Democratic Accountability in the NHS

Report of a conference on Democratic Accountability in the NHS held in Sheffield on 15^th September 1990

Brief survey of the debate – Cyril Taylor

The issue of democratic accountability has a long-standing history. When the Churchill Coalition issued a White Paper on a national health service, the proposals were so radical that they were torn to pieces by the BMA. The subsequent proposals by the incoming Labour Government in 1945 proposed a salaried GP service working in health centres. On the question of local organisation it was made very clear that the structures of local government (city and county) should be preserved. Separate local authorities should be established to administer the health service, with county and borough councils maintaining an interest in hospital administration. This would lead towards the development of a joint authority to administer health services locally.

The 1974 reorganisation, however, weakened the practical link between local authorities and the health service, while allowing for the appointment of local authorities representatives to the Area Health Boards. There was limited representation of professional and trade union interests, including the medical schools. Local authority members of Health Authorities were chosen for their general ability and personality and unbiased, constructive approach to decision-making. Health Authorities were not accountable to their local communities, and did not discuss political issues – a stark contrast to the political and local accountability of local authority councillors.

The Royal Commission appointed in 1977 heard evidence on various forms of accountability. They noted in particular the close link between social services and health services. The predominant view from health trade unions and the BMA was to take the social services out of local government into a separate health and social services authority. Various formulae for the election of health authority members have been put forward, and during the 1980s the SHA discussed options with the health trade unions, negotiated compromises and brought resolutions to Labour Party conference which emphasised the need for an elected element within health authorities. There has however been no commitment from the Labour Party to any form of elected health authorities. Meanwhile the 1990 NHS and Community Care Act has abolished the last vestige of accountability by removing local authority nominees from health authorities. The new members will in effect be appointed by, or with the approval of, the Secretary of State, with particular emphasis on their business and management expertise. It is against this background that the SHA submitted a resolution to the 1990 Labour Party Conference, calling for Regional Health Authorities to be integrated in the proposed elected regional tier of government, as a way of devolving power and opening up the possibility of democratic accountability within the NHS.

IMPLICATIONS OF THE PROPOSED REGIONAL TIER OF GOVERNMENT – Richard Caborn MP

Since 1987 Richard Caborn has been a member of the Department of Trade and lndustry Team, involved in the preparation of the Productive and Competitive Economy section of the Labour Party’s Policy Review. His particular remit included regional government, problems of the inner cities and urban regeneration, the democratic deficit, and the power relationships between tiers of government. The task was two-fold – to attack the government, and to prepare a document on regional government for the Labour Party.

The Policy Review

A draft document was circulated to all English CLPs during the Policy Review period, which resulted in some 130 comments. These were incorporated into a document entitled Regional Renaissance which was launched in 1989, as part of the European Election campaign. The ideas have been around for many years, but they are now being developed from a number of angles, including the imbalance in regional economies, the democratic deficit in all walks of life, the role of Europe, with the implications of centralised banking which needs the counterbalance of regional interests, and the possibility of regional assemblies electing a reformed Second Chamber (as suggested by Roy Hattersley). Regional Renaissance is not about the reorganisation of local government, but offers a new system of government for the UK The aim is to bring powers down from Whitehall, not to draw powers upwards, and to co-ordinate the work of departments of state, such as Environment, Transport, Trade and Industry, Education and Science and the Health Service which would be co-ordinated in a democratically elected regional tier of government, with a strategic planning role. Below this level, County Councils would be abolished and their functions would be taken on by most-purpose authorities, responsible for the provision and delivery of services. The principles of regional government have been incorporated in Looking to the Future, to be presented to the 1990 Labour Party Conference. The next stage is a further consultation process under a sub-committee chaired by Bryan Gould which is bringing together representatives of the Treasury, Environment, Trade & Industry, Education & Science and Transport, to look at ways of implementing regional policy. It is therefore particularly timely that this conference is taking place, opening discussion on running the health service in the context of the debates about breaking the branch line of power from Whitehall.

