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Date(s) - 16.07.2013


GMB Office


The most fundamental issue raised by the Francis Report 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 and Winterbourne View. Lack of voice is also the reason why carers and informal health are neglected, and why health services have been repeatedly reorganised.

Democracy is the missing dimension in health. 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.

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.

It is worth remembering that NHS staff are in contact with over 1.5 million patients every day, most of whom get good care and 90% are satisfied.  Over a million inspectors go into the NHS every day –as 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 ensure that services and support meet people’s health needs with care.

If the NHS were a country, its £100bn+ budget would make it the world’s 23rd largest state by expenditure[1], after Turkey but bigger than Greece or Indonesia. It would have a seat at the UN (it is represented in the World Health Organisation) and its civil service would be answerable to citizens through Parliament. Instead, it accountable to appointees of the Secretary of State who speaks for us all. In technical terms this is democratic centralism or, as Quentin Hogg famously called it, an “elective dictatorship”.[2]

Dictatorships are inherently suspicious of democracy and civil society, which are self-organised and independent. Our largest healthcare provider is not the NHS, but families and the community who deal with everyday health of children and the sick as well as long-term care of elderly and disabled people.

To deal with the complex factors which influence health and well-being we need a decision-making structure which makes connections and involves people in the decisions about policy and priorities, instead of one that fragments services responsibilities, creates competition and treats people as health consumers rather than agents whose actions influence health outcomes.

The public has barely a voice in health. 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. The 1974 NHS reorganisation created Joint Consultative Committees (JCCs) to promote joint planning between health and local authorities, but they had little power and were abolished. Health and Well-Being Boards which will face similar challenges and even greater financial pressures (see Health and wellbeing boards: system leaders or talking shops?).

Addressing the democratic deficit

Ministers and Parliament do not have the time to give health the sustained scrutiny needed, nor to develop the political framework which balances all the different issues and interests involved in health and well-being. The radical changes now sweeping through the NHS combined with rising demand and resource constraints will create even more conflicts over service closures and access to care. Since strategic decisions have been delegated to Clinical Commissioning Groups and NHS England the new regime could turn many more MP’s into ‘consumer champions’ for local services and make strategic decision-making even more difficult. Whoever wins the next election is almost certainly going to start yet another reorganisation to address the conflicts built into the new regime.

My plea is that this starts with a broader, more open accountable and democratic process to ensure that the public can influence provision for health better.

Most decisions about health need to be taken at a local level, so we need some kind of integrated democratic oversight of Clinical Commissioning Groups and Health & Well-Being Boards which is also connected to strategic decisions about housing, the environment, community development and other factors which influence health.

At a national level we need a “Parliament for Health” that brings together representatives of stakeholders concerned with different aspects of health to address these conflicts and bring a wider range of knowledge and experience to bear on policy decisions.

How would a Parliament for Health work?

A National Health Forum or “Parliament for Health” could be created within our system of Parliament to advise MPs and Ministers on all matters relevant to health. 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 MPs’ as part of to a new kind of second chamber, bringing a wider range of experience into the political process.

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

Its work could be done through a mixture of working groups, public meetings and online forums. The whole Health Forum might meet to conduct a “Public Reading Stage” of laws that affect health, discuss issues like those raised by Mid-Staff Hospital or tackle contentious policy areas like addiction, health inequalities, obesity and hospital reorganisation. This would replace the countless consultations, advisory groups and forums run by Whitehall and the NHS. It would probably cheaper to run, much more effective and could make expensive inquiries like Mid Staffordshire, Healthcare for All or the Kennedy inquiry unnecessary.

If we want to address the deeper issues in health, we needs to look beyond the institutional concerns of the Francis Report and give people the democratic power to scrutinise health services and create a coherent framework for health and wellbeing at all levels. By giving people a stronger voice and power we can share responsibility for a healthy society to flourish.

National Health Forum

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

For a more detailed description of how a ‘Parliament for Health’ could work, email: titus@democracymatters.info   Tel: 077203 94740

[2] Quintin Hogg, Dimbleby lecture 1976, The dilemma of democracy, Collins, 1978,


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