Can We Democratise the NHS?

For all of its many strengths the NHS has one enduring weakness – it lacks robust local public and patient engagement (PPE). In better times, when people felt the nationally run service was adequately meeting needs, this may not seem to have mattered that much. However now that the NHS and Social Care Act is attempting to palm responsibility for tough decision-making onto local Clinical Commissioning Groups (CCGs) the democratic fault lines are being exposed. It is the right time to ask – can we democratise the NHS?

Public and patient engagement (PPE) in the NHS has been weak ever since Bevan’s centralised model trumped Morrison’s municipalism in the 1940s. A succession of ineffective bodies have come and gone since the creation of Community Health Councils (CHCs) in the 1970s including PPI Forums, PALS and LINks. Indeed the Francis Report concluded that the long-gone CHCs actually represented the high point of public engagement.

Few believe that the latest centrally inspired PPE incarnation – Local HealthWatch (LHW) – will be breaking the mould. There will be no additional monies to set up the local bodies and, embarrassingly, the Department of Health had to withdraw a consultation document after it appeared to suggest LHW branches could be run for as little as 20k pa compared with the 100k spent by the predecessor LINks.  Subsequent restrictions have been placed upon LHW through regulations which state it would not be reasonable to take part in the ‘promotion of, or opposition to, the policy which any government or public authority proposes to adopt in relation to any matter’. This is likely to limit the extent to which challenges can be made to CCGs and LAs and it is not clear why anyone would want to devote their time unpaid to an organisation which is not allowed to affect any public policy.

At the same time the Health and Social Care Act seems to have upped the stakes on PPE – it was a crucial part of CCG authorisation and is said to be central to the Everyone Counts guidance and to Putting Patients First, the first business plan from NHS England. And the recent interim CCG ‘assurance framework’ issued by NHS England states that “the approach will focus heavily on the role of CCGs in securing patient and public engagement” and even refers to “our collective vision of a health system shaped by patient and citizen participation.”

The problem with all of this is that the envisaged mode of engagement is stunted. In line with market conceptions of healthcare, the focus is on ‘empowering consumers’ through access to better information and by gathering ‘feedback’. The shift from ‘patient’ to ‘customer’ or ‘user’ is central to this neo-liberal approach to public services, with user involvement portrayed as the feedback mechanism for the expression of consumer views. The newly published ‘Choice Framework depends upon access to the right information on which to base choices, and there is currently much ado about gathering ‘real time’ feedback from patients via the Friends and Family Test .

There is nothing wrong with information and feedback exercises, though there are certainly technical problems with the Friends and Family Test.  Nevertheless on their own they will fail to engage patients and the public in meaningful ways. We need to get beyond market governance as the only approach to PPE and start looking at two alternatives – representative and participatory governance respectively.

Representative governance is a variety of democracy founded on the principle of elected people representing a wider group of people in order to form an independent ruling body charged with the responsibility of acting in the people’s interest. In due course these representatives can be voted out of office by the same constituencies that elected them. It is not a model with any local history in the case of the NHS.

Representative governance could consist of a reprise of Morrison’s municipal control of the NHS via local authorities – this seems to be the commissioning model that is favoured by Andy Burnham and the Labour Party. An alternative might be to include an elected element into the governing body of CCGs.  However, if CCGs themselves wish to quickly gain public legitimacy they could follow (but drastically improve upon) the Foundation Trust member and governor model. Making best use of digital technology, as well as traditional approaches, the mission should be to build up the highest level of CCG public ‘membership’. From this a ‘public and patient congress’ could be elected with a role to act as a local ‘second chamber’ with some scrutinising, revising and advisory powers.

But even this will be insufficient to sustain legitimacy for some commissioning decisions. CCGs also need to embrace ‘participatory governance’ and this must be much better than the traditional set-piece consultation exercise or the ineffective patient reference groups at practice level. Central to this approach is the idea of an ongoing active partnership between the citizen and the state. The task facing CCGs here is to ensure services are co-commissioned, co-designed, co-delivered and co-assessed in line with the popular ‘engagement cycle’.

There are many practical ways in which this could be achieved. A long-standing approach is that of citizen’s panels where a cross-section or a selected stratum of the population make themselves available to deliberate on specific decisions about which there are known to be differing views.  One recent example of this has been in Ellesmere Port (2012) to engage the public in an inquiry into alcohol. Another is the idea of developing a cadre of ‘patient leaders’ along the lines proposed by the Centre for Patient Leadership. ‘Patient Leaders’ are described as ‘the patients, service users and carers with the knowledge and skills to become agents of change’ and the fullest account of how to develop them is found in the CPL’s recent publication, ‘Bring It On

Up and down the country CCGs are having to take tough decisions – the ‘fall guys’ in the eyes of some – and are encountering a surge of opposition from patients, the public and staff in affected agencies. Unlike PCTs, tucked away discreetly in obscure business parks, CCGs are in the public gaze. The public has been told repeatedly by the Government that their GPs are now in charge of the budget and they now feel they know who needs to be held to account. If politics (by Harold Lasswell’s definition – Lasswell, H (1958 with postscript), Politics: who gets what, when, how? Meridian Books) is about ‘who gets what, when and how?’ then CCGs are inescapably politically embroiled.

The bottom line for public sector organisations is defensible decision-making – ‘upwards’ to a higher authority and ‘outwards’ towards a local community. Whilst a robust PPE strategy will not eliminate controversy around a difficult decision, it will demonstrate that views have been heard, add understanding of the reasoning behind the decision and ultimately increase trust in the inclusiveness of the governance process. Many CCGs will have inherited a ‘communication and engagement strategy’ from their PCTs and will have cut and pasted this as a template for authorisation purposes. Now is the right time to completely rewrite these strategies – to recast them conceptually, relocate them into local contexts and show some courage and ambition in engaging with local populations. ‘The public’ doesn’t have to be a problem; it can – and must – be an important part of the solution.