Published in: Local Government Studies, Volume 22, Issue 2 Summer 1996
Introduction
Structural changes within the reformed health service along with certain well publicised management failures have heightened interest in the arrangements for securing public accountability in the health service. 1 Government ministers and health service interests have seemingly been stung by the criticism of a lack of public accountability at a local level. It would seem that the democratic deficit can no longer be ignored.
It is no coincidence that the Department of Health has been concerning itself with how best to involve the public. 2 Virginia Bottomley whilst she was still the Secretary of State for Health, had said that health authorities ‘must actively encourage public participation in the decision making process’. 3 Whilst he was still Minister for Health, Brian Mawhinney was reported as having said that ‘consultation with your local community is at the heart of your DHA’s purchasing agenda … to find out people’s views about health services, and to take account of these views….’ 4
In examining the issues relating to the public accountability of today’s health service, it will be argued in this article that the local choice dimension within the health service is increasing in significance. 5 The argument that the health service is (and always was) a national service will be challenged, as will the argument that public accountability does and should occur at the national level.
This in turn leads on to the consideration of how accountability in today’s health service can be best achieved. The view expressed in this article is that it is no longer sustainable to oppose some form of democratic accountability that is both public and local. Whilst this view is not in itself entirely new, indeed the author and others have expressed similar ideas previously, its relevance has arguably never been more apposite. 6 The alternative of simply tinkering with the present system and yet leaving in place unaccountable appointees to continue to make decisions at a local level is no longer sustainable.
There are a number of different models that could be employed in ensuring that local public accountability is achieved. The option to pass the responsibility over (some would say back) to local government is just one of the options that could be considered, along with the option of setting up directly elected, single purpose health authorities. However, before considering the strengths and weaknesses of both of these, it is necessary to question the view that the health service is and always was a national service.
A Wholly National Service – A Flawed View of History
Defenders of the present situation may give the impression that responsibility for the health service has been solely at the national level since 1948 and that any local government responsibility ended then. This is very far from the truth. Local authorities, through their direct responsibility for community health services and ambulance services, remained a crucial element of health service provision right up to 1974. It was only then that the health service moved fully into the world of appointed bodies. It is also important to note, as such initiatives as The Health of the Nation has recognised, that even today many local authority functions remain vital to health. 7
However, the National Association of Health Authorities and Trusts (NAHAT), amongst others, has argued that recent reforms of the health service ‘have not fundamentally altered the system of accountability’. 8 Indeed, Philip Hunt (NAHAT’s director) has since stated that ‘A plethora of mechanisms is already available to ensure that the NHS is accountable’. 9 Leaving aside the way in which this skates over the introduction of market systems of accountability, there is also a failure to acknowledge the removal of local authority representation from health authorities as part of the Working for Patients restructuring. 10
This was no minor change. Local authority representation made up a third of the board memberships prior to this restructuring and provided a direct link to the elected government of our local communities. The removal of elected local representatives is a change which is increasingly being mirrored across a range of local public services and something which has been commented on extensively. 11
A further significant change resulting from the Working for Patients restructuring was that health service managers became members of the authorities (as executive directors) for the first time. Placing executive officers onto the health authority boards as members has arguably confused their role as well as that of the non-executive members. Executive board members are now supposed to act both as managers and authority members. The roles are very different and potentially conflicting ones.
NAHAT argues that, ‘From an NHS point of view the new boards have proved their worth’. 12 However, the structural changes within the health service have created a situation in which the limited public accountability of health authorities that was in place before the recent reforms has receded even further with the creation of purchasing authorities, provider trusts and general practice fundholders (GPFHs).
The contention of this article is that those responsible for health services at the local level must be publicly accountable at the local level. As Stewart and Davis have said,
those who exercise public power should be accountable to those on whose behalf they exercise that power. This requires both, a means of holding to account; and the giving of an account. 13
If they act at a local level, they should be publicly accountable to local people.
Whereas it is clear that local councils are accountable to local people who can, if necessary, remove them via the electoral process, there is no way in which local people can hold the members of appointed boards to account. The boards can follow policies to which local people object, they can provide inadequate services for local people, they can even abuse their position, and there is nothing that local people can do directly to remove them. Regretably, the health services in the West Midlands and Wessex have provided ample illumination of a number of these issues. 14
The principle of public accountability needs to be embedded within public services but is currently seriously lacking and is being eroded at an ever increasing rate, including within the reformed health service. Or, as Stewart has put it,
Public institutions are justified by their basis in public accountability. Without that they are not rational in a democratic society. 15
Health Service Accountability
Public accountability in the health service is far from adequate. The health authority board members are government appointments and as such are not locally accountable. Rather, the limited accountability that is available is through a long and uncertain line of accountability to the government’s Secretary of State for Health. The minister is then accountable to parliament which is in turn accountable to the electorate. The abolition of the regional health authorities (RHAs) and the amalgamation of district health authorities (DHAs) with family health service authorities (FHSAs) from April 1996 does not make the appointment of members more transparent or open. Hennessy has referred to this generally as the development of ‘the alibi society – “Don’t bother me, I’m only the Secretary of State”‘ 16 It is the confused and tangled web of appointments, and hence accountability, that leads to this situation.