Power too centralised

The UK probably has the most centralised government in western Europe, with the Civil Service dictating from Whitehall. Currently the regional officers of government departments see their responsibility directly derived from Whitehall and the secretaries of state, rather than in relation to the region. They should become accountable to an elected regional assembly. Regional, area or district health authorities have never been democratically accountable to the people they represent. The current power relationship of centre to region or district illustrates the democratic deficit. The new Labour Party proposals for regional government offer a radical programme which will arouse a strong backlash from the civil service. The sub-committee is looking to organisations such as the SHA to open up this debate within the health service. The regional tier of government offers an opportunity for the NHS, which is the biggest spending department, to be incorporated directly or be responsible to an elected regional assembly. There are many possible forms this could take and there is a challenge for the SHA to draw up draft proposals. In countering arguments that a regional tier of government would be bureaucratic and expensive, it is important to look at the consequences of the lack of regional planning and government. The economy of the South East is overheated, but despite being the wealthiest region, its productivity is well below that of the least developed German Land. The UK economy needs equalisation across the country, with technological transfer at regional level. Decision-making is over-concentrated in the South East and centres of excellence need to be set up in the regions.

Devolution of finance

How should the regions be financed ? There is a pragmatic consensus against a precept or regional tax, and support for funding from national taxation, devolving finance as well as power based on population distribution. A proportion of the ‘slice’ apportioned to regional disbursement would be subject to conciliation by leaders of the regional councils based upon certain criteria, in order to redistribute resources and redress inequalities. This is a system which works well in the German Lander. It allows for the proportion to be devolved to be enshrined in legislation. Conciliation takes place without Treasury interference. This is an important curb on the powers of the Treasury, in favour of regional priorities. The successes of the Scottish and Welsh Development Agencies provide good starting models. The existence of Scottish and Welsh Secretaries of State in Cabinet and the Scottish and Welsh Offices enable the co-ordination of departments of state, which is totally lacking in England. Without such co-ordination and planning of departmental responsibilities, the contributors to inequalities in health (poverty, environment, transport) for example, cannot be addressed. In summing up, RICHARD CABORN noted the total absence of checks and balances against centralised decision-making in the NHS, along with many other centrally provided services. The democratic process has become a sham – there is an elected dictatorship in Parliament. The Labour Party proposals for the devolution of powers to Regional Assemblies are a challenge to centralised decision making – but they are still only a declaration of principles. No work has been done by the Health team to go beyond the statement in the Policy Review Report – which continues to propose the appointment of health authority members to ensure ‘a line of accountability to the local community’. There now needs to be hard thinking on translating principles into proposals for reorganising the health service at regional level, and there is a need for the SHA to fill this gap.

A CONSULTANTS VIEW – Dr Richard Warren

Richard Warren is a Consultant in Accident and Emergency, and Prospective Labour Parliamentary Candidate for Epsom & Ewell

An increasing number of problems arise from the lack of accountability in the NHS. The views of both the providers and the users of the health service are not being listened to. He illustrated the current unaccountability of NHS planning and provision in the case of Riverside Health Authority’s plans to knock down five hospitals and replace them by one hospital, in London’s expensive west end. The anticipated value of the sale of land on four sites was patently the prime motive – the views of those working in the hospitals affected and of the users were disregarded. In line with current usage, consultation meant the authority/government saying what it intended to do and then doing it. An appeal to the Secretary of State from the Community Health Council was of no avail. Only the local authority planning committee rejected the plans on the ground of over-density and traffic congestion – but this hurdle was overcome and the project has gone ahead. The views of local people were of no consequence. Although officially there are supposed to have been no bed closures or redundancies, in fact 160 beds have been closed, and there are now more private than NHS beds within the health authority area. Many GP practices have become completely private – and access to the NHS has been severely reduced.

