”!  However it must show expenditure over £25,000 which revealed that in 2013/14 it spent:
    *  £2.8 million on McKinsey (and its ‘sham’ “Healthier Together”)consultation.
    *  £13 million to the Big 4 (“bent”) accountants PWC, KPMG, EY and Deloitte. (Deloitte pocketing – £7 million;  KPMG – £ 3.48 million and PWC £1.84 million).
    I do not want the NHS budget squandered on even more “unelected quangos” of pointless bureaucrats like the proposed “new strategic body”:
    The Greater Manchester Strategic Health and Social Care Partnership Board – supported by:
    A joint commissioning board drawn from the 10 local authorities, clinical commissioning groups (CCGs) and NHS England.
    Question: Where are the “Hospital”Representatives on the above commissioning boards? The Specialists, Consultants, Surgeons, Specialists, Oncologists, Cardiologists, Neurologists, Urologists,  Radiologists, Radiotherapists, Pathologists, Psychologists, Geneticists, Haematologists, Paediatricians, Clinicians, Doctors, Nurses, Midwives, Allied Health Professionals, Paramedics et al – THE FRONT LINE OF THE NHS WHO ARE TREATING AND SAVING MILLIONS OF LIVES DAY IN DAY OUT…???
    I do not want the NHS budget to be squandered by a “Cabal” of uninformed, uneducated “non-medical” Councillors and their crony “Business Consultants” on local authority vanity projects” commissioned by Bernstein, Leese and their “overpaid”, “under-worked”, money-grabbing cohorts!
    I do not want an “unelected” Mayor to be foisted on Manchester – against the will of its residents who previously REJECTED AN ELECTED MAYOR IN 2012!!!  How dare George Osborne and Howard Bernstein override the will of Mancunians by “imposing” a Mayor we didn’t vote for and don’t want!  MANCHESTER MUST BE GIVEN A REFERENDUM TO VOTE ON THIS ISSUE!
    I do not want the National Health Service to be turned into a Regional Health “Business Opportunity” for grubby Council Leaders, Quangos, Privateers and Accountants!

    What I DO WANT:

    Is a National Health Service free at the point of use for everybody regardless of ability to pay – with responsibility for its administration, services and funding in the hands of the elected Secretary of State for Health and the Department of Health.


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    By happy coincidence we organised a dinner last night for leaders in the NHS in Greater Manchester to discuss Devo Manc and the NHS.

    Those present welcomed the announcement that control of the NHS budget is to be handed to Greater Manchester authorities and  look forward to working much more closely with these elected local authorities.  Under the right conditions this could be an opportunity to ensure that our Manchester Health Service – MHS  – brings much greater benefits to patients and communities.

    MHS patients must be equal partners in decisions about their own care and of their families.  The MHS should be much more democratically accountable than the NHS has been in the past.  Manchester still has huge inequalities in health. The average age at death of people living in the most deprived parts of the conurbation is ten years less than among those living in the most prosperous areas.  The NHS has never been able to tackle inequality on its own but the MHS will be the biggest employer in the region and with local councils must use its muscle to reduce inequality.  At the same time we want to see an end to wasteful and damaging competition between hospitals.

    MHS should bring much closer working between social services, citizens, patients, carers, families, communities, hospitals, family doctors, pharmacists and other clinicians, researchers and the voluntary sector and to establish real parity of esteem between mental and physical health.

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    For all of its many strengths the NHS has one enduring weakness – it lacks robust local public and patient engagement (PPE). In better times, when people felt the nationally run service was adequately meeting needs, this may not seem to have mattered that much. However now that the NHS and Social Care Act is attempting to palm responsibility for tough decision-making onto local Clinical Commissioning Groups (CCGs) the democratic fault lines are being exposed. It is the right time to ask – can we democratise the NHS?

    Public and patient engagement (PPE) in the NHS has been weak ever since Bevan’s centralised model trumped Morrison’s municipalism in the 1940s. A succession of ineffective bodies have come and gone since the creation of Community Health Councils (CHCs) in the 1970s including PPI Forums, PALS and LINks. Indeed the Francis Report concluded that the long-gone CHCs actually represented the high point of public engagement.

