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    Democratic control of NHS

    Part of our response to the Labour Party Policy consultation June 2012
    1. Commissioners elected by local people and required to be responsive (we need to distinguish the how from the what; the latter is a matter for national debate and decision in terms of the coverage the NHS offers but how that coverage is delivered can be a local matter)
    2. Provide enforcement mechanisms for the NHS Constitution.
    3. Local people involved in Clinical Commissioning Groups in the same way as parents are involved with schools
    4.  By introduction of democracy to the NHS – and this needs to be for provider organizations as well as for commissioning ones (if we stick with this wasteful split).
    5. By introducing deliberative democratic processes for policy decisions at local, regional and national level (the Brazilian participatory budgeting process is one viable model of this).
    6. Make very public the expectations of basic courtesy and kindness required of all health staff – I had a hospital appointment yesterday and only one of the two staff who attended me bothered to introduce himself. My mother was in hospital last summer and still staff came and did interventions on the ward without explanation or introduction.
    7. Commissioners have less demands from above and more from below.
    8. Providers are ranked by responsiveness.
    9. Ensure that *every* service provider is covered by the same rules of transparency and accountability, regardless of whether they are public, voluntary or private sector. This means open board meetings, FoI-able, a single standard complaints system, and a mechanism for patients to challenge decisions. We have yet to see how the “lay” members on CCGs will perform their duties, I suspect that we will need to ensure common standards. My feeling is that lay members should attend each GP patient involvement group at least once a year, and similarly for patient support groups. I think lay members should have a “direct connection” with patients.
    10. Legislate for transparency of decision making (including non-financial contract details) and a wider social base of non-execs.
    11. Make Board members personally liable for misuse of public funds by paying whistleblowers to keep silent
    12. More power to Foundation Trust Governors. Specifically: We propose a series of measures which might improve the Foundation Trust governance model but unless there is a genuine will to transfer power then the model is fatally flawed. (We accept that some Foundation Trusts will already have implemented some of these.)

    a)     Most important – more independence. We should strengthen the idea that the members own the hospital and the Governors are their elected representatives. The Secretary of State, Monitor or any other regulator (apart from CQC on issues of patient safety) should only be able to intervene through the Governors.  If Governors represent the owners of the Trust and are there to hold the Board to account then any external regulation must involve them.

    b)     As well as approving the annual plan the Council of Governors should have to formally approve all major transactions and all major changes to service delivery, including any closure of facilities, any changes to the limit on private patient income and any Trust wide changes in staff terms and conditions.

    c)      The power to appoint or remove the Chair or Non executive directors should only be exercised by the Council of Governors in special session.

    d)     The targets for recruiting more members should be scrapped. Instead there should be measures of the effectiveness of their involvement.

    e)     Governors meetings should be open to the public.

    f)       It should be possible for members or the public to contact Governors without going through the staff of the Trust, and Governors need to be able to communicate with members without interference from the staff. The Trust should at least supply a public email address for each Governor.

    g)     Governors should be entitled to:

    a)     ask questions about any aspect of the Trust’s business and have their questions answered;

    b)     membership of any senior Trust committees;

    c)      observe and contribute (without a vote) at Board meetings and to see all the papers;

    d)     attend closed sessions and Board in committee sessions;

    a)     a governors’ own Steering Group with responsibility to determine the Council of Governors agenda; regular joint Board/Council of Governors meetings. All major policies must be timetabled to allow full Council of Governors advice and to be signed off by Council of Governors.

    h)     There should be radical improvements to the actual election process. Minimum standards should be established for the election processes and for eligibility. In particular:

    a)     constituencies should be neither too big nor too small – big enough for a contested election, but small enough for candidates to know the area.

    b)     Candidates should be given sufficient opportunity to say something about themselves in the election process and why they want to be Governors.

    c)      If they have to be proposed or seconded by other members the list of members must be published.

    d)     The Trust should facilitate hustings meetings where possible

    e)     Governors should be elected by the Alternative Vote model.

    i)       Governors should be able to have recourse to the regulator to ensure the above are enforced.

    j)       Any rules which prevent members of Local Involvement Networks or any similar bodies from being Governors should be scrapped.

    k)     We should reaffirm that the equality legislation applies to Governors and support must be provided to people who need provision for disability, money to pay for child care etc.

    l)       Governors should be entitled to time off work for public service. Staff Governors should be entitled to time off with pay and cover for their work.

    m)   There should be a national Code of Conduct which every Foundation Trust has to adopt and enforce on their governors (they could add to it). This should make clear issues around conflict of interest, communications with the media, standards of behaviour, role and responsibilities. It should also cover how governors could be removed for unacceptable conduct in breach of the code, or non attendance. These matters should not be open to local decision making.

    n)     There should be appropriate funding for governor training and development and member engagement. The Foundation Trust Governors Association should also get appropriate funding, for example for developing training courses and materials, and its role should be acknowledged. A national one day induction course should be established and no governor would be able to take office until they have been through the course. Annual follow up half day courses should also be mandatory.

    o)     Governors should be given opportunities to meet with governors from other Foundation Trusts.  Membership of the Foundation Trust Governors Association should be open to individual Governors, even if their Trust does not subscribe.

    p)     A good job description for the role of Governor should be published before an election so candidates really know what is involved – in terms of formal tasks, opportunities for involvement in the hospital, and time commitment.

    q)     Foundation Trusts should use common terms and be prevented from calling their Governors by other names, such as “councillors” as some do, because it just confuses the public.

    r)      Monitor should

    a)     consult widely and publish new guidance around the roles and responsibilities of members, governors and members’ councils. Some independent research and publication of best practice should be undertaken.

    b)     have one nominated board member responsible for liaison with governors.

    c)      have responsibility for supervising the democratic governance arrangements for all Foundation Trusts.

    s)      All Councils of Governors should consult with their membership and propose formal arrangements through which members are regularly informed, given the chance to participate and consulted formally on major issues before the Council decides its position.

    1 Comment

     

    The procurement exercise in Staffordshire which outsources the commissioning of £1.2 bn of NHS services has at last made the mainstream media.  An announcement has been made that it has been decided that the next stage of the procurement will now get under way with a full blown EU procurement (competitive dialogue).  The decision was made in private for reasons which are unclear, so there is no public record.

    The procurement has of course already been under way for some time with the request to submit pre-qualification questionnaires in March. But there was absolutely no information about any of the details. Leading up to the announcement there has been a flurry of activity as the CCGs involved try to put right the numerous defects in the way they have gone about this exercise.  They have also got together to establish a special web site to promote what they are doing – though it too lacks the necessary information.

    There is no record in any CCG minutes of how the key decisions were made and no papers setting out why; but there is no obvious justification for such secrecy.

    The formal procurement is for two contracts; one for Transforming End of Life Care and the other for Cancer Care.  The contracts are for 10 years and are for an “integrator” (lead contractor) to manage existing contracts for two years and then to take full responsibility for the management of the provision of care.  The integrator can be a private body and given the requirements this is the most likely outcome.

    Before the procurement a lot of good work had been carried out around the need to improve services and to integrate provision and in general the aims are not disputed.  The way the CCGs have gone about approaching the implementation of worthy aims is hugely controversial and potentially unlawful.

    It is totally unclear how the decision was taken to use a major competitive procurement exercise rather than use the existing powers that commissioners have to arrange the provision of services.  The decision to go down a route that opens the door to a private provider effectively taking over the commissioning role has never been discussed.

    The fear that private sector organisations would take over CCG responsibilities and make decisions over provision of services was much discussed during the passage of the H&SC Bill and after the pause there were reassurances that this could not happen – well it is happening.

    The clear danger of having 10 year contracts of this sort is clear even to those who are relaxed about greater private provision.  The NHS is undergoing a period when major changes are necessary as care moves from hospital to the community and as barriers between social, physical and mental health are dismantled – everyone agrees on this.  But if commissioners have given away their right to manage provision they can’t respond they can only look to contract variations and disputes with their lead contractor.  It is pretty fundamental that decisions about the allocation of resources and the priorities that are set cannot be made by private sector organisations under some contract – it just doesn’t work like that!

    The duties on CCGs to have proper arrangements in place to allow discussion with patients and the public are clear enough.  How services are commissioned and how decisions are made about who provides what are clearly matters on which patients and the public (and staff) have the right to be involved.

    As with other procurements that have fallen apart we again see CCGs charging ahead without having in place the necessary framework of proper information disclosure and governance and paying, at best, lip service to public and patient involvement.

    It is not just essential but also arguably a legal requirement for the CCGs to stop what they are doing and to consult properly about what they are proposing to put in place.  If after such discussions they decide to proceed through competitive procurement of a lead contractor model then they have to ensure openness and transparency in every step they take along the way.  They have to involve patients and users in setting out requirements, defining criteria and in evaluating the responses from potential providers.  They have to make public all the necessary information and stop hiding behind spurious claims to commercial confidentiality – it is up to the CCGs to make arrangements to ensure openness not hide things.  They have to show that what they do is consistent with the policies they have established (and formally agreed) and with the various assurances that have been set out by Ministers and the various quangos who oversee the NHS and what it does.

    Only if this is done can anyone have an honest view on whether what results is really in the best interest of the patients and our NHS.

    There is a real danger here.  If the route to integration is by using private providers as surrogate commissioners then the whole drive to a worthwhile aim is totally undermined.

     

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    TEN MESSAGES on PUBLIC and PATIENT ENGAGEMENT

    ‘Power to the people!’ The Citizen Smith slogan seems to be all the rage in the Labour Party right now as it crafts a distinctive election strategy for the NHS. Pulling away from the role of markets and bringing local accountability into the NHS looks like a good policy double whammy, and the commitment seems genuine. In recent weeks:

    • Ed Miliband, in his Hugo Young lecture committed the next Labour government to ‘people-powered public services’, devolving power not just to users but also to ‘the local level’.
    • Labour’s draft consultation paper on health  expresses similar sentiments, emphasising that people should be ‘not mere consumers of services but genuine and active partners in designing and shaping their care and support’.
    • The detailed report of the Oldham Commission, set up by Andy Burnham, contains an eight-point depiction of ‘whole person care’, one of which is ‘I and my community have a real say in our local services’.

    This is positive stuff and all consistent with the ‘grass roots’ outlook of Labour’s new strategy guru, David Axelrod. There’s only one problem – there is no policy! Nothing in the Oldham Report, nothing in the party draft consultation and only ill-thought out ideas from the Labour leader himself, such as describing Health and Wellbeing Boards as ‘independent bodies’ to be charged with ‘consulting the local community’.

    This isn’t good enough, and Labour is missing an open goal in not being more explicit. Here are ten suggestions to get the ball rolling.

