19 June 2008
Some politicians are pushing for primary care trusts to be more democratically accountable but NHS managers argue that the current reforms should be given more time before making changes. Richard Lewis reports on a thorny issue
The accountability of primary care trusts has recently been the subject of intense debate. Politicians such as health minister Ben Bradshaw and Communities Secretary Hazel Blears have called for PCTs to be more democratically accountable, and Prime Minister Gordon Brown has asked health minister Lord Darzi to include PCT accountability in his wider review of the NHS, which is soon to be published. Both major opposition parties also agree that reform is needed.
However, if there is a growing political consensus that something needs to be done to make PCTs more locally accountable, there is still considerable disagreement as to exactly what this should be.
Perhaps unsurprisingly, Sir Simon Milton, chair of the Local Government Association, has spoken in favour of bringing PCTs under local authority control (although the recent LGA commission on NHS accountability has not recommended this).
By contrast, the NHS Confederation, which represents NHS management, argues that the current reforms to PCT accountability should be allowed to bed in before more changes are considered. These reforms centre on the creation of new Local Involvement Networks (Links), which are replacing the unloved – and apparently ineffective – Patients' Forums.
So who should prevail? The answer depends largely on what is being pursued. Some seek a political goal, seeing democratic accountability as an intrinsically 'good thing'. Others consider the involvement of local people to be a way of ensuring services are more closely aligned with what patients want. These are very different goals, yet too often are confused in public debate.
Pursuing a political goal makes reform of PCT governance inevitable. The trusts currently have little connection with their local communities, and are certainly not democratic. They are accountable to their strategic health authority, which is accountable to the health secretary. Non-executive directors are drawn from the local community but do not 'represent' the public. Instead, an increasing emphasis is placed on the effective corporate function of the board, comprising executive and non-executive members. And local people do not select PCT non-executive directors – this role falls to the independent Appointments Commission.
Milton's proposal to transfer accountability for PCT commissioning wholesale to local authorities would be relatively simple to achieve. However, it would also be controversial, not least because NHS services are funded from national, rather than local, taxation.
There are less radical reforms that could begin to address the 'democratic deficit'. Local councillors, for example, could be given places on PCT boards; the council leader could even become the chair of the trust or at least a non-executive director.
However, this intertwined accountability for the NHS and local authorities raises potentially complex political questions. PCTs are likely to remain accountable for their performance to strategic health authorities and the Department of Health (there seems little prospect that the NHS will be cut completely loose from central politics).
Councillors on PCT boards would therefore face a dual accountability – to their electorate and to SHAs. Where local and national political parties differ, it is easy to foresee problems. In addition, would the trust board lose its corporate coherence if its members faced in different directions?
An alternative political solution would be to institute new arrangements such as the election of PCT boards. This would be similar to the path followed in New Zealand, where a majority of district health board members are subject to public elections at the same time as local elections (although political parties do not campaign along party lines in these elections). The Scottish Government is consulting on a similar approach for the direct election of health boards. However, democratic powers are limited in both these cases because the elected bodies are (or will be) accountable for their performance to central government.
An alternative to the direct election of some or all trust directors would be to create 'foundation PCTs' modelled on existing NHS foundation trusts. In many ways, foundation PCTs would be an obvious next step, as they would build on the current NHS solution to the problem of insufficient local public accountability.
In this model, local people could elect governors who would have a number of defined rights, such as the hiring and firing of the board, signing off the PCT's commissioning plan and even provoking SHA intervention if they were not content with current management. Elected governors work in schools and are beginning to mature in foundation hospitals. But would they attract enough interest among the public if extended to PCTs? Commissioning is complex and PCTs lack the powerful symbolism of the local hospital. The cost of such a solution could be significant but its benefits are less certain. So if there are potential problems with the options for radical and political reform, should the NHS be content with incremental changes to the current systems of local public accountability?
There is certainly more that could be done to involve people in decision-making without having to overhaul the governance systems. PCTs could understand local views far better than now through greater use of surveys or focus groups. The current programme to improve commissioning places great emphasis on the development of these skills.
However, more structured approaches to listening to and understanding the views of local people could be encouraged or even mandated. One idea is a formal 'citizens' jury' to offer views on vital PCT decisions. This could comprise people drawn at random from GP lists, who would be reimbursed for their time and offered information and access to local experts to help them reach informed decisions. Juries might be only temporary, to ensure fresh views and avoid the danger of 'capture' by the PCT establishment. Or the trusts could follow the example set by the National Institute for Health and Clinical Excellence, where a citizens' panel is allowed to build up its expertise over an extended period of time.
The NHS Confederation is right to point out that public involvement procedures within the NHS are in transition. Care must be taken not to impose a new solution before current policy has been demonstrably found wanting.
However, even if the new Links prove effective in articulating local voices, this might still not be enough to satisfy those who want more overt democratic control over the NHS.
NHS chief executive David Nicholson has made clear that PCTs are on the beginning of a journey of decentralisation. Over time, the trusts (at least, the successful ones) will enjoy more autonomy and increasing freedom to set their own targets. In this context, the accountability question will become ever more pressing.
Richard Lewis is a director in Ernst & Young's health advisory practice and joint author of the King's Fund report Should PCTs be made more accountable? which can be downloaded free from the website www.kingsfund.org.uk
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