    Few believe that the latest centrally inspired PPE incarnation – Local HealthWatch (LHW) – will be breaking the mould. There will be no additional monies to set up the local bodies and, embarrassingly, the Department of Health had to withdraw a consultation document after it appeared to suggest LHW branches could be run for as little as 20k pa compared with the 100k spent by the predecessor LINks.  Subsequent restrictions have been placed upon LHW through regulations which state it would not be reasonable to take part in the ‘promotion of, or opposition to, the policy which any government or public authority proposes to adopt in relation to any matter’. This is likely to limit the extent to which challenges can be made to CCGs and LAs and it is not clear why anyone would want to devote their time unpaid to an organisation which is not allowed to affect any public policy.

    At the same time the Health and Social Care Act seems to have upped the stakes on PPE – it was a crucial part of CCG authorisation and is said to be central to the Everyone Counts guidance and to Putting Patients First, the first business plan from NHS England. And the recent interim CCG ‘assurance framework’ issued by NHS England states that “the approach will focus heavily on the role of CCGs in securing patient and public engagement” and even refers to “our collective vision of a health system shaped by patient and citizen participation.”

    The problem with all of this is that the envisaged mode of engagement is stunted. In line with market conceptions of healthcare, the focus is on ‘empowering consumers’ through access to better information and by gathering ‘feedback’. The shift from ‘patient’ to ‘customer’ or ‘user’ is central to this neo-liberal approach to public services, with user involvement portrayed as the feedback mechanism for the expression of consumer views. The newly published ‘Choice Framework depends upon access to the right information on which to base choices, and there is currently much ado about gathering ‘real time’ feedback from patients via the Friends and Family Test .

    There is nothing wrong with information and feedback exercises, though there are certainly technical problems with the Friends and Family Test.  Nevertheless on their own they will fail to engage patients and the public in meaningful ways. We need to get beyond market governance as the only approach to PPE and start looking at two alternatives – representative and participatory governance respectively.

    Representative governance is a variety of democracy founded on the principle of elected people representing a wider group of people in order to form an independent ruling body charged with the responsibility of acting in the people’s interest. In due course these representatives can be voted out of office by the same constituencies that elected them. It is not a model with any local history in the case of the NHS.

    Representative governance could consist of a reprise of Morrison’s municipal control of the NHS via local authorities – this seems to be the commissioning model that is favoured by Andy Burnham and the Labour Party. An alternative might be to include an elected element into the governing body of CCGs.  However, if CCGs themselves wish to quickly gain public legitimacy they could follow (but drastically improve upon) the Foundation Trust member and governor model. Making best use of digital technology, as well as traditional approaches, the mission should be to build up the highest level of CCG public ‘membership’. From this a ‘public and patient congress’ could be elected with a role to act as a local ‘second chamber’ with some scrutinising, revising and advisory powers.

    But even this will be insufficient to sustain legitimacy for some commissioning decisions. CCGs also need to embrace ‘participatory governance’ and this must be much better than the traditional set-piece consultation exercise or the ineffective patient reference groups at practice level. Central to this approach is the idea of an ongoing active partnership between the citizen and the state. The task facing CCGs here is to ensure services are co-commissioned, co-designed, co-delivered and co-assessed in line with the popular ‘engagement cycle’.

    There are many practical ways in which this could be achieved. A long-standing approach is that of citizen’s panels where a cross-section or a selected stratum of the population make themselves available to deliberate on specific decisions about which there are known to be differing views.  One recent example of this has been in Ellesmere Port (2012) to engage the public in an inquiry into alcohol. Another is the idea of developing a cadre of ‘patient leaders’ along the lines proposed by the Centre for Patient Leadership. ‘Patient Leaders’ are described as ‘the patients, service users and carers with the knowledge and skills to become agents of change’ and the fullest account of how to develop them is found in the CPL’s recent publication, ‘Bring It On

    Up and down the country CCGs are having to take tough decisions – the ‘fall guys’ in the eyes of some – and are encountering a surge of opposition from patients, the public and staff in affected agencies. Unlike PCTs, tucked away discreetly in obscure business parks, CCGs are in the public gaze. The public has been told repeatedly by the Government that their GPs are now in charge of the budget and they now feel they know who needs to be held to account. If politics (by Harold Lasswell’s definition – Lasswell, H (1958 with postscript), Politics: who gets what, when, how? Meridian Books) is about ‘who gets what, when and how?’ then CCGs are inescapably politically embroiled.