    1. Coordinate existing forums: There are too many weak and fragmented bodies right now – Local HealthWatch, foundation trust governors, lay members of CCG boards and others. Together they might add up to more than the sum of their parts but there is no way of currently doing this.
    2. Empower elected FT governors: Alan Milburn’s recent assertion that Foundation Trusts are ‘owned and controlled by the public locally’ is nonsense. FT Governors are toothless and invisible to their miniscule electorates – they need to be properly staffed and funded and given autonomy from the grip of their FT boards of directors.
    3. Real public engagement in NHS commissioning: Most CCGs are stuck on a failed engagement model centred on ‘public meetings’. The need here is to promote the development of genuinely participative models – citizens panels and juries, patient and community leaders, participatory budgeting and harnessing the power of digital engagement.
    4. A Patient Congress in every Clinical Commissioning Group locality: Some effort is currently going into the creation of a national ‘NHS Citizens Assembly’ that somehow might call the board of NHS England to account. Without local roots this will falter. A representative and (at least partly) elected local Patient Congress could be the missing link in democratic transmission to the Assembly.
    5. Proper support for Patient Reference Groups: There are hundreds of these small groups at practice level taking an interest in such matters as patient appointment arrangements and opening hours. Generally they are unpublicised, unsupported and unrepresentative. They need help to up their game.
    6. Deeper understanding of ‘the patient experience’: In line with the focus on ‘consumerism’ there is much current preoccupation with recording and measuring patient feedback via the Friends and Family Test. This needs to be deepened (to get a narrative rather than a tick-box score) and extended (to capture patient journeys rather than separate interventions).
    7. Open up the invisible quangos: While CCGs have all manner of obligations laid upon them to involve and engage the public, other powerful bodies can too easily slip below the engagement radar – Local Area Teams of NHS England, Commissioning Support Units, CQC and Monitor. All of these bodies have huge sway over local healthcare but remain unknown and unaccountable to local people. 
    8. Promote and enforce the NHS Constitution: Most people are blissfully unaware of the NHS Constitution and even if aware of it will be (understandably) unclear as to its status. There is an opportunity to turn it into an NHS Bill of Rights.
    9. Strengthen and fund Local HealthWatch: The Francis Report argued that the prime local forums for public engagement have gone steadily downhill since the first of them – Community Health Councils – was abolished by Patricia Hewitt. We need to get back to a CHC-type model, possibly along the lines of the patient congress approach. A robust LHW could be the organising vehicle for such a shift.
    10. Reinvigorate local government: It will only be possible to bring some healthcare remit back into democratically elected local government once it has constitutional autonomy and is free of the pro-market, centralised paradigm.

    Lots of work to be done under these headings, but time is running out. There aren’t many political open goals awaiting a shot on target but surely this is one of them? Shoot!

    Professor Bob Hudson,

    School of Applied Social Sciences, University of Durham

    3 Comments

    The Co-operative Party are proposing an amendment to Labour’s Health Policy see the Your Britain website.

    Insert on pg 6 at line 42:
    “In 2003 the previous Labour government established Foundation Trust Hospitals in England with the aim of making hospital services more accountable to local communities by giving Trust members a real say over their running. Ten years on the consensus is that, whilst more than 2 million people are members of Foundation Trusts, the model has not achieved its full potential and there is a need to re-awaken the original ambition behind it. One Nation Labour believes in more ‘people-powered’ public services and so a future Labour Government will consider ways of strengthening the role of members within Foundation Trusts and work to better engage and involve NHS staff in Trust membership.”

    We’ve never been very comfortable with the ideas around Foundation Trusts.  In 2010 we agreed a statement including these words:

    • Local NHS facilities should remain publicly owned and Foundation Trusts should be a model for community multi stakeholder ownership.
    • The governance structures within which Foundation Trusts operate are flawed and are insufficiently undemocratic and must be extensively reformed.
    • Both purchasers and providers should be responsive to their local community and commissioning of services should be under proper democratic control
    • Whilst we accept that there will be a major increase in the number and scale of Foundation Trusts we do not accept denationalisation. Foundation Trusts must remain clearly part of the NHS family with a duty of partnership with both commissioners and other NHS partners. There must be explicit restrictions on sale and use of assets, on varying terms and conditions of employment and on non NHS income.

    Our statement went on to propose a long list of improvements we wanted to see in the governance of Foundation Trusts. Things haven’t improved since.  Although many of our members are involved in Foundation Trusts, as members, governors, employees and board members, few seem convinced that the present model has much to be said for it. If we move away from the idea that each NHS Trust is competing in a market with all the other Trusts then perhaps this is not the place for a democratic voice?

     

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    Ways Forward For Public and Patient Involvement In England 2014

    Practical Approaches To Patient And Public Involvement

    The Briefest Of Summaries Of The Best Ways Forward In PPI For England

    Current policy as outlined in Participation Guidance  is generally good with clear requirements for the system as a whole. However, much more can be done.

    PRINCIPLES:

    • Democratic legitimacy needs to be increased in the NHS. In particular, commissioning and planning for the local and national NHS should increasingly be in the hands of elected people.
    • Perhaps more than democratic accountability, we need participatory accountability. That is, a system that supports, encourages and welcomes communities and individuals being part of the prioritising, planning and monitoring of services as equals and agenda-setters.
    • As part of this process, the NHS needs to develop techniques and approaches for a proactive dialogue with the people it serves, locally and nationally.
    • PPI needs to be integral to all aspects of commissioning and providing
    • Commissioners and providers need to show that they have listened and responded and they need to be monitored on their response
    • We need to include in the discussion both individual involvement (the process of consultation between patient and clinician) and collective involvement (the participation of communities and groups in the planning, development and monitoring of services)

    WHAT NEEDS TO BE DONE TO IMPROVE INDIVIDUAL PARTICIPATION

    • Active care planning
    • Training for clinicians in promoting shared decision-making and self-care
    • Promoting the dissemination and use of
      • Decision Aids
      • Online patient record access
      • Condition-specific patient education programmes
      • Group appointments
      • Coaching and question-prompts for patients
    • Realigning incentives
    • Changing external and legal factors

    WHAT NEEDS TO BE DONE TO IMPROVE COLLECTIVE PARTICIPATION

    • Promote and disseminate the use of community development as a joint process between Clinical Commissioning Groups, Local Authorities, HealthWatch  and Health and Wellbeing Boards
    • GP surgeries to become more responsive to their populations
    • GP surgeries and CCGs to work more closely with local 3rd sector groups
    • Feedback from patients to become increasingly:
      • a key safety lever
      • part of the payment process for providers
      • part of choosing services
    • A strong independent HW
      • ring-fenced funding
      • continuity
      • effective data collection and evidence-based feedback to commissioners
    • More responsive and accountable commissioners, responsiveness monitored by NHS England
      • An increasing focus on communities and patients as experts in identifying local issues and solutions
      • PPI at every stage and every part of the CCG including prioritising, finances, planning, monitoring
      • Patient Participation Groups to collectively advise the CCG
      • Stronger representation on the CCG of councillors and lay people
      • Consider other options for CCGs governance:
        • with Foundation Trust-type arrangements
        • elected representatives
      • Commissioning community development
      • Prioritising individual involvement
    •         A stronger push at national level to share power with patients and citizens
      • NHS England to demonstrate responsiveness in its own commissioning
      • Community development to be promoted by making it easier to jointly commission
      • A shift towards Health and Wellbeing Boardss initially vetting CCG plans, then taking on more of the commissioning responsibilities. Then eventually LAs taking over commissioning with CCGs as key partners.

    WHY IS PPI IMPORTANT?

    See a good summary

    INDIVIDUAL INVOLVEMENT

    This means participation in the consultation between patient and clinician (nurse, GP, hospital doctor, AHP)

    There is moderately good evidence that care and outcomes improve when people are involved in shared decision-making and in self-care. It probably saves money too.

    For the process to be effective, both the patient and the clinician need to be involved in the dialogue and support has to be offered to both. Shared decision making relies on two sources of expertise:

    • The health professional is an expert on the effectiveness, probable benefits and potential harms of treatment options
    • The patient is an expert on herself, her social circumstances, attitudes to illness and risk, values and preferences.

    Both parties must be willing to share information and accept responsibility for joint decision making. The clinician must provide patients with information about the diagnosis and treatment options and the patient must tell the clinician about their preferences

    “A colleague with rheumatoid arthritis likens the experience of living with chronic illness to flying a small plane. If it is flown well, one gets where one wants to go with the exhilaration of mastering a complicated set of challenges. If it is flown badly, one either crashes or lands shakily in the wrong airport,reluctant to ever leave the ground again. The patient must be the pilot, because the other possible pilot, the health care professional, is only in the plane a few hours every year, and this plane rarely touches ground.

    If chronically ill patients must pilot their planes, then the role of health care is to ensure skilled pilots, safe planes, flight plans that safely get the pilots to their destinations, and air traffic control surveillance to prevent mishaps and keep them on course. “

    This implies a substantial shift in clinical activity across the whole of the NHS.

    Practical interventions to make individual involvement routine

    1. Care planning. Not just having a care plan, but an active process of jointly planning care for people with Long Term Conditions. See the House of Care for more details.
    2. Training clinicians in shared decision-making (SDM) and promoting self-care. There is evidence that this changes behaviour, to some extent in the long-term. Unless clinicians alter our approach to the consultation, little will  change. There are quite a few training courses now and lots of work on practicalities by the Health Foundation.
    3. Decision aids for patients need to be available in every Out Patient Department and every GP clinic. Decision aids help to increase patient involvement in decision making and increase patients’ confidence in the process. Some studies suggest they also produce a better match between patients’ preferences and the treatments chosen, leading to increased satisfaction. There is no evidence that they make patients more anxious. Several trials have shown that decision aids can lead to a significant reduction in rates of elective surgery with no adverse effect on patient satisfaction or health outcomes.The best ways of harnessing Decision Aids need to be established, taught and reinforced.
    4. Patient online record access. This is now government policy for it to be available to anyone who asks from April 2015. has been shown to improve relationships, improve patient confidence and understanding and self-reported efficacy, and reduce the demand for appointments and telephone calls to practices. There is some evidence that self-care and compliance is improved. Patient record access needs to be available for every patient across the UK. It is emerging that patients particularly value transactional services that can be linked with record access. These include:
    • reliable information linked with their own record
    • using access to ensure that professionals and family members are informed of all their current treatment and care plans
    • the ability to improve the accuracy of the record
    • the ability (in the future) to add to the record
    • the ability to book appointments and repeat prescriptions electronically through the record.
    • the ability to see how their care management relates to good practice in the field, for instance through links with the Map of Medicine.
    1. Condition-specific patient education programmes such as the Expert Patient Programme have involved people with asthma, diabetes or arthritis. Evidence is reasonable that they make a difference to outcomes and self-confidence to manage.These are programmes for patients. Clinicians may need support and encouragement to offer such groups on a routine basis. In addition, there may need to be support or incentives for clinicians to offer interventions such as asthma self-management on a routine, systematised basis, perhaps on a cluster basis.
    2. Group appointments. These are appointments where groups of patients with the same Long Term Condition (typically diabetes or asthma) are seen together by a clinician. The aim is both to teach people good practice but also to enable patients to learn from each other and for the clinician to learn from the wisdom of the group. Better health outcomes (blood glucose control and blood pressure) are reported for group-based educational approaches for patients with Type 2 diabetes.
    3. Realigning incentives so that professionals are required to involve patients in decision making. In this brave new world clinicians would be monitored for their ability to accomplish this task. Training would be provided in shared decision making and the use of decision aids and patient engagement would be incorporated into clinical guidelines, using patient feedback to check progress. Health professionals and managers would require the use of decision aids to achieve performance targets. Relevant metrics might include the percentage of patients who report having had the opportunity to make informed decisions. Such metrics could be incorporated into accreditation and reimbursement strategies.
    4. External factors and legal requirements, such as the requirement to demonstrate true informed consent (see for example the 2007 legislative changes in Washington State), could also provide a strong incentive to make the shift from traditional paternalistic practice. Those concerned with risk management could benefit from insights derived from research into shared decision making and risk communication. Clinicians are always vulnerable to legal challenge and being able to demonstrate that effective methods have been used to communicate risk may prove to be a useful defence in court cases.
    5. Coaching and question prompts for patients. These have included coaching in how to raise issues and express preferences, question cards that act as prompts on appropriate questions to ask the doctor, encouragement to keep diaries or lists of topics for discussion, and summaries or audiotapes of the main points discussed for the patients to review later.

    As a result of prompts, evidence suggests:

    • improved knowledge and recall.
    • Increased involvement and question asking,
    • Increased perception of control.
    • Prompt sheets more effective than generalised information,
    • Patient focused approaches are more effective than those targeted at health professionals.
    • Mixed results for satisfaction.
    • Length of consultation unchanged, even where question asking increases.