Powers of Managers

On the question of consultant accountability, Richard Warren pointed out that consultants no longer had the power and influence they used to wield. The 1984 Griffiths Report on Management had identified areas of weak management. But the Government hi-jacked Griffiths’ procedures in order to pursue their battle with perceived interest groups – such as they had done during the miners’ and teachers’ disputes. Consultants had in the past been able to gum up the wheels, but the new system of district and unit managers gives management overriding power, reflected in the fact that district managers are paid twice as much as consultants. Shroud-waving no longer carries weight.

Under the Government’s current reforms, consultants are to become accountable, not for their clinical judgment, but for their use of money. Budget-holding is supposed to make consultants more responsible in their use of resources. But beds and blood will be budgeted for – when the money runs out before the end of the year the consultant will be in breach of contract if s/he continues to treat. Doctors and consultants will have to make decisions to withhold treatment or on types of treatment on grounds of finance. The newly-appointed business dominated health authorities will be able to place all responsibility for potentially contentious decisions on consultants.

The many problems facing the health service at present could be solved by open debate and greater accountability. It must be a priority for the SHA and for the Labour Party to find ways of bringing democratic decision-making into the NHS.

HEALTH SERVICE WORKERS’ PERSPECTIVE – Bob Quick

Bob Quick is COHSE Regional Secretary for East Midlands and South Yorkshire, and Chair of Sheffield District Labour Party

There is wide agreement within the labour movement on the importance of the health service, on its need for more funds and that the emphasis in the NHS should be transferred from acute, hospital-based care to primary care. We also agree that low pay in the NHS should be ended, opted-out hospitals should be brought back into the NHS and that the market has no place in health care.

However, the issue of how to democratise the NHS has not been resolved. The debate has a long history. The newly created NHS was unable to get to grips with changing the system of appointing boards, and the same faces reappeared. Barbara Castle published a White Paper in 1976 with proposals to make health authority members more accountable – but her departure from government meant a lost opportunity.

The options

The debate within the Labour Party has been between two views those proposing the management of health under local government in unitary local authorities, responsible for all public services, and those favouring the continuation of separate health authorities. Unitory local authorities make a great deal of sense in terms of the interaction of agencies such as housing, social services, environmental health, primary health care. The alternative model, supported by the trade unions and the SHA, has been for keeping health separate from local government, but that the authorities managing local services should be democratised.

A range of options has been put forward and debated during the 1980s – elected representatives of health workers, directly elected health councillors, and representatives of patients’ groups such as voluntary organisations. This unresolved /debate has unfortunately damaged progress on this issue. Debates within the Labour Party NEC in the mid 1980s revealed the tensions and the strong opposition of the local government spokesman, Jack Cunningham, to the proposals for separate health authorities. Michael Meacher presented a policy paper in 1986 which was shelved and never adopted. The 1987 manifesto made no reference to democratising the NHS, and the deep divisions remain.

The Northern Ireland model, whereby health and social services are administered outside local government, offers lessons. But, whatever model is adopted, the health trade unions want to place democratisation of the NHS high on the agenda for a future Labour Government, giving a place for the voice of employees of all levels. The argument that health workers would oppose decisions to close hospitals on the grounds of self-interest are not valid. Nor has anyone questioned the self-interest of consultants who have sat on health authorities hitherto.

Appointment versus Election

The Policy Review statement on accountability which gives powers to the local authorities to appoint health authority members is not acceptable. Appointment has nothing to do with democratic accountability. Election is to do with democratic accountability. In March 1990 Robin Cook warned general managers that they would be watched for their conduct in their implementation of government policies, and that he would appoint shadow chairmen of health authorities, but with no reference to seeking views of the local labour movement. He did not even refer to the possibility of the labour movement setting up shadow health authorities. However, when the Local Government Information Unit called a meeting in September to co-ordinate the activities of local authorities opposing opt-out proposals, it was encouraging to learn of the number of shadow health authorities which are being set up. The District Labour Party in Sheffield has agreed to set up such a shadow authority to monitor the local health services.