    The bottom line for public sector organisations is defensible decision-making – ‘upwards’ to a higher authority and ‘outwards’ towards a local community. Whilst a robust PPE strategy will not eliminate controversy around a difficult decision, it will demonstrate that views have been heard, add understanding of the reasoning behind the decision and ultimately increase trust in the inclusiveness of the governance process. Many CCGs will have inherited a ‘communication and engagement strategy’ from their PCTs and will have cut and pasted this as a template for authorisation purposes. Now is the right time to completely rewrite these strategies – to recast them conceptually, relocate them into local contexts and show some courage and ambition in engaging with local populations. ‘The public’ doesn’t have to be a problem; it can – and must – be an important part of the solution.

    Tagged | Comments Off on Can We Democratise the NHS?

    In the context of whole person we need health services to be aligned with all the other public services. We need to focus on tackling the social determinants of poor health, investing in better health, and only the public service approach can do that.  Only local authorities can be the focal point for bringing public services together.  Only those who are accountable to us through a democratic process should be allowed to make decisions about how public funds are allocated and priorities set.

    But, the antipathy that exists within the health service to local government is matched only by the reluctance of most local authorities, already coping with austerity, to get involved in health services which are seen as shambolic.

    Whatever method is used to plan or commission should take into account all of the public services and the total of resources available.  It is incidentally an argument against ring fencing of funding for separate services.

    There are three reasons why local authorities ought to also have the strategic responsibility for the planning/commissioning of health services:-

    • it brings the democratic accountability we rely on for (most) other public services
    • it allows for total public funds for an area to be allocated to best overall advantage and for strategic investment decisions – population based decisions
    • it allows for economies of scale – especially in management, administration and support functions

    And arguably there is one further reason:-

    • Local authorities are better managed than health services (in terms of procurement, sharing services, service integration, commissioning) – they are many years ahead on the “best value” journey.  They are also far better at resisting vested interests and conflicts of interest – its one reason why we have democracy.

    Alongside the basic ideological case for democracy this is about how we get the greatest value from public funds. For most of the lifetime of our NHS public money flowed to the “providers” of healthcare based on history – just roll over what was used the previous year plus a bit. Long waits and restrictions on access balanced the books.  There was no planning, no sense of public involvement in decision making and no measures of value for money.  Two decades of commissioning by various flavours of NHS bodies have not managed to change things much and we constantly hear (for example) that the priority attached to acute care is detrimental to developing community care – care closer to home.  The biggest inefficiencies in our NHS are arguably no longer in providers being “inefficient” in delivery (although they are) – it is that we allocate spending on the wrong things.

    Responsibility and funding for social care is with local authorities and subject to means testing in contrast to free “health” care.  Sixty years ago this did not appear to matter much, now the fact that our care is split between two armed camps that do their best not to communicate and have huge cultural differences matters a lot.  Not to mention the issues around totally inadequate funding for social care impacting on health.

    Finally we can note that because funding streams are separate there are fewer incentives to cooperate, and even some perverse incentives to compete for funding.  If local authorities invest in better housing then health improves but it is the NHS that gets the gains. We have the current situation of one public body imposing fines on another – which should be a ludicrous idea but which has a twisted logic in the current fragmented set up.

    So does change require a reorganisation?

    The reality is that in many parts of the country the local authorities and the NHS are already working together – and where it works best is where the local relationships are good, informal arrangements are made and they ignore the complexities of governance and just do it.  That can be built on and encouraged but each locality has to be left to find its own way.

    We could start by a few simple measures:-

    • give Health and Wellbeing Boards the responsibility to sign off Clinical Commissioning Group plans (now rests with NHS England) – and to monitor delivery
    • and sign off on social care budgets and commissioning plans

    (both plans must explain how they took the other into account)

    • make a joint commissioning framework (and policies) mandatory as with Joint Strategic Needs Assessment and the area Wellbeing Strategy
    • strengthen governance of CCGs by having non executive directors to prevent conflicts of interest so that all of primary care (including GPs) can be brought into their local remit (currently with NHS England)
    • set financial limits above which agreement from the LA would be required (~£5m)

    and in a longer time frame

    • make CCGs and LAs coterminous (many CCGs are smaller than their  Local Authority)
    • integrate commissioning and other support functions
    • pool the whole budgets.

    None of that requires any major whole system reorganisation.  And it should not be done through top down imposition; each locality should be left to find its own way at its own pace so long as it delivered improving and better integrated care.