    However,

    • No impact on uptake of ante-natal tests.
    • Mixed results in relation to medication adherence and clinic attendance.
    • Mixed results in relation to treatment outcomes.

    COLLECTIVE INVOLVEMENT

    This refers to the involvement of people collectively influencing the planning and delivery of local or national healthcare services.

    Democratic Accountability

    The Secretary of State is the only elected person in the NHS. As a matter of principle, there needs to be more democratic involvement in the NHS. Critically, planning the NHS should be done with democratic legitimacy. Currently there is a real risk that planning will lend up being done by the private sector as Commissioning Support Units get taken over and gain more power.

    The most obvious way is to involve local authorities more over time.

    The first step would be to give Health and Wellbeing Boards more say and a veto over CCGs’ plans. Increasingly HWBs could take over local planning. Eventually Local Authorities would be in charge.

    Advantages would be:

    • Holistic planning and procurement
    • Probably a stronger focus on the social determinants of health
    • Less duplication

    Disadvantages:

    • Political vagaries interfering with evidence-based planning.

    However, to listen to NHS staff discussing this, you’d think that Local Authorities could never commission or plan anything, hobbled by politics. This is patently not the case. And there is precious little evidence-based planning in the NHS (or anywhere) now.

    Other options include elected Clinical Commissioning Groups, elected Boards for practices, Foundation CCGs, having the same sort of structure as FTs. However, as was found in Scotland, it is unlikely that new democratic structures like this would attract enough voters to be viable.

    Participatory Accountability.

    This is the process that happens to some extent now, with Patient Participation Groups, Health Watch and so on. NHS policy on this kind of participation is pretty good. The demands on CCGs to be transparent and to involve local people in planning are clear in the recent guidance and in the NHS Constitution.

    However, practice on the ground remains poor, but is improving.

    Practical ways of improving participatory accountability.

    1. Community development to become a key approach.
    Community development (CD) enables people to organise and collaborate to:

    • identify their own needs and aspirations
    • take action to exert influence on the decisions which affect their lives
    • improve the quality of their own lives, the communities in which they live, and societies of which they are a part.

    CD aims to address imbalances in power and bring about change founded on social justice, equality and inclusion[i]. It increases community activity at two levels:

    • within the community itself: to increase social networks and productivity – more friendships, less isolation, more volunteering, more mutual aid, more informal care, better flow of information, more trust and co-operation, positive behaviour change;
    • between the community and local services and authorities: better communication, dialogue, feedback, engagement, involvement in service change.

    The process begins by identifying the issues that matter most to those residents who speak up and take action, not by imposing an agenda pre-defined by health or other public service agencies. If the relevant topics are anti-social behaviour, housing or environment, those are the initial priorities for the work. All issues have a health benefit. As social networks expand, most major issues will emerge through one group of residents or another. As communities work together with agencies to solve the problems that matter to them, confidence grows, leaders appear, social capital improves and the benefits to health become apparent. Some impacts are direct, through the effects of participation on individuals; some are indirect, through service change and increase in social trust.

    A resident-led partnership is often the vehicle by which this transformation takes place. This brings together local people with public agencies dealing with health, education, housing, police and other issues, in ways that have often not happened in that area before. As a local resident put it: “It’s no longer them and us – it’s us and us.”

    CD is best carried out through expert community development workers but can be done by other front line service workers if they are trained for it. CD tends to be geographically-based (highlighting the most troubled communities in the area), but there are good examples of work with communities of interest, for instance people with diabetes, or the disabled.

    One strand of CD is broadly known as the ‘asset-based approach’. Whilst medicine traditionally seeks needs and problems to which to respond, asset-based approaches look for the positives: the leaders, the skills, the strengths of individuals and communities, and builds on those.

    2. GP surgeries more responsive to their local  populations

    • Every practice to have a patient participation group or panel.
    • Every practice to work with and collaborate with their local Healthwatch
    • Every practice to introduce easy to use feedback channels and to be responsive to this feedback
    • Practices to involve patients in the recruitment of doctors and other staff
    • The Care Quality Commission to monitor whether practices make changes in response to patients’ views.
    • Quality and Outcome Framework incentives re-introduced to encourage responsiveness, in particular:
      • Quality of care being in part defined by patients
      • Points assigned to responsiveness on areas other than merely access
      • Practices will be encouraged to work with local community development workers

    3. More responsive and accountable commissioning

    • Patients’, citizens, community-based organisations and Healthwatch views to be incorporated into the commissioning process in the following areas:
      • Needs assessment
      • Choosing priorities for investment and disinvestment
      • Monitoring quality
      • Identifying problem areas and successful areas of service provision
      • Determining the shape of service development
      • Deciding on how to spend any savings
      • Patient participation groups link up to advise the CCG
      • Greater involvement of condition specific and community groups in the commissioning process. For instance  through local third sector, voluntary and community organisations
      • Community development workers to be commissioned  in each CCG, jointly with local authorities, through the HWB
        • CCG boards to be elected.  Perhaps along the lines of parent-governors in schools.
        • Participatory budgeting linked with the LA.
        • The CQC to demand evidence that local commissioners and providers have taken on board patients’ views in the areas specified above
        • CCGs’ commissioning plans to be signed off by Health and Wellbeing Board. Eventually, commissioning to be taken over by HWB and later, perhaps, the Local Authority.
        • Local Authority councillors to form half of every Board
        • Pilots to explore CCGs as Foundation Trusts

     4. A stronger push at national level to share power with patients and citizens

    • Ensure HealthWatch England is a representative organisation of Local HealthWatches. That it sit outside the Care Quality Commission. That LHWs be adequately funded with ring-fenced money. That LHW has more powers to change CCGs’ plans than now.
    • Shared decision making and sharing of information, including the sharing with patients of electronic patient records, to be incorporated as key components of training for  health professionals, and led by patients
    • An improved system for eliciting, analysing and responding to patient and user feedback, including a simplified complaints handling system,  a single phone number, and a requirement for NHS bodies to respond via internet platforms
    • Greater emphasis on community development in the agendas of health commissioners, local authorities, local strategic partnerships and HW, as a means of improving public health.
    • HW representatives to be represented on national forums for  the sharing of experience and good practice
    • Continued national support for the deployment of patient reported outcome measures (PROMs) and quality accounts as mechanisms for developing a more patient-centred service.
    •  Investment in HW to support their role of monitoring delivery of the rights guaranteed by the NHS Constitution.
    • Provider pay to be more dependent on patient feedback than now.
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    The “Ten Years After”  paper from Cooperatives UK is a welcome attempt to reinvigorate the debate about the role of members in the Foundation Trust model (FT) model. There are nearly 2 million members of FTs across England – a mass membership of a size rivalling the T&G at its height, but with arguably less influence and profile than a small parish council.
     
    The 2002 Department of Health policy document on FTs stated that “the members of an NHS FT will become its owners, taking on responsibility for their local hospitals from national Government… The members of an NHS Foundation Trust will, collectively, be its legal owners. This is a real and not a paper exercise in social ownership.” In retrospect, this is about as believable as the tooth fairy.
     
    Many FT Chairs would be delighted to jettison the membership model – indeed Lansley’s “Liberating the NHS” included a plan to move to some “staff membership only” FTs, though the appetite for that swiftly dissipated.
     
    Until 2010 the membership agenda was all about size. FT applicants were constantly pressured to acquire more and more members, with no clear policy or rationale about what to do with these 100s of 1000s of recruits once they had been signed up. The main beneficiary has possibly been Electoral Reform Services Ltd, who get paid to send out hundreds of thousands of ballot papers to FT members every year, in the certain knowledge that only a small minority will even be sent back. The only concrete right given to FT members is the right to participate in governor elections – but nationally over half of governor elections are uncontested. On the minority of occasions when elections do take place, turnout averages under 20%. The ‘model’ FT election rules are so outdated that they do not permit electronic voting.
     
    Since 2010, the membership agenda for FTs has essentially been optional. In regulatory terms, there appears to be no downside to having a small or unrepresentative membership. Oxleas in South East London have around a third of the public members of an average FT but it didn’t stop them being one of the winners when the Trust Special Administrator came to town. There is nothing concrete in the Monitor Risk Assessment Framework (previously the Compliance Framework) that holds FTs to account on membership engagement. You can have zero contested elections and zero public attendance at governors and Board meetings, and it will have zero impact on your governance risk rating.
     
    A public engagement model centred around the acute and tertiary sector is clearly flawed. An involvement model predicated on affording the greatest power to those who can attend the most meetings will also gain limited traction. But there remains massive potential to be unlocked from the 2 million FT members who to date in collective terms have been virtually invisible in society. So now is surely the time to be on the side of engaging and empowering patient, public and staff FT members. There are examples of good practice in FT membership engagement which can be easily replicated. Like it or not, the tools are there to incentivise FTs to more genuinely engage their members. If Monitor set down some basic standards for member engagement in the risk assessment framework that put some hard currency – ie, the governance risk rating – on the line, then you would see action from FTs quicker that you could say “industrial democracy.”
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    SOME IMPLICATIONS FOR WELSH NHS

    In April 2013 the  First Minister, Carwyn Jones, established a commission chaired by Sir Paul Williams to independently review all aspects of Wales’ public services to see how they are currently working and how they can be improved in the future. On Monday, January 20th Sir Paul, who was formerly the Chief Executive of NHS Cymru, published his Commission’s report.

    It is a very important document which plans to fashion public services in Wales for the next generation. Due to its recent 2009 structural reform which ended the “internal market in Wales  the Commission was asked to exempt the NHS from direct recommendations. Nonetheless there are implications for the NHS in a number of its key  recommendations.

    Public Services in Wales

    The Commission’s overall view is that public services in Wales have islands of good performance. There is therefore an urgent need for these to be extended to become the norm.

    Welsh public services need greater ambition and greatly improved performance across the whole sector. We need to raise the bar to higher than being “best in Wales”. These problems run much deeper than what arises from the complexities and difficulties created by the myriad of existing structures and organisational boundaries. Transformative improvement is needed, not least because   projections anticipate that Welsh public services’ resource will decline by up to £4-5bn for the next decade or so.

    This reduction will have a major effect on the role of the state and public services in delivering “the common good”  both in terms of practical service delivery and in being an important dividing line in policy terms.

    The Report accepts that public services in Wales will not be subject to the invisible hand of  commercial and competition challenge. Consequently the  visible hand of public accountability and scrutiny must fill this gap as a means of driving performance. However this is done  very inadequately in Wales at the moment.

    Public engagement is often seen as a bureaucratic necessity which, as the Report agrees, almost invariably changes nothing. This perception is particularly true of the NHS. Scrutiny is seen as threatening and usually evokes a negative and defensive response.

    The Report recommends a move to a total integration of health and local government services in Powys on the basis that this large rural area has only community based health care with hospital services being delivered from outside its border. While earlier moves in this direction did not reach fruition, this integration should be welcomed as an important innovation which could provide wider lessons for NHS areas that do have a hospital network.

    Community Health Councils (CHCs) are recommended to continue with an enhanced advocacy role but probably with a diminished inspection role. CHCs spend a lot of time and effort on their inspection programme but it is not clear that it adds anything to the inspection programmes carried out by other regulators.  However the Commission does not acknowledge that while CHCs have been an important part of the NHS landscape in Wales for decades, they  have seriously underperformed in terms of being an effective patients’ voice.

    They do come to the fore when major service re-configuration is taking place but their day to day work is very low key and is almost unnoticed by the public. The purpose and role of CHCs is valuable but we need a better way of giving effect to it. One option is that this might be achieved by CHC functions being linked to more organically to mainstream democratic structures and processes.