But accountability at district level is not enough. Neighbourhood health committees could have an important two-way role in representing the views of local people.

Democratic accountability is an important issue. The SHA resolution to Labour Party conference could be the start to a campaign within the labour movement.

REPRESENTING USERS’ VIEWS – Sylvia Hikins

Sylvia Hikins is Chair of Liverpool Central and Southern CHC and a college lecturer

The 1982 reorganisation of the NHS introduced yet greater centralisation and reduced accountability. The 1990 NHS & Community Care Act and the imposition of the GP and Dental contracts have further undermined any democratic consultation. The farce of ‘consultation’ on opt-out, and the threats to managers and consultants if they did not support expressions of interest in opting out are further indications of the centralised control. Against this background the question of democratisation is ever more urgent. Not that the situation has ever been very much better. An article written in 1981 describes the way in which district management team members were deluged with information, clouding their decision-making capacity, and resulting in them rubber-stamping the decisions of officers. Chairs of health authorities worked closely with officers to secure the support of members, who were despised as insufficiently professional and realistic in relation to NHS problems.

Defining democracy

How then can the needs of the local community be better represented ? Is the local authority model really democratic and accountable ? Perhaps we should examine definitions of democracy. The Oxford Dictionary gives two definitions: ‘sovereign power resides with the people and is exercised either directly by them or by officers elected by them’; or, ‘a social state in which all have equal rights’. Local authorities fall into the first category, but are in fact often seen as insensitive, bureaucratic, hierarchical and non-empowering. This may account for low turnouts at elections. The history of housing is a particularly clear example of City Fathers’ patronage, culminating in high rise flats. Such local government becomes the ‘local state’.

But the second definition of the social state in which all have equal rights offers empowerment of people at neighbourhood and community level through, for example, housing associations, housing co-ops, tenant participation. Cynthia Cockburn in The Local State, published in 1977, says that ‘representation of the views of the public has traditionally been the role of the councillor. Increasingly it has been recognised that with the growth of the Council’s services and the rise in people’s expectations from life, traditional channels of communication need to be supplemented by new structures if the views of all the people are to be made known to the Council. There is a growing social awareness among individuals not satisfied with the more traditional outlets for community service. New structures are required which will afford the opportunity to assume a greater personal responsibility in the finding of local solutions to local problems.

Participative democracy

This means a less directed and more consultative and participative approach in the democratic model. This definition of democracy is many-faceted. It goes beyond the formal structures and extends to those who use the NHS and those who work with in the NHS. It is more consultative, more participative and it will in fact change the relationship between the users and the providers. So we are not just tinkering with whether we elect a district health authority or whether we appoint them, because either way you can still be left with this ‘local state’ type of hierarchy, rather than a wider participatory model. If we agree that the NHS must have accountability, involvement of patients and communities, opportunity for public debate and access to information, we have to consider all of these factors, and create a structure which will accommodate them. It is not just simply a case of electing a district health authority.

That sounds grandiose. How will we do it? In the first place it means the delegation of both political and other forms of power to people in neighbourhoods, to people who use the service, to people who work in the service, which goes right against the hierarchical management structures at present in the NHS. But we could do it. We could start. If Labour wins the next election, we could for example, replace all those on DHAs who are unsympathetic to the NHS. This is an obvious, but dictatorial thing that must be done. Then we could start to create some of things that have been discussed today – neighbourhood health advisory groups on patch systems that would work with the new DHAs and perhaps put their ideas of how the community perceives its health needs through health forums. Then we could decide what kind of democratic model of an elected DHA we want to have. But at the same time we need to legislate on issues like a Charter of Health Rights, something users of the service will have of right, and a Charter of Patients’ Rights which we need once inside the service. We need to look at other things like ‘no fault’ compensation schemes, and the strengthening of the role of community health councils and their partnership with the local neighbourhoods. We need to legislate so that they have a voice that must be heard, because one of the problems with the CHCs as presently constituted is that they have no teeth.

