Power to the People?


‘Power to the people!’ The Citizen Smith slogan seems to be all the rage in the Labour Party right now as it crafts a distinctive election strategy for the NHS. Pulling away from the role of markets and bringing local accountability into the NHS looks like a good policy double whammy, and the commitment seems genuine. In recent weeks:

  • Ed Miliband, in his Hugo Young lecture committed the next Labour government to ‘people-powered public services’, devolving power not just to users but also to ‘the local level’.
  • Labour’s draft consultation paper on health  expresses similar sentiments, emphasising that people should be ‘not mere consumers of services but genuine and active partners in designing and shaping their care and support’.
  • The detailed report of the Oldham Commission, set up by Andy Burnham, contains an eight-point depiction of ‘whole person care’, one of which is ‘I and my community have a real say in our local services’.

This is positive stuff and all consistent with the ‘grass roots’ outlook of Labour’s new strategy guru, David Axelrod. There’s only one problem – there is no policy! Nothing in the Oldham Report, nothing in the party draft consultation and only ill-thought out ideas from the Labour leader himself, such as describing Health and Wellbeing Boards as ‘independent bodies’ to be charged with ‘consulting the local community’.

This isn’t good enough, and Labour is missing an open goal in not being more explicit. Here are ten suggestions to get the ball rolling.

  1. Coordinate existing forums: There are too many weak and fragmented bodies right now – Local HealthWatch, foundation trust governors, lay members of CCG boards and others. Together they might add up to more than the sum of their parts but there is no way of currently doing this.
  2. Empower elected FT governors: Alan Milburn’s recent assertion that Foundation Trusts are ‘owned and controlled by the public locally’ is nonsense. FT Governors are toothless and invisible to their miniscule electorates – they need to be properly staffed and funded and given autonomy from the grip of their FT boards of directors.
  3. Real public engagement in NHS commissioning: Most CCGs are stuck on a failed engagement model centred on ‘public meetings’. The need here is to promote the development of genuinely participative models – citizens panels and juries, patient and community leaders, participatory budgeting and harnessing the power of digital engagement.
  4. A Patient Congress in every Clinical Commissioning Group locality: Some effort is currently going into the creation of a national ‘NHS Citizens Assembly’ that somehow might call the board of NHS England to account. Without local roots this will falter. A representative and (at least partly) elected local Patient Congress could be the missing link in democratic transmission to the Assembly.
  5. Proper support for Patient Reference Groups: There are hundreds of these small groups at practice level taking an interest in such matters as patient appointment arrangements and opening hours. Generally they are unpublicised, unsupported and unrepresentative. They need help to up their game.
  6. Deeper understanding of ‘the patient experience’: In line with the focus on ‘consumerism’ there is much current preoccupation with recording and measuring patient feedback via the Friends and Family Test. This needs to be deepened (to get a narrative rather than a tick-box score) and extended (to capture patient journeys rather than separate interventions).
  7. Open up the invisible quangos: While CCGs have all manner of obligations laid upon them to involve and engage the public, other powerful bodies can too easily slip below the engagement radar – Local Area Teams of NHS England, Commissioning Support Units, CQC and Monitor. All of these bodies have huge sway over local healthcare but remain unknown and unaccountable to local people. 
  8. Promote and enforce the NHS Constitution: Most people are blissfully unaware of the NHS Constitution and even if aware of it will be (understandably) unclear as to its status. There is an opportunity to turn it into an NHS Bill of Rights.
  9. Strengthen and fund Local HealthWatch: The Francis Report argued that the prime local forums for public engagement have gone steadily downhill since the first of them – Community Health Councils – was abolished by Patricia Hewitt. We need to get back to a CHC-type model, possibly along the lines of the patient congress approach. A robust LHW could be the organising vehicle for such a shift.
  10. Reinvigorate local government: It will only be possible to bring some healthcare remit back into democratically elected local government once it has constitutional autonomy and is free of the pro-market, centralised paradigm.

Lots of work to be done under these headings, but time is running out. There aren’t many political open goals awaiting a shot on target but surely this is one of them? Shoot!

Professor Bob Hudson,

School of Applied Social Sciences, University of Durham