    This might be a role for an enhanced CHC but also it could also be a role of a democratic body such as the local authority perhaps enhanced with third sector and other public interest groups. We could also consider an enhanced role for CHCs in social services scrutiny though there could be an overlap with local government scrutiny which would be an unwelcome duplication. Again this is an argument for an integrated public scrutiny system incorporating local government.

    A fundamental weakness in proposing democratic scrutiny of the NHS by local government is that its current scrutiny of its own services is not an exemplar of good practice. The Williams Commission makes clear that local government scrutiny must see massive improvement and the proposal to extend local government’s scrutiny role in the NHS should be seen in this context.

    The Report correctly is critical of the adequacy of the current performance of Local Health Board non-exec board members. They are appointed for their technocratic expertise but this creates a major gap in local democratic accountability. A balance  has to be drawn between local accountability and professional expertise in carrying out board duties but the Report suggests that the current balance is not right.  This seems to be correct.

    The present LHB structure ,which is the outcome of the abolition of the internal market in Wales, is correct but it needs to improve its governance performance. Too often LHB boards have the mind-set and behave like a former acute hospital trust board ( with all their weaknesses). They have not been able to incorporate the good community links that the earlier LHB boards had created, accepting that the former LHB boards were too big and unwieldy. As well they are still struggling to give effective priority to primary and community health care.

    Interestingly the Report highlighted the apparent paradox that Board members are corporately responsible for their own decision making and still have, potentially, a self-scrutiny role. It seems to suggest that the scrutiny role is not compatible with the corporate decision role. The unstated but obvious implication of that is that there is a need for external scrutiny and challenge. If this external scrutiny was to have some democratic basis it might help to fill the accountability deficit that the Commission identified.

    The Report did flirt with the idea of democratically elected LHB non-executives but it did not explore the idea in any depth. Is this something that the SHA might wish to consider though it is likely that LHB elections would resemble the Police Commissioner elections which have provided a somewhat limited popular mandate?

    The Report was very clear in  rejecting the transfer of adult social services to the NHS. On balance  their conclusions are correct even if the decision is fairly finely balanced. The Report says, as an alternative, that there are sufficient mechanisms in place to allow joint, integrated social services commissioning  and delivery. This is the case as there has been an insufficient use of these mechanisms — a symptom of the overall sluggish public service performance in Wales.

    The Report recommends closer links between the Ambulance and Fire Service. Again this is something that should be welcomed. The Fire and Ambulance service is a joint service in many countries like France and in parts of the USA. There are obvious synergies between the services though there are massive operational and cultural differences at the moment.

    Interestingly the Report is very positive about many aspects of the performance of the Fire & Rescue Service. This stands in contrast the on-going challenges facing the ambulance service. An immediate priority must be to improve the performance of the ambulance service. Nonetheless a clear signal as to the direction of travel should be given to both emergency response organisations with a medium objective of much closer integration of the two services. A key early issue in this context is the station network of both services. The Welsh Government should require that no decision on station network of either service is taken in isolation and should consider the implications for its partner blue light organisation.

    The Welsh ambulance service has been to the fore in enhancing the skills of its paramedic staff to cover conditions that are not immediate life threatening conditions. These enhanced skills do overlap with some GP out of hours work. At the moment the ambulance service is seen as part of hospital out-reach services. Consequently they are obliged to transfer their patients to Accident & Emergency Departments if they are not being brought to the hospital for admission. Some flexibility in these arrangements could allow the ambulance service to also interface with  primary care  and bring patients to that service if clinically appropriate rather than mechanically bringing them to A & E Departments.

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    Ed Mayo is Secretary General of Co-operatives UK.  This article was first published on his blog.

    Foreword

    by Peter Hunt, Chief Executive of Mutuo

    NHS Foundation Trusts have made an enormous contribution to the growth of the mutual sector in the UK. They have been a vital innovation, intended to marry public service values and entrepreneurialism with a different relationship with the public. The ten years since the advent of NHS Foundation Trusts marks a decade worth celebrating, with some outstanding successes.

    Mutuo has been involved throughout, by helping to share the experience of long standing co-operative and mutual businesses with new public service mutuals. Mutuals are defined by member ownership and control – and making membership meaningful is an opportunity and challenge shared by all mutuals, including long established co-ops no less than new fledgling public service mutuals. We have seen some NHS Foundation Trusts embrace the best practice of progressive mutuals, but there is a wider need to reawaken the founding intentions of Foundation Trusts and the spirit of mutuality. The legislative framework has not made it easier to do this and it is timely to consider how to deepen the democratic basis of Foundation Trusts for the next decade.

     Democratic Form for Foundation Trusts – the role of membership

    To mark the ten year anniversary of the creation of NHS Foundation Trusts in England this short report sets out how we can move towards a more democratic and participative model of health care through a strengthening of the role of membership.

    This could help ensure that Foundation Trusts reach the original aims that were envisioned of grass-roots membership, enabling communities to influence healthcare provision and ensuring the accountability of directors. Such a focus would be particularly timely in light of the Government’s initial response to the Francis report earlier this year, as well as the wider, ‘much-debated’ changes in the organisation of health service commissioning and provision contained in the Health and Social Care Act (2012).

    Context – a co-operative vision for healthcare

    NHS Foundation Trusts were created in 2003. It was a ground-breaking new legal structure called a “public benefit corporation” which was in part modelled on traditional co-operative and mutual societies. For the first time in the NHS, this introduced the concept of grass-roots membership (patients public and staff) for NHS organisations, together with a form of democratic governance. This was a break with tradition – and provided a new model which for the first time enabled communities through their elected representatives to influence healthcare provision.

    The co-operative sector was supportive of Foundation Trusts from an early stage, recognising that the inspiration came in part from co-operative and mutual societies. I played a role in this personally, in a former role, contributing to the formative work on the model and chairing the Department of Health Governance Advisory Group for Foundation Trusts that developed initial guidance on models of working.

    The promise that democratic engagement offers remains worthwhile. There are good examples of health co-operatives worldwide, which have been able to promote a model in which responsibility for health development lies with the citizen and they, in a group or community setting, are at the centre of action for well-being, rather than what the UK still has, which is a provider-led model of healthcare centred, above all, on acute, secondary healthcare services.

    The UK does have examples of participatory co-operatives in healthcare, outside of the NHS. Benenden Healthcare, for example, has a membership of 900,000, organised in branches with a highly democratic structure. The society has been voted the UK’s most trusted healthcare provider for three years, in 2011, 2012 and 2013. But Benenden exemplifies not just satisfaction but also responsibility. The claim rate on services is significantly lower than for private health insurers, because, rather than seeing it as an individual consumer transaction, operating as a zero-sum game, Benenden members are aware that they are drawing on support that is pooled and to be shared equitably for all members according to need.

    It is also important to recognise that there is a different experience over the last ten years, with its own positive lessons and cautions, from patient and public involvement in health and social care in Scotland and Wales.

    The Reality – mutuality in question

    Given the way in which patient focus, service quality and health development have moved into the mainstream discourse of health policy, we might expect such examples to have informed the development of NHS practice. If anything, the opposite is true. Although there are some models of good practice, most notably amongst metal health providers, the overall field of Foundation Trusts has widened but it has not deepened in terms of democratic practice and participation.

    This has not been helped by the focus of the regulator and inspectors on finance and traditional NHS professional concerns, while the widening of the numbers of Foundation Trusts has not encouraged a deepening in terms of the practice or culture of mutuality. The findings of the Francis report are relevant, particularly that there was no culture of listening to patients, the failure of the Board to get a grip of its accountability and governance structure, the lack of effective engagement with patients and the public, and the lack of transparency.

    I accept that the legislative framework for Foundation Trusts in terms of accountability has been somewhat compromised and clumsy from the start, lacking the clarity that would have combined genuine community accountability with a public purpose and ethos to shape operations in line with a national of resources, baselines and benchmarks.

    The underlying model was a simple enough concept: members elect governors who, together with a number of other governors appointed by external bodies, appoint the chair and other non-executive directors. The non-executive directors appoint the executive directors. The board of directors runs the Trust. The council of governors hold the directors to account and represent the interests of the members and the wider public.

    In practice the chain of accountability was always going to be complex. Trusts were deliberately made accountable to Parliament via the risk regulator Monitor. What’s more, the development of membership tended to be less of a priority for many trusts than the development of the governor role.

    There are some important differences from a traditional  co-operative approach. In a co-operative organisation, the grass-roots members are the “owners” and its custodians. Their role is to provide the ultimate protection of the organisation, to make sure that it continues to deliver its corporate purpose. Like grass-roots members of most corporate bodies, their role is limited to:

    • approve changes to the constitution;
    • approve strategic mergers;
    • decide whether to cease trading.

    It is recognised that public benefit corporations operate in a different context and that now these functions (the first two, at least) are the responsibility of the council of governors. However, the effect is to leave members with a more marginal role.

    The Foundation Trust Network recognises the need to support the role of governors and develop the chain of accountability from governor to trust member to the broader public, and I welcome their consistent efforts over the years to develop guidance for trusts and build capacity for wider member and public engagement and accountability. They point me to one Foundation Trust where over ten thousand members took part in voting and to some of the creative ways in which Foundation Trusts focusing on mental health have engaged their service users through membership. These are, to be sure, examples of best practice that the wider co-operative sector can learn from, just as there are outstanding co-operatives models of governance on challenges such as gender equality, with the Co-operative Women’s Challenge, and youth participation. After all, the point about participatory governance is that its effectiveness depends on the quality of participation. This is an enduring and
    persistent focus and challenge for all member-owned co-operatives and mutuals, not something somehow to be solved and then left alone.

    Overall, Monitor, the regulator report that there were over two million members of Foundation Trusts in 2011/12 and in a survey of practice that over 50% of trusts say that members have influenced what they do, on issues such as communication and the development of new services. Whether members feel as if they have an influence on what the trust does is not a question though that was asked. Ultimately though, this is what matters. Democratic accountability is not just about giving an account of what you do, but whether others know that their voice is taken into account.

    The role of membership

    I therefore argue for a reconsideration of the membership in Foundation Trusts, which I see as now having a limited role and lacking a voice. This is a cause for concern as it has a number of consequences, including making membership a relatively uninteresting proposition, with a knock-on effect in terms of recruitment and retention. This can also make governors more exposed as they lack the support or pressure of an active membership. It could also limit the range of individuals seeking
    election, thereby making it difficult for governors to represent the full community.

    The hollowing out of membership has been exacerbated by the Health and Social Care Act 2012, which required certain decisions to be authorised by governors, rather than members. While the act could have strengthened the position of members, in fact it did the opposite by requiring changes to the constitution to be approved by the governors (and directors). Previously trusts could choose for constitutional changes to be approved by their members. Public benefit corporations are now different in this respect from all other corporate bodies requiring governors to approve a range of other decisions including “significant transactions”, mergers and acquisitions, and taking on or substantially increasing the amount of private work.

    The act introduces for the first time a requirement for an annual meeting of its members. Whilst in principle this is a good thing, it does not really enhance the position of members because

    • The annual meeting has to be open to members of the public, so membership of the trust does not give anything additional.
    • Members themselves have no rights in a Foundation Trust other than the right to vote in elections of governors. By comparison, members of a company (shareholders), who similarly have the right to attend the annual meeting, have a number of other substantial legal rights such as the power to remove directors. This makes their right to attend the AGM and ask questions rather more substantial than the equivalent for members of the Foundation Trust.

    In summary, of the three core features of co-operative membership (information, voice and representation), members of an NHS Foundation Trust have representation, but patchy information and no voice as members. The role of members is therefore minimal, and membership a relatively unattractive proposition. There is therefore no real sense of “community ownership” of a trust. This either leads to an ownership deficit, or the feeling that the governors are somehow the members.