Empowerment of users

If we work along that model there would be new legislative parameters which would concentrate on the rights of the patients and the rights of local communities and combine these with the wider overall model. This kind of democratised NHS would collectively empower the users of the NHS and those working within it and be sensitive to the needs of the neighbourhood. The operation of the new elected DHAs would have to work within these parameters.

Nye Bevan believed that the best form of democracy for the NHS was for it to be controlled by the Minister and accountable to Parliament. This view had much support in the labour movement in the pre-Thatcher era, and I suspect there is still much covert support for that model. But whilst such an approach maintains a uniform national service, it creates an excessive concentration of power and it is insensitive to local needs. It is an outdated way of running the NHS. The opposite of charity and patronage is empowerment, and I believe the structure of the NHS must be reformed, along with new democratically elected and accountable health authorities. If this is twinned with a Charter of Health Rights, the provision of legally enforceable standards of health care and patients’ rights which protect the dignity and welfare of the individual and responsiveness to the needs of the local community, the NHS will itself grow healthily in to the twenty first century.

A PUBLIC HEALTH PERSPECTIVE – Dr Steve Watkins

Steve Watkins is a Community Physician and President of the Medical Practitioners’ Union

Experience as an active trade unionist, involved with the politics of health since qualifying, and as a community physician for ten years used to confirm a long held belief in a model for the organisation of health care which is co-terminous with the local authority, possibly part of that local authority, and democratically elected from people of the area to run on their behalf a comprehensive range of health services to meet their needs – both for primary and secondary care. This model underlies most of approaches to democratisation, which have been discussed in the past and described in earlier contributions to this conference.

But the experience of preparing to implement the 1990 NHS and Community Care Act has proved this model to be a chimera. This model has never existed, and never can exist.

Implementation of the NHS Act

This conclusion is based on the experience of trying to implement the 1990 NHS and Community Care Act in the Reddish area of Stockport – a deprived part of the DHA area – four miles from the District General Hospital and one and half miles from Manchester Royal Infirmary. Traditional patterns of patient referral have been to hospitals in Manchester, and have been of no concern to Stockport Health Authority in the past – but now as a purchaser, the Health Authority will have to pay for those patient flows. There is a choice between buying in, rather than providing services for the people of Reddish re-drawing boundaries so that Reddish falls within a Manchester Health District (which destroys co-terminosity); or diverting the patient flows to Stockport’s DGH, which defies common sense. This situation is not unique. There are many areas where hospital catchment areas do not match local authority boundaries.

Faced with the consequences of the purchaser/provider split, who should decide whether patient flows from Reddish to Manchester should continue ? Should it be the Minister, the RHA, a DHA with workers elected from the staff of the DGH (doctors and managers with a particular interest in a particular unit), or should it be the people of Reddish ? I therefore strongly support the suggestion already made in early discussion that the unit from which we should be planning healthcare should be at neighbourhood level.

Locality Plans

Stockport is planning to operate the NHS changes in this way, by building purchasing intentions up from locality plans, created in the localities, though not democratically controlled (that would not be sanctioned!). This is something a Labour Government could build on, by matching the managerial structure with a democratic structure under which the decisions could be taken by elected representatives of the people of the localities. Though everyone present undoubtedly disapproves of the purchaser/provider split, it would allow for neighbourhood health committees to run the primary sector and then commission the secondary care services that they require, which is the WHO Health for All concept of a primary-care-led service in which all services are co-ordinated around the locality.

MPU proposals

When the Government published its White Paper Working for Patients in 1989, the Medical Practitioners’ Union responded with constructive criticism – consisting of forty-eight proposals. These included the condition that purchasing authorities should be democratically elected; neighbourhood health committees should be set up; provider units should be turned into workers’ co-operatives; and the whole system should be properly funded. This was a political stunt – and the MPU was never invited to discuss these ideas further with the Government – but the merits of the proposals appear stronger now. What is wrong with a model of creating workers’ co-operatives in the NHS, to provide their services in accordance with strategic plans drawn up by democratically elected representatives of the people ? That is the way to solve the conflict which has always run through the democracy debate – are we talking about democracy for the workers or for the people ? The resolution of that issue is that decisions about what the objectives, goals and basic strategies of the NHS should be an issue for popular democracy, for the elected representatives of the people, and the issue of how that is put into effect – the practical decisions about running the hospitals – is an issue for workers’ democracy. This enables the two models of democracy to run in harmony with each other.

