Friday, 23 October 2009

Local democratic control of health spending

The headline debates of 21st October were on two subjects chosen by Liberal Democrats, the plight of Equitable Life pensioners and climate change. Vince Cable's introduction to the former is well worth reading. However, my eye was caught by a ten-minute rule Bill introduced by another Liberal Democrat, Dr John Pugh. It pointed up a problem of financial control in the NHS in England which has echoes this side of the border.

The Local Health Services and Democratic Involvement Bill seeks to require, among other things, Primary Care Trusts to obtain prior approval for their spending plans, involving relevant local authorities.

Dr Pugh harboured few illusions about the odds of the Bill making it to the statute book, but in his presentation he made one or two sharp points.

"The local NHS is a huge taxpayer-funded service, affects everyone, is important to everyone, but is sadly totally remote from democratic decision making," he said. "Those who take the trouble to get elected to secure a mandate can make decisions about [where people] may smoke and what, but not about what happens in the local NHS in their area.

"MPs can protest at the actions of such bodies, [but] the thought of allowing anyone who has gone through the sordid process of getting elected anywhere near decision making has given successive Governments the vapours, and has been resisted hook, line and sinker, much to the satisfaction of hospital chief executives and health service managers.

"When an MP raises in this place decisions that their constituents oppose, and tasks a Minister about it, time and again the Minister, with almost comic sincerity, in Pontius Pilate fashion, says, 'This is a matter for local decision making,' as though 'local decision making' implied that local people—outside the quango circle—had any part in it.

"That is a perversion of democracy, but it satisfies the professionals, who like the prescription and genuinely fear the alternative—democratic accountability. [...] Liberal Democrats are very comfortable with the idea of elected health boards. We believe in removing appointees who have been whisked smugly or, in some cases, humbly into power because they have impressed some other appointee who has previously been whisked smugly or humbly into power, and replacing them with elected individuals who have had to impress the citizens served by the local trust, who gain community support and approval, and who, ultimately, justify their position to the people whom they serve.

"My Bill is simply a bridge to that position. It involves even less change, and uses existing institutions. I propose that primary care trusts, as currently constituted, lay before the health scrutiny committees of existing councils, as currently constituted, their annual plans and their big decisions—not for scrutiny or consultation, but for approval, agreement and amendment. I propose a kind of democratic lock on the local NHS: a move beyond mere consultation. I propose a genuine redistribution of power from one existing institution to another existing, established institution. This is such a good idea that I believe that the model has already been embraced voluntarily in some areas."

Dr Pugh concluded: "I genuinely see no reason why this model cannot work—in fact, it does work— and produce not simply good decisions, but good decisions with a popular mandate. That would be nice. Our NHS could be reclaimed, without micro-management or meddling, and not with government by experts but with popular government, expertly informed."

Sadly, the Bill will almost certainly fail to get a second reading, so we won't even hear the government's arguments against it, but these would no doubt be similar to those of Edwina Hart in centralising the NHS in Wales.

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