    Eight actions to strengthen membership as a form of community governance

    In order to address the fact that members have representation but lack a voice, I am making an eight point set of recommendations that form a democratic membership agenda for Foundation Trusts, in line with the original spirit of the model:

     

    1. Ensure that members have a voice in ownership and governance arrangements, and, create the opportunity for more pro-active engagement with members and communities.
    2. Develop practices at the grass-roots level to reinforce  communication between members and governors,  including access to elected governors, some right of approach and dialogue, and, the ability to require feedback and updates. This will help to ensure that governors are accountable and will compel them to engage with members and the local community.
    3. Review whether members should be included in the decisions currently under the control of governors.
    4. Insist that governors have dialogue with members on the issues upon which the Health and Social Care Act now requires them to decide, and, possibly other issues such as executive pay and patient safety too.
    5. Require Foundation Trusts to publish clear forward plans to members so that people know what is coming up.
    6. Through relevant regulatory and inspection frameworks, encourage Foundation Trusts to engage with their local communities via the AGM and other member or public events on decisions that their governors are likely to have to make in the future. When Governors do have to make a decision, they should do so as representatives of their community who are responding to their communities’ wishes, rather than on their own gut-response.
    7. Take other steps to create a greater sense of ownership. These could include consideration of measures such as the requirement for two-way dialogue, responsibility around health promotion, and, escalated complaints and feedback, as well as closer connections around
      membership with the operations of HealthWatch.
    8. Engage employees more systematically as members, for example through its own constituency, following the example of the co-operative Rochdale Borough-Wide Housing. NHS staff have a stake in and can make a vital contribution to the success of any Foundation Trust.

    Increasing and improving the role of members through representation and engagement will help to increase accountability, ensure that healthcare provision works for the area, and, recognises the importance of community to cost-effective and inclusive health development in years to come.

    The SHA produced a discussion document on Foundation Trusts in 2010 which also contained proposals to improve accountability, involvement and democracy.

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    Monday 28th October will be the date when, just like Wallace,     Mr Rory Phillips QC got up and put on the wrong trousers. Then search as he might, there was no sight nor sound of Grommit coming to the rescue.

    We now know that Lewisham has secured an historic 3 Minute Verdict victory and that Jeremy Hunt has told the Commons that he will
    respect the Courts as the final arbiter of what the law means.’
    – accepting the Court’s decision instead of continuing to try to bend and break it to his own agenda, Dame Joan Ruddock (Lewisham/Deptford) having gracefully admonished him :

    ‘Let me remind the Court told the SoS that his actions were illegal – that he lost the Appeal. Will he now leave Lewisham hospital alone and learn to respect the views of medical staff…‘   http://bit.ly/1amNdwr

    After all the words, the meetings, the marching and the fundraising – the denouement. 11.43 am on Tuesday 29th October and with Mr Phillips’ arguments in fizzled out mode, we were suddenly told by the Master of the Rolls that he and his fellow Lords Justice were just ‘popping out for a moment to see what to do next’ – and with instruction for the rest of us to stay put.  Did they want more information or had they heard enough to let us all go?

    But no –
    in less time than it takes to make a cup of tea, the 3 Minute Verdict was with us. The Government’s ultra vires Appeal dismissed – unanimously.

    The court was filled with stunned silence, the judges filed out to rows of bowed heads and then the realisation of the moment burst the silence with spontaneous applause and then dissolving into tears of shock and relief from those of us who have put a year of our lives to one side to fight on – 12 months to the day since Kershaw’s plans were revealed to Lewisham.

    Now this evening we hear that the government will not be pursuing the case to the Supreme Court – presumably at last taking sound legal advice that there will be no future in it.

    poster4hunt1-213x300  How this came to pass via the Court of Appeal makes for an extraordinary conclusion to a daily year-long fight. On 7th November, the written verdict was released and their conclusions are, to say the least, damning of the government’s actions.

    Master of the Rolls Lord John Dyson ( the second most senior judge in England ) who clearly sweeps as he cleans up all before him, was accompanied on either side by Lord Justice Sir Nicholas Underhill and Lord Justice Sir Jeremy Mirth Sullivan – whose names alone promise a degree of mental agility which was far from present in the government’s case, for try as he might Mr Phillips could not make a pig’s ear into anything resembling a piece of legal silk befitting his status.

    In his July verdict, Mr Justice Silber had given 8 reasons for his decision. Mr Phillips had obviously needed to trounce this and offered a myriad reasons for those findings as being ‘incorrect’  – as one wag in the gallery afterwards said, it was a performance which reminded him of a 6 year old being caught in the act and coming up with excuse after excuse to avoid the obvious truth from coming out.

    In Court we were dragged through paragraphs, clauses, points and sections such that even the Master of the Rolls himself declared he had too many bundles, whilst his colleague declared ‘the bundle I am looking at is even bigger than the original!’ But perhaps even worse, given the weighty bundle issue, certain key papers from the government team had nevertheless been left out. Woops.  Certainly nothing of the kind had occurred at our immaculately run Lewisham People’s Commission with Michael Mansfield QC and team.

    9173983207_c762f73642_z  Mr Phillips again returned to discussions of the interpretation of width – not of trouser sizes but of land mass. Lewisham was deemed to be ‘narrow’ whereas the ‘wide’ interpretation could seemingly refer to anything from the borough next door, to all of south east England and even to all of England in its’ entirety – ‘a complex matrix of inter-dependent services ‘ – according to Mr P, anything else being ‘half a job’.

    As David Lock QC said for the campaign – going wide would lend itself to the view, that ‘just like dominoes’, any other hospital in England could be brought under the South London Healthcare Trust TSA wing. According to Mr Rory P it ‘wouldn’t be kosher if it didn’t bring in a wider area’ – which is an interesting non clinical perspective.

    We were repeatedly assured that the TSA model is not a background route to re-configuration, but then Mr Hunt’s QC spent a large chunk of time describing the different re-configurations, whilst also plying an argument focused on how exceptional was this situation – and moreover how exceptional was the 5A TSA legislation. However it was clear that two exceptions do not re-configure into a justification.

    The judgement reads – ‘far from assisting the Appellants case, the nature of the powers conferred by Chapter 5A – a procedure that is an exception to the normal reconfiguration process that Parliament has prescribed in the 2006 Act, which must be completed within tight time limits and with limited consultation – tend to support a narrow, rather than a broad interpretation of the powers conferred upon the TSA. Parliament would have been astute to guard against conferring too broad a power which might be used as aback door approach to reconfiguration.

    Back doors clearly being left more than ajar, once again we had all found ourselves in the deceptively innocuous sounding jaws of ‘in relation to’ – even on occasion daringly extending to ‘relating to’.

    ie. trust? which trust?

     Lewisham_simon-way-2-gimped

    Context and construct were apparently all. At one point we veered across to the Local Govt Act 2000 and then rather unexpectedly down the leafy lanes of the Town and Country Planning Act. On day two Mr Phillips apologised for bringing irrelevant areas into his argument – and he did not mean Lewisham.

    The warning calls from the Judiciary Bench came thicker and faster
    ‘It’s in your skeleton!’ ( aka ‘skelly’)
    ‘We do know all this – but is it material?!’
    ‘Do you really have to continue?’

    Notably there was much emphasis from Mr Phillips on ‘the same words in the same statute may not have the same meaning’ until David Locke QC put paid to that little device with a direct quote from the appropriate guidance : ’ In relation to in the multiple meanings refers to the particular NHS body – not other NHS bodies’. Which pretty much consigned the government’s argument to the mortuary of spin – now borne out in writing where the Lords Justice state that the Appellants ( Government’s) submission that their ‘recommendations for Lewisham (in Chapter 5 of the Kershaw recommendations) naturally follow from the Chapter 4 SLHT recommendations…..attributes an unrealistically broad and ill-defined meaning to the words “in relation to”. 

    Subsquently, the Lords Justice have also chosen to reveal that Mr Phillips somewhat bottled his own ‘narrow interpretation’ argument which he had presented in his Skeleton ie. that accepting Justice Silber’s interpretation would be ‘likely to prove to be a dead letter’ – which in legal parlance is likely to mean something very impolite.

    We were even told that Jeremy Hunt sits at the ‘apex’ of our NHS – perhaps in the hope that we would feel both admiration and sympathy for his pointy end predicament – despite the H&SC Act having divested the SoS of his duty to the NHS.  Mr Hunt had apparently taken his actions empathetically ‘all for the NHS’ whilst painfully grappling along with Kershaw, all for the sake of Lewisham. Poor thing.

    Once again Mr Phillips ( plus Mr Hunt ) is in receipt of a legal rebuke within the Judgement –
    the fact that he may appoint a TSA only when he considers it “appropriate in the interests of the health service” (section 65B(2)) is misplaced.’

    Concluding that whether ‘in relation to’ was examined in the context of the 2006 Act as a whole, or in the context of Chapter 5A in isolation, – the ‘natural meaning is that adopted by Silber J.’ ie Jeremy was wrong – and indeed acted illegally.

    As Ms Laing for Lewisham Council said – ‘the TSA should have stopped at 4’, but like tumbleweed Team Hunt just kept on rolling. …

    8404507197_c69463a1d2_z

    As for the Court of Appeal’s conclusions on consultation – ie. did the Lewisham GPs and the Lewisham people have a right to flag up their dismay and fear about the plan and have their views listened to, or could their opinion legally be diluted by CCGs in Kent by the government’s nationally interconnected argument? They jointly took the decision to dismiss this element of the Appeal as irrelevant in the light of the ‘strained and unnatural’ interpretation of the ultra vires over-the-border aspect – they did though observe :

    ‘The absence of any requirement to consult any other Trust that might be affected by the recommendations is, in our view, a powerful indication that Parliament gave a TSA power to recommend action which would affect or concern or have an impact on the Trust to which he had been appointed and no other Trust’  
    saved

     

    Meanwhile – so many hospitals in London and elsewhere are now under grave threat.

    The victory won in the court by the people of Lewisham will give hope by people who are disappointed by today’s announcement’ said Andy Burnham to the Commons on 30th October  http://bit.ly/1amNdwr questioning the announcement of service closures and downsizing in North West London, a time when A&E targets in London have been missed on 48 out of the past 52 weeks due to extreme pressures on the service

    Yes, fight on we did – and when I paid a visit to Lewisham Hospital the following morning, did every single inch of it feel worth it. The Riverside building they would set up to sell off as a private concern and the 60% they wanted to demolish to use the site for private property development now felt at once less fragile and more firmly rooted in the ground.

    8419711594_5b0c547255_z

    As we also know, the government are in the midst of pursuing a Clause in the Care Bill which the laid down a week before the hearing and which would enable them to take their longed for  ‘wider approach’ – so clearly they felt wobbly at the knees with regard to the Lewisham question even before proceedings began.

    At one point Mr Phillips had said that he felt it was ‘his duty’ to introduce Care Bill Amendment 168A into the case – however Master of the Rolls Dyson immediately rebuked him, saying that it was not indeed relevant because at that point ‘the government could not be 100% certain of winning this Appeal’.  Indeed, Lord Justice Mirth Sullivan felt moved to join in with ‘one might observe it contains wording you wouldn’t use if minded to confer this sort of power in the first place’.  At which point mirth was not just on the bench but also in the public seating area.

    In judicial terms we might not be too far off the mark if we read that as being a legal ‘you cannot be serious?’ to the drafters of said Amendment 168A – lately morphed into hospital land-grab Clause 118, nestled cuckoo-like in Chapter 4 of the Care Bill, currently making its’ way through the Common http://services.parliament.uk/bills/2013-14/care.html  and despite Earl Howe’s ‘dear me no’ protests, so accurely assessed by the Court of Appeal thus :

    ‘The new clause provides that references in Chapter 5A to taking action in relation to an NHS trust include a reference to taking action “in relation to another NHS Trust”. This is precisely the kind of provision that one would have expected to see in Chapter 5A if Parliament had intended it to have the meaning attributed to it by the Appellants.’