A projection for the health service in ten to fifteen years time would be a primary-care-led service, in which elected neighbourhood health committees were running the primary care system and were commissioning the services they required from the secondary care system through some kind of district-level co-ordinating machinery, from a set of provider units which work as co-operatives. This could not be done overnight – and it must be recognised that there would need to be a will to create such co-operatives. The first stage in the creation of workers’ co-operatives on the provider side would be a move towards participative systems of management. The MPU has put forward a system of introducing this through performance-related pay for unit general managers based on the degree of confidence which that manager is able to command from the workforce. This would quickly stimulate interest in participative systems of management. Performance-related pay is an effective way of motivating managers, but in the past the targets have been bed closures and balancing the budget. Most managers would prefer to have more pleasant and creative goals set for them -currently, as public servants, they are obliged to carry out the Government’s policies. The Labour Party need not assume that it will find health service management as a block.

Neighbourhood Health Committees

The MPU has suggested how neighbourhood health committees should be established. Initially they should be advisory bodies which should progressively be given more power over a period of perhaps five to seven years, starting with powers to manage primary care services, and then progressing to powers to identify needs for hospital services as an advisory body to the DHA and then ultimately becoming the agents who commission those services. They would grow into their new roles.

The role of the district, the issue of local government control and the issue of a merger with social services need further consideration. Preparations for the implementation of ‘Caring for People’ have provided opportunities for health and local authorities to sit down together to define the boundaries between health care and social care. At the extremes there are distinct health care or social care functions, but a whole range of services for sick and disabled people cannot be clearly divided between health and social services. In Stockport therefore arrangements for joint planning and management have been started.

Selective integration

The MPU has long argued for a merger of health and social services. Should that merger be inside or outside local government ? This depends on how far local government is capable of taking on the ability to enable and empower local communities. Where local authorities are committed to decentralisation and the creation of an integrated social policy which grows from the base upwards and actually empowers people, then it makes sense to run the kind of health service proposed within the local authority. But of course most local authorities do not follow this model, and giving them control of the health service would strangle the process. In many parts of the country, handing the health service over to local authority control would be to deliver it into the hands of its worst enemies.

There is however no need to apply a model universally. The MPU has suggested a number of criteria to be met before a local authority could be given control of the NHS. These should include a good record in health and social service issues, a commitment to an integrated social policy, and to working in a de-centralised way. Where local authorities do not meet these criteria, the MPU would like to see the creation of health and social services boards which are elected from the bottom up, which are joint committees constituted by the neighbourhood health committees in the area. This should produce a model of democracy which listens to the people.

POINTS RAISED IN DISCUSSION

The issues raised in discussion highlighted :

The new situation in which power has been usurped by a new race of managers working competitively and in which the Government and managers will be able to shift the blame on to consultants, departments and GPs who exceed their budgets. The current philosophy in nursing reinforces the cult of the individual and of individual responsibility, with an emphasis on counselling and coping with stress instead of the removal of stressors, such as competition.
The functions of RHAs which should become committees of the Regional Assemblies, with strategic functions in providing equal access to health care. The distribution of funding is vital. RHAs need to lay down stringent minimum standards, and guarantee rights to a given level of service. Nye Bevan warned of the dangers of a patchwork quilt service – prior to the NHS there was very uneven provision through local government.
The need for co-operation between local authorities and health authorities. Health authorities are able to over-ride local planners – these conflicts should be resolved by co-operation between health and local authority planners, rather than through (unsuccessful) appeals to the Minister. The advantages and disadvantages of the amalgamation of health and social services were considered. Since social services have – or should have – close links with housing, education and other services – the merger of health and social services could damage this. Planning, housing, health all need an integrated approach.

