Devo All – The Role for Local Authorities (in England)

Accountability Devolution

It has long been SHA policy that greater democratic accountability should be introduced into our health care system.  The NHS has never had any form of effective accountability.

Since there are already elected and democratically accountable local authorities which deal with most local public services it has been our view that health care should be added to their responsibilities – thus ‘integrating’ with social care and then to public health, housing, environmental health, planning, economic development and other services.  It has never been suggested that we have a separate elected body just to deal with health care (as was tried unsuccessfully in Scotland) as this just perpetuates division.  Leaving the NHS as the only public service outside the local authorities’ settlement is simply unacceptable fragmentation.

There remains strong support for the NATIONAL nature of the system and for both health and social care – having national frameworks which define entitlement and assessment, national terms and conditions for staff (and strong regulation over terms and conditions of staff in non-public care suppliers), one NICE and one system for system oversight and regulation.

Whilst WHAT is decided nationally the HOW is determined locally at whatever level makes most sense.

This does inevitably lead to local variation but that has always been the case – rural vs urban being an obvious example.  Our policy is for local decision making over the distribution of services, over local funding arrangements and priorities – decisions made through the democratic processes. Nothing in this allows any area to opt out of its statutory responsibilities and we would favour some strong and swift mechanism to resolve and disputes, again locally.  This is in contrast to the NHS where everything is effectively decided remotely without any accountability or transparently.

It is possible to make the necessary changes, over a long period, by following the approach adopted by Andy Burnham, through the existing organisations. This does maintain the separate nature of the multitude of health care providers and some ‘commissioning’ or planning as a separate function; obviously health care providers would not be managed by local authorities.

The obvious risk is that local authorities will be subject to funding cuts then blamed when services deteriorate.  They will look at outsourcing options as they did so disastrously with social care.  The solution as spelt out again by Andy Burnham is ‘preferred provider’, repeal of the Health & Social Care Act and specific procurement guidance applicable to all care services.

Progressively moving local decision making away from the traditional NHS bureaucracy is going to be contested every step of the way by those whose strong vested interests have shaped how the system works at present.  But unless we genuinely embrace the idea of democratic accountability we are not going to get integration of all public services focused on improving wellbeing and addressing the huge issues around the determinants of poor health, of inequality, exclusion and unacceptable variation which have been endemic in the NHS since its inception.

Whilst democracy has its risks the alternatives have more.