    The Lewisham ruling and the ensuing Clause 118 are key components in the current and future re-configuration plans for the Government’s would-be dismantle of NHS A&Es and land-grab of hospitals in England – and further afield into Scotland and Wales if they can manage it. The back door having closed, the front door is under attack. The story is not over. The fight is not over.

    In the meantime please encourage your MPs to support EDM 656 http://www.parliament.uk/edm/2013-14/656

    Send letters to your local press to encourage readers to sign and circulate the 38Degrees petition http://you.38degrees.org.uk/petitions/jeremy-hunt-should-resign-and-take-his-hospital-closure-clause-with-him .

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    WANTED– A SOCIALIST HEALTH SERVICE

    An SMA discussion document. Probably 1966

    ” . . , it is essential to struggle, not merely for particular advances in particular fields, but for a socialist advance in the National Health Service as a whole.  We believe that democratic Regional Health Authorities can provide the basis for this advance and that no half measures will serve, and we call upon the Labour Movement to join us in campaigning for this end”.

    SOCIALIST MEDICAL ASSOCIATION 13 Prince of Wales Terrace, London, W.8 (WEStern 7770)

    PRICE SIXPENCE (plus postage 3d.)

    “.. it is essential to struggle, not merely for particular advances in particular fields, but for a socialist advance in the National Health Service as a whole.  We believe that democratic Regional Health Authorities can provide the basis for this advance and that no half measures will serve, and we call upon the Labour Movement to join us in campaigning for this end”.

    Trichotomy

    The-present administration of the National Health Service is chaotic, fragmented, and unsuited to its further progress.

    It arose as an amalgam of compromises with historical leftovers from a century of uneven advance in the provision of medical care.

    Its three major divisions are, first, public health through the local authorities, themselves part of an admittedly difficult structure of local government, in need of reform, secondly the personal services of family doctor, dentist, pharmacist and optician, through the executive councils which derive from a “panel”, system of insurance devised in 1911 for a section only of the population (employees); thirdly the hospital service, which is a new structure under the Regional Hospital Boards, but these are entirely undemocratic and based on nominations and (except in Scotland) separate from the powerful teaching hospitals.

    This completely unintegrated structure has many critics and few defenders, yet without a clear perspective for a reformed structure little progress is made in campaigning for a change.  It is the task of socialists and the working-class movement to work out the necessary, policies, for, as the Socialist Medical Association has always proclaimed, the health of the people is the responsibility of the people themselves.

    Divisions

    Apart from the divisions broadly outlined above, there are many other aspects of social policy which profoundly affect medical care. The drug industry is in private hands and the development of new drugs, prescribing habits, costs, and the attitude of the public (for example, in seeking medication for real or imagined ills instead of developing preventive medicine) are all factors influenced by the search of drug firms for profits, and are not necessarily in the public interest. Quality and design in other supply sectors, from dental equipment to hospital beds, are also in private hands.

    Broader social problems of behaviour, which a unified health service would have to take account of and actively influence, and for which in the present situation the Ministry of Health cannot deploy any coherent programme, should also be borne in mind.  Thus the safety design of vehicles (it is only now that safety belts are compulsory, but general design, speed, drink and driving, psychological attitudes of driving, are other factors which could be mentioned) is of vital concern to orthopaedic surgeons who have to deal with accidents.  And, looked at generally, we are still waiting for a coordinated accident service.

    Housing has enormous effects on health.  There is not only design (e.g., for old people) and questions of priorities, but the effect of slums on health, which is counted socially in broken homes, delinquency, increased illness, even lead-poisoning in children from the crumbling plaster of old houses.

    Health and safety in workplaces is the responsibility of management, that is, in private hands, and a diversity of Government departments shares the task of enforcing the legislation on safety, itself inadequate,  This entire aspect of health is at present a vacuum so far as the NHS goes.

    No planning

    Finally, despite the growth of studies and research in costing and efficiency, largely in the hospital service, and apart from the basic need  for an increased global sum to finance the NHS, where shortages are producing a state of quiet desperation in every sector of the service, the question of priorities remains, and would remain even in a socialist society.

    Is it better to have a new cobalt bomb for treating cancer, or a new geriatric ward? Six research teams are seeking funds for questions ranging from study of a rare disorder to the sociology of the reasons for illegitimacy. Who decides? Such decisions should not be made except in the context of an informed and actively concerned public, so that the issues involved are looked at from every point of views for what seems to be only a technical problem of allocating funds is often a profoundly political one.  Great glamour may accrue to a new artificial limb system — but the thalidomide disaster was in large part a failure, to insist on proper controls for drug development — an apparently mundane and even “negative” affair,

    The Community is responsible

    These considerations should serve to show that a new and democratic structure for the NHS must develop from the basic principle of community care, and community health.  At present there are as many health services as health workers, for each sees the NHS locally and narrowly as his place of work, as a means of livelihood, and not as the instrument for service to society.  Each patient also has his own NHS, which is to serve him (people speak of “my General Practitioner”) and complains when he has to wait, unconcerned with the wider problem of society’s needs and his own duty to help solve it.

    The recognition of social responsibility as the keynote for administration would also need to take account of the extent to which the priorities of the NHS are distorted by the class structure and inequalities of wealth in society.  For this reason alone, participation by the Labour Movement is vital,

    A few examples of this distortion will help to show the changed emphasis required.

    Thus the private sector in medicine should be clearly separated from the NHS.  Private beds in NHS hospitals divert scarce resources, corrupt the attitudes of the medical profession, and serve as a method of queue-jumping,  Through the maintenance of part-time consultant appointments the loyalties of specialists are divided between private and public work, and even within MS hospitals this helps to scatter their energies between different hospitals.  All this is to the detriment of the working class, and to the planning of comprehensive services and the elimination of waiting lists (that this can be done has been shown notably by the Oxford RHB).

    Even in the use of hospital beds it was shown by Cartwright (“Human Relations and Hospital Care”) that higher income groups had a favoured admission rate and use of hospital facilities because of ease of communication with doctors, and their superior “know-how” on getting attention.

    The NHS has decreased the disproportion in resources going to well-to-do areas, which in pre-1948 days left many industrial areas devoid of whole departments and specialities in medical care, but prestige teaching hospital projects are still favoured, and the disproportion is by no means overcome.

    Similar examples of the better use by middle and upper class sections of such facilities as family planning, ante-natal clinics, the new cervical screening test, and general practitioners, are well known.

    In the perinatal mortality survey it was clearly shown that the use of medical facilities was in inverse relation to the need for them, the sections of the population with the highest perinatal mortality making least use of proper ante-natal care, being attended later in pregnancy, and being booked less often for hospital confinement.

    These defects can only be overcome by planned health education, involving participation in running the NHS by much wider sections of the population.

    Integration necessary

    Now for some examples of an integrated approach in medical care.

    First, family doctors.  Here, despite the changes of the “Charter” which abolish the “pool” system of payment and attempt to relate payment more accurately to work done and expenses incurred in running a practice, general practice remains fragmented.

    Under the ten-year local authority plan, ten times as many health centres will be operative in 1974 as in 1964, but this is still only ten per cent of general practice.  GPs remain out off from community care (mental health, social work, school health, occupational medicine, health education).  It will be very difficult to apply new computerised systems of epidemiology, diagnostic aid and information retrieval without standardised and organised, family doctor units. GPs remain cut off from hospitals too. Many are still denied X-ray and pathology facilities and certainly under-use them.  Most have no access to physiotherapy. Only a third attend refresher courses, and the organisation of post-graduate, medical education (apart from the College of GPs which is in any case a private body) is largely out of their hands. Separation from hospitals has aided the neglect of general practice by teaching hospitals.

    New screening programmes, health checks and pre-symptomatic diagnosis are all fields eminently suited to general practice at present being developed outside it with difficulties therefore in co-ordination, in dealing with treatment for cases discovered, and in evaluating results.

    It is easy to see how a unified administration could bring these threads together and raise the status of general practice, but this demands health centres as a pre-condition.

    A second example is the reports of the Select Committee on Maternal Deaths.  Each death associated with pregnancy is analysed for avoidable factors, and in nearly half the cases these are found. This is related to the confusion of three different authorities responsible for the care of the expectant mother.  For instance toxaemia, if diagnosed as soon as it develops, as the monthly (and later fortnightly or weekly) readings of blood pressure are designed to do, can be treated.  Failure to attend for check-up may result in dangerous delay in treatment and this is in fact a major reason why toxaemia still heads the list of causes of maternal deaths.

    Division of responsibility for maternity care leads to wrong bookings (e.g. for home instead of hospital confinement) and has delayed the extension of the scheme for discharging women 48 hours after confinement — for there is no unified midwives’ organisation for after-care.  Auxiliary midwives resent having care of the woman only after labour, and hospital midwives the extra pressure of an increased hospital delivery rate.

    Again in geriatric, care, it is of the utmost importance that appropriate action be taken immediately, before irreversible changes occur. Thus an old lady may fall and, although there is no fracture, take to her bed through pain and shock.  If she is not to be bedridden, welfare services, perhaps new housing, or a local authority home, a short term admission to hospital for rehabilitation, possibly psychiatric advice, may all be required.  Each is differently administered, and can only co-operate or assess priorities on an ad. Hoc basis. No one has responsibility for seeing that some­thing is done, least of all the GP who is supposed to be in command.

    In particular, the hospital may demur at an admission which would “block” a bed for acute illness if the patient may not be able to return home, whilst the local authority may feel unable to cope with a “frail” person, or simply administer its waiting list on a different set of priorities. These difficulties are of course exacerbated by an overall shortage of money and places, but this is not the only question.  Parochial boundaries, narrowness of outlook, and accountability to different authorities and different paymasters are very important in causing delay.  The different pockets used to pay different sections of the NHS is well brought out in the strictures on GPs to cut prescribing costs.

    A major cause for the rise in drug costs is the use of new expensive remedies which may in fact keep patients out of hospital, e.g., in treating old people with heart failure or bronchitis, and so save hospital costs of £40 or more a week.  But this saving of course is from another source.

    Similarly, in the provision of medical care for new towns, planners have great difficulty in getting the various parts of the NHS together, and “Moreover, even if they do agree, the money necessary for the buildings and their maintenance and running costs is still difficult to obtain.  Often it can be found only by persuading the various interests to contribute roughly in proportion to the use they would make of the services” (British Medical Journal, October 30. 1965)

    From Ambulances to Medical Education

    These examples can be multiplied to cover every aspect of medical care, whether in provision of ambulances (see the 1964 Confederation of Health Service Employees’ resolution to the Trades Union Congress calling for a unified national health service), in standardisation of records (it took four years for a committee, which reported in 1965, to recommend standard records — for hospitals only — to be implemented by 1968), in psychiatric care, follow-up and after-care, the provision of community services such as rehabilitation, hostels, day-centres, social centres, social workers, regular medical supervision.  All demand integration of in-patient (and here the separation of mental hospitals from the general hospitals is long outmoded), local authority and general practitioner.  Only where local initiative has overcome inertia has anything been done to make a reality of comprehensive psychiatric care.

    Finally, the whole structure of medical education (as detailed in the SMA evidence to the Royal Commission) should be recast, so that education serves, the needs and uses all the resources of the NHS. The teaching of all health workers would similarly be brought within the orbit of the NHS.  The special colleges would no longer grant degrees or determine career structures.  Students must be involved in planning and operating the courses.  All hospitals, not just the present unrepresentative teaching hospitals, must be used, along with- greater emphasis on psychiatry, general practice, preventive, occupational and community medicine.