Any moves towards democratic control must be backed with commitment to the necessary resources. User and worker participation in the democratic process applies to all local authority services as well as to health services.

STEVE WATKINS, in summing up, considered that many of the comments during the discussion for and against local authority control of the health service reinforce the MPU’s arguments for selectivity. Incorporation of health services into integrated, decentralised local authority management could be a successful middle way. Setting plans and strategies is not enough: it is how they are implemented that counts. We should give more scope to health workers, who have plenty of good ideas on how to run the NHS on a day-to-day basis. We need a system of management which taps this body of knowledge. There are many good, committed and Labour voting managers in the NHS ready tO change direction, if we can give them the right guidelines.

SYLVIA HIKINS endorsed the setting up of neighbourhood health committees as a high priority. This is the only way of redressing the imbalances in health care and tackling the inverse care law that those who most need services get least. People in run-down neighbourhoods know what they need, but have given up trying to get it. We therefore still have a national sickness service, dominated by a medical mafia which soaks up money into high technology medicine. The democratic debate is about trusting people to define their needs, and put them in a planned perspective.

BOB QUICK welcomed the valuable debate, and the agreement on the importance of neighbourhood health committees. The boundaries between health and social services are becoming increasingly blurred, and one effect of this is in the planned merger of public service unions – COHSE, NUPE and NALGO – as a reflection of their changing roles. The Labour Party has always been weak on tackling patronage, and should not continue to be involved in this. We should not replace Tory Party patronage with Labour Party patronage, however much attempt is made to reflect all walks of life. The Socialist Health Association has a role to play in drawing up a blueprint for social accountability.

APPENDICES

Resolution Submitted by SHA to Labour Party ConferenceConference welcomes the commitment in the Labour Party policy Review Final Report to the development of regional government. The SHA supports elected regional government and sees it as a way of developing power in the NHS and opening up the possibility of democratic control accountability within the NHS. Accordingly we call on the next Labour Government to integrate RHAs into the proposed regional tier of government.Conference further calls upon the NEC to establish, as a matter of urgency, a national health forum to represent the views of Labour members, including representatives from regional health committees, health trade unions, the SHA and others concerned with health issues, to discuss the strategy for health and t develop proposals for a democratic health service to be implemented by the next Labour Government. For example, the SHA believes that at local level; there should be district committees, directly elected, plus representation from the staff in the NHS, also elected.Composite 24, passed unanimously by Labour Party Conference, October 1990Conference welcomes the commitment in the Labour Party Policy final report to the development of regional government. Conference supports elected regional government and sees it as a way of devolving power in the National Health Service and opening up the possibility of democratic accountability within the NHS.Conference further calls upon the National Executive Committee to establish, as a matter of urgency, a national health forum to represent the views of Labour members, including representatives from regional health committees, health trade unions, the Socialist Health Association, Community Health Councils and others concerned with health issues, to discuss the strategy for health and to develop proposals for a democratic health service to be implemented by the next Labour government.Conference believes that the next Labour government should ensure that District and Regional Health Authorities are democratically elected and accountable with representatives from the general public, the NHS workforce, and patient/consumer groups.
Conference recognises that the SHA believes that Regional Health Authorities should be integrated into the proposed regional tier of government.

Glossary

A bigger glossary of acronyms

BMA	British Medical Association
CHC	Community Health Council
CLP	Constituency Labour Party
DGH	District General Hospital
DHA	District Health Authority
GP	General Practitioner
MPU	Medical Practitioners Union, part of MSF
NEC	National Executive Committee of the Labour Party
RHA	Regional Health Authority
SHA	Socialist Health Association
WHO	World Health Organisation

Report of a conference on Democratic Accountability in the NHS held in Sheffield on 15th September 1990

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