Government health warning, by George Jones and John Stewart

5 Jul 07
Taking the politics out of the NHS sounds like an attractive idea. But an independent board would be bad for democracy and bad for our health, argue George Jones and John Stewart

06 July 2007

Taking the politics out of the NHS sounds like an attractive idea. But an independent board would be bad for democracy and bad for our health, argue George Jones and John Stewart

With a new PM and major Cabinet reshuffle, change is in the air right across government. At the Department of Health, under new Health Secretary Alan Johnson, there are many fresh challenges ahead – but also some unfinished business.

One issue that had been in and out of former health secretary Patricia Hewitt's in-tray for some time is the vexed question of an independent NHS board. This was being seriously considered at one stage and there are still rumours of the idea being revived. But in one of her last speeches, Hewitt – apparently after discussing the matter with Gordon Brown – appeared to reject the concept.

The Conservatives, on the other hand, have decided to run with the idea of an independent board in their policy statement on NHS autonomy and accountability. However, their approach is deeply flawed. Advocates of an NHS board cite in their support the success of Brown's handing over of responsibility for the bank rate to the Monetary Policy Committee of the Bank of England. But success in one policy area cannot guarantee it in others, and the health services present different issues.

The decision on the bank rate is a single judgement made monthly and with one clear objective – keeping inflation below the chancellor's specified level. In health, there is a myriad of decisions, subject to external pressures and competing objectives, made continually. Nor can there be a single target to guide any independent board on its decisions.

Independent boards are nothing new in the management of public services. In the 1940s, deputy prime minister Herbert Morrison set them up to run the nationalised industries, free from detailed ministerial control. But experience showed that this freedom was illusory. Investment and pricing decisions were subject to hidden ministerial control, and accountability was confused.

The driving force for this control lay in the political pressures to which ministers were subject. These are inevitable in the health service, and would be even greater than for the nationalised industries.

Experience shows that one cannot sustain a distinction between strategy, and implementation and execution. Health care will always be a topic of public concern and raise political issues. When public pressure became intense over the nationalised industries, ministers could not maintain an arm's-length relationship with the boards. They developed itchy fingers and interfered. Ministerial intervention will be an even greater temptation in health, which arouses much more public emotion.

The proposal to hand over responsibilities to an independent board is rooted in the assumption that the health service's problems are political. This analysis has a superficial attraction. The slogan 'get the politics out of health' has a populist appeal. Yet politics is inherent in health care, where choices have to be made between conflicting needs, and public values are at stake.

Issues in the government of health cannot be resolved on technical grounds. How many resources should be devoted to acute care or to the mentally ill? What priority should be given to the reduction of waiting lists? These and many other issues are political, because they involve conflicts over values that are contested. Those who want to take politics out of health will surely be ready to take political action if dissatisfied with the health service, and even – as Wyre Forest has shown – be ready to vote about it in parliamentary and local elections.

The problem with the government of health is not one of too much politics but of too much centralisation. And that would still be the case if the department's responsibilities were handed to a central board. The complex of organisations delivering personal care cannot be run from a central location, whether a department or a board. It is unmanageable, and has been made even more unmanageable by the proliferation of central targets, inspections, various quangos and endless ministerial initiatives emanating from those remote from the people and institutions delivering and receiving health services.

The big question facing Brown, who has poured huge sums into the NHS, is how to raise public confidence in health care. The approach needed is localisation. Without this there is no legitimate basis for action, and citizens and health institutions will look to the centre – particularly the centre envisaged in the Conservative's policy document.

This problem of a lack of accountability was recognised by the previous government, which responded by creating foundation trusts, with boards of governors elected by members. But this experiment has failed to democratise the health service. Membership is generally low compared with the potential electorate, and turnouts in elections to the board have usually been poor. The board itself has only limited power; real control lies with the boards of directors. This attempt to create an artificial membership has not succeeded and cannot provide democratic legitimacy for localisation.

The only firm basis for local accountability is provided by local elections. Separate local elections for health authorities offer one possibility, but that would entrench their separateness from the main community services. They need to be integrated, and without the complexities and duplications of partnership working and Local Area Agreements.

The obvious basis for local accountability is the local authority responsible for social services. It is not enough to argue that councils are being given a greater role in health through the development of their overview and scrutiny roles. These do not give local authorities powers, and are no substitute for responsibility for the local government of health. Local authorities should not be merely appraisers or critics of health but decision-makers responsible for the government of health at local level, especially in the commissioning role currently given to primary care trusts

Localisation of the government of health in this way must be accompanied by radical change in the financing of local government. Councils should no longer draw most of their resources from central government, but from taxes levied on their own voters. Fusing decisions to spend with decisions on how to raise resources will make decision-making more responsible. The Treasury should rejoice to have gained allies in ensuring resources are used responsibly.

The new government needs to reflect on the recent experience of overspending in the health service. Compare that with local government, where such overspending is rare and is always corrected in the succeeding year. An appointed board will always call for more resources from the centre to which it is accountable. The local authority knows any overspend will have to be met by increased local taxation or reduced expenditure, and for both it is accountable.

Localisation does not remove politics from the government of health. There will be political protests and pressures on local authorities, but their response will be based on an understanding of local circumstances. Ministers and MPs must allow space for that political process to develop. Localisation requires a vibrant local politics, which cannot develop in the face of continuous central government intervention. It is essential for a renewed democracy.

The government and the Opposition formally support localisation of our health services, but neither provide any basis for local accountability. Both Hewitt and the Tories rejected basing accountability on councils or local elections. The furthest the government was prepared to go was to stress the local authority's role in working closely with primary care trusts, but without a clear responsibility for health. It is also suggested that some primary care trusts might decide that the board of the trust should contain some directly elected members, creating the confusion of partial local accountability.

The Conservative statement rejects local authority responsibility for commissioning because it requires 'a unique mix of professional input, national standards and local priority setting'. But far from being 'unique', that is the position with many local authority functions. The statement recognises the importance of local authorities as a basis for local accountability, suggesting many ways that they can be consulted, can scrutinise or can work jointly with health authorities, but all falling far short of accountability through a clear local authority responsibility.

The dilemma in both approaches is they do not provide an authoritative basis for local accountability to work. Without that, centralisation will not be challenged – and health authorities will inevitably continue to look upwards to the centre. The new health secretary should waste no time in addressing this problem.

George Jones is emeritus professor of government at the London School of Economics and John Stewart is emeritus professor of local government at the University of Birmingham


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