    Undoubtedly the fragmentation of the health service is exacerbated by, and a potent cause of, disunity within the medical profession.  The various fields of work, wherein it is possible to function only collectively, appear to individual doctors as antagonistic.

    Many aspects of medical care can only be dealt with if this disunity is consciously overcome, for institutions in society embody social values and attitudes which can be changed only by an open struggle against these institutions. Thus the emotional element in illness, and the presentation of stress as illness (so-called psychomatic disease) demand a coherent response from doctors, an acceptance of collective responsibility.  At present it is far too easy to pass the buck, to refer the patient, to fob him off with drugs alone, to submit to pressures by the patient to play doctors off against each other.  Patients also fail to accept their commitment, fail to keep appointments, change doctors without good ground or go from one hospital to another, fail to carry out treatment, use money to get their own way.

    Similarly, problems of casualty and emergency work, night and week­end services, over-prescribing and self-prescribing, chronic diseases with social implications, drug addiction, problem families, the continued care of patients with any complaint referred to hospital and thus removed from the GP’s sphere — all these problems demand a unified medical profession.  This disunity is expressed in quite separate pay structures and careers, which itself engenders suspicion and jealousy.  The basis of employment for doctors in the NHS must be a unified, salaried, wholetime service, as the SMA has always believed, and this single career structure would cover GPs, hospital doctors, teaching, public health, research, industrial medicine, and administration, and would involve increments for  responsibility and special factors.  Without this, doctors will never be able to accept the status of member of a health team and a trade union approach to the working of the NHS, for temptations to a special “contractual” (professional) attitude will inevitably lead to hierarchical values and a predilection to private practice.

    Not a formal problem

    This long introduction serves to show that the structure of the NHS is not formal. On the contrary, the entire range of relations between society and individuals, and society and health, is involved.  The question of control in the NHS is not the right to have representatives, but collective control, the development of collective methods of work, of collective structures to elect representatives with right of recall, with full reports of decisions, and a constant and informed debate on the issues in medical care.  And as responsibility for the patient remains with the individual health worker, the democratic structure of the NHS must retain local initiative, down to health centre and hospital ward.

    Our answer

    The NHS should be based on Regional Health Authorities.  In the reform of local authority structures at present under consideration it is obvious that questions of scale, planning, finance and staffing all point to the necessity for large Authorities of the size of the Greater London Council or at least the larger RHB areas.  It is not necessary to enter the discussion as to the form of Regional Government that may be adopted. There seems little point in creating them as miniature parliaments.  From our standpoint, a Regional Health Authority could be set up without a Regional Government at all, and indeed such a government could be a co-ordinated structure derived from the autonomously functioning parts responsible for health, education, transport, housing, etc., rather than the other way round.

    The local authorities, as first tier of this two-tier structure, would presumably retain much more their present irregularity of size and area, but based on historical and geographical reality, and thus a sense of local identity.  Elections from these smaller authorities (corresponding to boroughs, etc.) in proportion to population would provide one section of members for the RHA.

    Workers’ control

    The health workers would elect further members, and here new organs would be required for the elections.  All employees of the NHS would form the electoral body, based on workplace and on area.  The proto­type for this exists in the Joint Consultative Committees which are set up under Whitley Council machinery to provide for consultation between management and staff on conditions and running of the hospital.  Very few meet regularly, or have any effect, since they have no statutory powers. We suggest that they should have powers to form management, along with the present managerial section (hospital secretary, representatives of the community, as in the hospital management committees) and that they should elect members to the Regional Health Authority.

    This covers roughly the interests of the public and the worker, but two further sections need representation.  First, the trade unions and Labour Movement should have a number of members they elect.  It is not enough to appoint a Socialist Chairman to have a Socialist Regional Health Authority.  Working-class values, which alone can express the experiences which called the National Health Service into being, must be present.  Secondly, there are many voluntary bodies which represent patients with specific problems (St. John’s Ambulance, spastics, diabetics, alcoholics, AIMS, Mother and Child Care Hospitals, Patients Association, National Cervical Cancer Prevention Campaign, ate.).  These also should elect members.

    There is also the question of ultimate responsibility, through the Minister of Health, to the public for a national service (or at any rate to the Treasury).  Here one or two members might still be nominated, but only for, say, three years, to represent this.  The Chairman, however, should be elected by the Regional Health Authority committee itself.

    How it will work

    The Regional Health Authority, then, will act

    1. as agent for the Minister;
    2. the planning authority;
    3. the employing authority.

    It will plan resources and priorities, have a budget extending over, say, five years, use bulk buying (and develop direct ownership of supplies and ancillaries, direct building, etc.).  It will plan research both clinical and operational, develop record-keeping and statistical methods, and regional facilities for rehabilitation, convalescence, special clinical departments and centres, alcoholic, drug addiction and other psychiatric units, accident services, blood transfusion, and so on.  It will be responsible for medical education and post-graduate education through regional centres.

    As an employer, the Regional Health Authority would be responsible for career structures, for paying for further education and qualifications, guaranteeing security of employment, stability of administration and development of training for all grades of staff, including administrative. There has to be a balance between a stable structure and the need to ensure flexibility and mobility of staff, providing variety of experience and new ideas and people between regions.

    Area Health Boards

    At the day to day level, under the Regional Health Authority, actual medical care would be carried out by Area Health Boards, made up with as little dislocation as possible of existing organizations from local medical committees, local health authorities and hospital management committees, but with the perspective of transforming this, as health centres develop, and as the joint consultative committees get under way.  The final aim is a system of self-management, involving all the workers in the health industry, at this day to day level. So in a health centre the doctors? dentists, pharmacist, nurses, clerical staff, etc., would all meet from time to time to determine the policy and consider all matters affecting that centre, and also elect representatives to the Area Health Board co-ordinating the health centres, hospital and remaining local authority services, within the local community.

    The Regional Health Authority would nominate a number of specialist advisory committees to deal with various technical aspects.  Thus a cervical screening campaign might need a gynaecologist, pathologist, medical officer of health, general practitioner, social-workers, etc. Or in occupational health, medical, managerial (of factories), trade unions, safety engineers, inspectors and so on (i.e,, a full Occupational Health Service as part of the. National Health Service). We must emphasise here the vital role of workers and statutory safety delegates.

    Welfare Departments

    A parallel discussion on the provision of welfare services is at present going on, with the usual paraphernalia of Royal Commissions. Again, the important and central issue is the integration of the at-present fragmented social services and, perhaps even more important, though not clearly stated, the question of direction.  There are arguments about whether a new welfare service should be part of or separate from the National Health Service, whether doctors or social workers should be in charge, how large the departments should be, and so on.  A further consideration, which the SMA Social Workers’ Group has been at pains to point out, is the trend towards using the social services to cover up deficiencies in the existing system and to compensate for poverty, instead of using the skills for which they were trained.

    In our view, it is essential to have a co-ordinated, efficient, unified welfare department, which would correlate the work of different social workers so that duplication is avoided; provide a satisfactory career structure and enable those in-need to go straight to a single centre for help instead of being harried from pillar to post.  Moreover many problems are multiple: a family may need educational, child care, probation, financial and housing help, etc., for different members of the family or at different stages of a crisis.  The very varied services for psychiatry (after care, child guidance, special schools, mental subnormality, day centres and hostels, sheltered workshops, etc.) or for old people (laundries, meals on wheels, libraries, health visitors, day centres and clubs, health clinics, etc.) similarly range widely.

    A unified social work department could function locally, alongside the health centres which combine family doctor and local health authority work, both under the Regional Health Authority.  They could share a management service section dealing with finance, development programmes, staffing, registers (and specific registers for groups at risk). The social work units would be directed by professionally qualified people, and combine all fields of social work, but be able to work with health workers through direct contact in health centres where needed.  Again the formal structure is less important than the principle of enabling the people working in a field to make decisions about work and to do so as parts of a comprehensive health and welfare programme for the community.

    A socialist perspective

    The problems of providing medical care in our society are complex, and it is easy to try to 1ook at them one by one, to devise ten-year plans for hospitals, new looks for general practice, or encourage research on an empirical basis.

    This is a terribly wasteful and irrational way of using medical resources for, as society grows in complexity, the inter-relatedness of all its parts, its dependence on social production and social values, becomes ever more apparent.  Moreover, without a clear perspective and a sense of participation in whatever decisions and orders of priorities are made, disillusionment and cynicism become prevalent, and health workers become aware that all too often lack of resources and poor organization make heroic efforts seem a waste of time.

    This is why it is essential to struggle, not merely for particular advances in particular fields, but for a socialist advance in the National Health Service as a whole. We believe that democratic Regional Health Authorities can provide the basis for this advance and that no half measures will serve, and we call upon the Labour Movement to join us in campaigning for this end.

    SUGGESTED FURTHER READING

    SOCIALIST CHARTER FOR HEALTH — a comment on the BMA “doctors’ charter”, and a general survey and analysis designed to set the stream of socialist thought for many years (l/- post free printed)

    THE CASE FOR HEALTH CENTRES — the brilliant and widely-quoted summary of the socialist case for the reorganization of general practice from health centres (l/- printed)

    A SOCIALIST VIEW OF SOCIAL WORK — Socialist social workers consider         the history and present position of social work in Britain, and suggest ways in which existing services can be extended and improved (1/6 post free printed)

    POVERTY AND OLD PEOPLE — Drs Janet Posner and Geoffrey Richman present a discussion document and a programme for action (9d. mimeographed)

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    Do we need more democracy in health?

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

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

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

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

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

    What do we mean by democracy in health?

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

    Who has  voice & power in health?

    Who has voice & power in health?

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

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

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

    Parliament for Health

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

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

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

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

    Parliament for Health Powers:

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

    Health and wellbeing board

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

     

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    The most fundamental issue raised by the Francis Report on Mid-Staffordshire Hospital is not about institutions or even culture but about voice and power: who is heard, who is silenced and who, tragically, dies from deafness.   Lack of voice was also at the centre of earlier scandals at Alder Hey, the Bristol Royal Infirmary and Winterbourne View Hospital. It will arise again from the many of the inquiries into other scandals emerging from whistle blowers and patients.

    Democracy is the missing dimension in the health debate. When the founder of the NHS Aneurin Bevan said “The sound of a bedpan falling in Tredegar Hospital would resound in the Palace of Westminster” he did not mean Whitehall targets for catching bedpans. He meant that patients would be heard by politicians. We now know that the system is incapable of hearing the people who use and pay for the service, and that thousands have died prematurely as a result.

    The Francis Report said “It is a significant part of the Stafford story that patients and relatives felt excluded from effective participation in the patients’ care.” (§1.17, p46) The public had “no effective voice – other than CURE – throughout the worst crisis any district general hospital in the NHS can ever have known.” (§1.23, p47). But just 14 of Francis’s recommendations refer to patient participation on boards or inspections, the accountability of commissioners, role of MPs and organisation of Local HealthWatch. These are useful, but cannot address the profound lack of democratic accountability, involvement and scrutiny in health policy and provision. To address this, patients, carers and the public need a stronger voice at the frontline, where services are provided, and also at the very top, where the design, priorities and funding for health and social care are decided.

    Ann Clwyd’s description of her husband’s death “like a battery hen” in Cardiff’s University Hospital and the “hundreds and hundreds” who have written to her show the tragic consequences of not listening. Numerous inquiries such as Alder Hey, the Kennedy inquiry into deaths in Bristol Royal Infirmary and Healthcare for All  about people with learning disabilities have produced volumes of recommendations for changes in organization and culture of health services, yet the problems persist because they cannot be answered by institutional measures alone.  Tragically the problems won’t be solved by Francis’s 290 recommendations in his 1,782 page £13m report, because the fundamental issues are about power, voice and human relationships that are at the heart of health care.

    This paper makes the case for a National Health Forum or “Parliament for Health” to give organisations of patients, civil society and other interests in health matters a powerful voice at the highest level, above the bureaucracy of the Department for Health and the NHS Commissioning Board, advising Parliament and the Minister on all health matters. It also calls for local health services to be accountable to an inclusive representative forum linked to local councils and more representative and accountable boards for individual services as part of a wider democratisation of health.

    The following section shows why we need a “Parliament for Health” and in part two shows how it would work, followed by a diagram showing how it would fit into existing structures.

    Why we need a Parliament for Health

    The Francis Report and Ann Clwyd’s experiences are just the latest horror stories about failures in our health and care services. NHS staff are in contact with over 1.5 million patients every day, most of whom get good care and 90% are satisfied, too many people have a bad or even terminal experience through mal-treatment, neglect or hospital acquired infections. More bad news will be revealed as new inquiries are held, whistle-blowers defy gagging orders and more patients’ tell their stories.

    Our problems in health are much wider than leadership, management and organisational culture of NHS institutions. Services are just the most visible part of health care. It also includes the way we look after our own health, how we care for each other, where we work or the lack of work as well as the food, drink, tobacco and other drugs we consume and the influence of our peers. Our largest healthcare provider is not the NHS but families, who deal with everyday health of children and the sick as well as long-term care of elderly and disabled people.

    These issues present problems which cost more lives and misery than mismanagement at Mid-Staffordshire or any other hospital.  Decisions about funding priorities and the allocation of resources are critical for health outcomes in families as well as hospitals. We spend about £1,700 per person per year on health services through taxes, £106bn in 2011. Indirect costs of ill-health are about the same, another £100bn a year or £1,600 each. Add to that the soaring cost of personal care, the lack of support for carers and the value provided by six million unpaid carers (variously valued at £23bn to £119bn, and we have a very complex picture for the state of health in Britain.

    If the NHS were a country, its £106bn budget would make it the 55th largest country in the world, about the size of New Zealand or Vietnam in terms of GDP. It would have a seat at the UN (it is represented in the World Health Organisation, WHO) and its civil service, including the NHS Commissioning Board, Monitor and other bodies, would be answerable to citizens through Parliament. Instead, it accountable to appointees answerable to the Secretary of State who alone speaks for us all.

    Many urgent issues need to be dealt with in our health services. Some are strategic and others local to an area or institution. But strategic decisions create the framework for the whole system and set the conditions which allow tragedies like Staffordshire and Cardiff University Hospital to occur. The radical changes now sweeping through the NHS combined with rising demand and resource constraints will create many more conflicts over service closures and access to care. These strategic decisions are political, about the priorities, structure and funding for every aspect of health, including the balance between prevention and cure, personal and collective responsibility, or between environmental, societal and medical factors.

    Health is one of many areas where our political system has failed for decades and Governments have kept people powerless to do much about it, as whistle blowers in the health service show. Our centrally run health service gives Ministers the illusion of control, so we have had decades of ‘start-stop and start again’ health reorganisations which make it harder for people themselves to take part in creating the provision for health they need.

    Successive Governments have grappled with the complexity of preventative health, primary care, hospitals, nursing, the cost and effectiveness of medicines, social care, mental health, an aging population, addiction and myriad issues that affect our well-being. Since 1974 the NHS has been almost continuously reorganised in pursuit of better patient care, greater clinical leadership, devolved responsibility and less bureaucracy. The objectives have been largely consistent, but Governments have taken us on an expensive rollercoaster, plunging and twisting through GP Fundholding, Care in the Community, Family Practitioner Committees, Primary Care Groups, Primary Care Trusts (PCTs) and now Clinical Commissioning Groups (CCGs). While some interest groups (GPs, consultants, dentists) have done well out of this mystery tour, many others have not, the public is losing out, and the cost is enormous. There has been almost no democratic debate the proper framework for health, including the balance between public and private providers, between civic and personal responsibility or the role of employers and business. We have focused too much on publically funded institutions and ignored the bigger role of other factors.

    The Francis Report will be added to the shelf of recommendations and another transitory Government will give the NHS another shake. Some improvements may occur, if we’re lucky, but many problems will persist and some will get worse because political attention and resource is elsewhere: when you turn the spotlight on one problem, the rest are left in the dark. Some things may get better due to lack of interference, while others get worse through neglect.

    Most battles over health reform are among politicians and the professionals. The public is rarely involved in difficult debates about how to balance priorities between prevention, primary care, social care, hospitals or our £9 billion annual drugs bill  (2011), except when mobilised to fight over a particular hospital, treatment or reorganisation.

    Whatever the rhetoric, the public has barely a token voice in how we look after health as a society and how services are provided. Formal participation has been channelled through a succession of weak bodies, from Community Health Councils (1974-2003), Patient Forums (2004-8), LINks (Local Health Involvement Networks, 2008-2012) and now Local HealthWatch. There is a tiny amount public participation through representation on health trusts, and more active involvement through fundraising, self-help groups, volunteering and charitable provision such as hospices, but these are largely excluded from decision-making and ignored if they go against the professionals’ wishes. In many areas the voluntary sector, PCTs or local councils have forums for health and social care, which comment on decisions but are powerless.

    The 1974 NHS reorganisation created Joint Consultative Committees (JCCs) to promote joint planning between health and local authorities, but they did not have the power to be effective and were abolished. Now the Government is setting up local Health and Well-Being Boards which will face similar challenges and even greater financial pressures than those which undermined the JCCs in 1974 (see Health and wellbeing boards: system leaders or talking shops?).

    When the Coalition Government ran into political difficulty over its health service reforms, it set up the NHS Future Forum, a group of health experts led by GP Professor Steve Field, but barely two or three of its 55 members represented patients or the public. It listened to more than 11,000 people face to face at over 300 events as well as engaging with people online, but then public involvement stopped. Then it is set up the Nursing and Care Quality Forum for another burst of consultation.

    But Ministers and Parliament do not have the time or capacity to give health matters the sustained scrutiny they need, nor to develop the political framework which balances all the different issues and interests involved in health and well-being. What we need, therefore, is a permanent “Parliament for Health” to grapple with these issues in public. A Parliament for Health could have directly elected representatives (MHPs) or be indirectly elected from local Health and Well-Being Boards and other stakeholder groups, with a majority of from civil society, to ensure that the people are in charge of the professionals, as it should be in a democracy. Part two describes how it could work in more detail.

    If all health-related policy and legislation had been systematically scrutinised by “Health Parliament”, with a majority of representatives from patients and the public, feeding into the democratic processes of Parliament, Governments would not have been able to lurch from one reorganisation to another. Sustained public dialogue between interest groups involved in health, including the public, is more likely to have created better patient care, greater clinical leadership, devolved responsibility, less bureaucracy and greater emphasis on public health, health promotion and well-being. Problems like those at Staffordshire, Cardiff’s University Hospital, Alder Hey, the Bristol Royal Infirmary, Great Ormond Street and elsewhere are much more likely to have been raised by “Health MPs”, listened to and dealt with than the regulators who have clearly failed.

    An effective Health Forum would be more challenging than the countless consultations, advisory groups and forums run by Whitehall and the NHS, and probably cheaper to run. It could also be a place where issues are discussed frankly and in depth, bringing a wider range of knowledge and experience to bear on policy decisions. It could even make expensive inquiries like Mid Staffordshire, Healthcare for All or the Kennedy inquiry unnecessary, because it would give people a powerful platform above the bureaucracies, linked directly to Parliament.

    How would a Parliament for Health work?

    A representative National Health Forum within our system of Parliament could bring together representatives of stakeholders concerned with different aspects of health. I suggest that at least half the membership should be representatives of patient groups, democratic organisations of civil society and elected representatives from other tiers of government, including parish and local councillors and MEPs; about a quarter could representatives of staff and professional associations, and the final quarter made up of researchers and other stakeholders. It could be co-chaired by back bench members of parliament from health related select committees. In time it could have directly elected ‘Health Representatives’ as part of to a new kind of second chamber, bringing a wider range of experience and expertise into the political process. But MPs could set up a “Health Parliament” or Forum now, as an extension of the Select Committee to strengthen their oversight of health matters.

    A Parliament for Health should have statutory rights to discuss all legislation that impacts on their health, to conduct investigations into the implementation of policy and report directly to the House of Commons through Member of Parliament (the Co-Chairs). It could have the following tasks:

    1. Propose national priorities in health, for the NHS as well as public health;
    2. Hold the NHS Commissioning Board, Monitor and other strategic health bodies to account on behalf of Parliament (which should have the final say);
    3. Scrutinise the work of our representatives on the World Health Organisation, EU Council of Health Ministers, the Food and Agricultural Organisation (FAO) and other international bodies which influence health;
    4. Promote dialogue round critical issues raised by the Francis Report, the Bristol Royal Infirmary inquiry and other investigations, and scrutinise their implementation;
    5. Recommend priorities for research and development in health policy and provision;
    6. Organise public consultation on proposals by the Government, taking consultation on major health matters from the NHS and Whitehall;
    7. Pre-legislative scrutiny of proposed bills before they are presented to the Commons, to draw attention to health implications
    8. Scrutinise and revise legislation through a “public reading stage” before the second reading in Parliament;
    9. Contribute to consensus building, where appropriate;
    10. Advise and assist on policy implementation;
    11. Monitor implementation of all policies that affect health;
    12. Review and evaluate the impact of legislation.

    Failures in the NHS are symptoms that Parliament does not have the capacity to exercise democratic oversight and accountability of health services. The Health Select Committee does an excellent job, but it does not have the time to address the vast range of issues and variety of institutions which make up health provision. A Parliament for Health (or National Health Policy Forum) could dramatically increase the knowledge and experience to inform health policy-making. The Forum would be a permanent consultative body, with part-time members, elected for perhaps seven years, longer than a Parliament.

    To increase public access and participation, most of its work could be done through a mixture of working groups, open public meetings and online forums. The whole Forum could meet to conclude a “Public Reading Stage” of relevant legislation, to discuss major issues like those raised by Mid-Staff Hospital or contentious policy areas like addiction, inequality in health, obesity, hospital reorganisation, major health bills or other critical issues.

    The Government’s proposal of a Chief Health Inspector may be a useful lightning conductor for failings in future, but over a million inspectors go into the NHS every day – patients, their families and frontline staff. They are also the people who will make most difference to the health of the nation, in homes, workplaces, shops and streets as much as in waiting rooms, wards and surgeries. We are the people who determine what happens to our health, we pay for it through our taxes, and we deserve better democratic accountability from bottom to top to make sure that health services and support meet people’s needs with care.

    If the Government wants to address the deeper issues in health, it needs to look beyond the institutional matters raised by the Francis Report and give the public, patients, professionals and researchers a forum to scrutinise everything that concerns health and wellbeing to support the Select Committee system and strengthen our Parliamentary democracy and our health.

    A National Health Forum will not be enough to strengthen democratic development of health. Local Health and Well-Being Boards need to have greater democratic legitimacy and oversight of all provision for health including hospitals and primary care to look at the actual needs for health and balance of priorities in each area. Access to exercise, parks, playgrounds, fast-food and pharmacies can’t be separated from decisions about GP practices or A&E services. Each hospital, health centre and clinical service also needs a board with independent representatives of patients and the community. By deepening democratic dialogue about health and well-being at all levels we can share responsibility for a healthy society to flourish.

    Titus Alexander, Convenor, Democracy Matters, writing in personal capacity

    Email: titus@democracymatters.info   Tel: 077203 94740

    The table shows where a National Health Forum would belong in the current structure of health services.

    NHS 2013

    A ‘Parliament for Health’ is one of 12 Citizen’s Policy Forums proposed to deepen Parliamentary democracy.

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