The health service is structured on the principle of sets of appointees watching, cajoling and interacting with other sets of appointees. It is difficult, therefore to pinpoint the locus of power and authority within such a system. One is unsure as to whether one appointee has greater status than another. Crucially, it is extremely difficult to locate the point of access for members of the public.
The burden of accountability on ministers increases as effective local accountability decreases. Furthermore, health authorities, trusts and General Practice fundholders (GPFHs) are not subject to the rigorous processes of public accountability that apply to elected local councils. For example, many hold their meetings in private. For all the attempts at administrative and managerial restructuring there has been little or no energy devoted to tackling the lack of an effective political voice for affected communities – unless one accepts William Waldegrave’s argument that accountability has been ensured by the recent reforms, in that the newly reformed service is more responsive to the customer / consumer. He argued that this, the mimicking of the market, allows for a more responsive (and therefore accountable) service. 17
Hunt has argued that the health service is a national service and that ‘… proper accountability is being exercised’, at least at the national level. Therefore for some there would seem to be nothing drastically wrong with current mechanisms for accountability?’ 18
This line of argument essentially takes the view that because the health service is a national, rather than a local service, it therefore needs to be steered by national policy and decision making. Accountability is ensured via accountability to parliament along with other supporting mechanisms:
The Secretary of State is accountable to Parliament…. Parliamentary accountability is reinforced by the work of the Select Committee on Health and the Public Accounts Committee … [which is] supported by the National Audit Office. 19
At the same time, it is argued, the health service reforms have allowed for a better managed, more efficient decision making service to be operated. Indeed, Working for Patients argued that what was needed were structures which could:
handle the complex managerial and contractual issues that the new system demands, and that [for] health authorities … to discharge their new responsibilities in a business-like way they need to be smaller and to bring together executive and non-executive members to provide a single focus for effective decision making. 20
In contrast, locally accountable services would lead to an over bureaucratised and stifling situation.
Perhaps managerial improvements have occurred and certainly codes of practice on openness have been drawn up since the events which lead to the 1994 House of Commons Public Accounts Committee commenting that management “failings” represented “a departure from the standards of public conduct which have mainly been established during the past 140 years”. 21 Even so, such improvements have not gone far enough. 22 Local public accountability is still absent.
Public accountability for the health service at a local level is required. Whilst not wishing to deny the desirability of a national framework, it must be accepted that ever since its inception, there have been discrepancies over the nature and level of health care provision, whether between regions or more locally. The recent debate about inequities in the new funding formula is just one of the more recent examples of disagreements over inequitable levels of funding between health authorities. 23
Health authorities are doing more than simply managing health services at a local level. Rather, local health authorities are daily making decisions about local needs and local priorities. National policy considerations such as Priority Setting demonstrates that they are encouraged to do so. 24 At the same time, evidence of actual choices being made at the local level continues to be produced; the case of Jaymee Bowen (‘Child B’) being perhaps the most notable recent example. 25 As Ham has said, ‘responsibility for setting priorities hinges crucially on the decisions taken by health authorities locally on the interpretation of national policies – as the Cambridge case [Jaymee Bowen – ‘Child B’] shows well.’ 26
Furthermore, the new health service is all about purchasers making local choices. Indeed, in many ways that is why they are there. (If they are not making local choices then perhaps they too should be abolished along with the RHAs and be replaced by local offices of the NHS Executive at the district level.) The health authorities and GPFHs are choosing what to purchase, how much and from whom. Essentially local choices are being made; indeed this has been acknowledged by, amongst others, Ron Zimmern (the Director of Public Heath for Cambridge Health Commission – the health authority responsible for not funding ‘Child B’s’ treatment). 27
Local public accountability in the health service is therefore both appropriate and necessary. As Stewart has said more generally,
“Accountability at [the] local level is appropriate where services are delivered at local level and where choices are made at that level about the nature and level of services”. 28
Without it there is an overburdening at the national level. Ministers have been reluctant to accept personal responsibility for failings at a regional or local level, for example in the West Midlands and Wessex RHAs. Instead, if anyone, local appointees have ‘carried the can’. For accountability to reside at national level, then one would reasonably expect the ministers concerned to take full responsibility for the actions of their non elected appointees in the health authorities and trust units. This has not happened.
Interrelated with this is the change in the nature of the provider units. They are now, as health service trusts, literally in the business of seeking out contracts. The new trusts may be giving preferential treatment to GPFHs. At the same time that this is happening, trusts may be winning contracts to supply services outside their locality and conversely may be losing out on contracts with their local purchasers (a recent example of this being the winning of a contract by a trust in Burton-on Trent for community nursing in Cardiff ). 29 Whereas in the past district hospitals and community services would have provided most everything for the local community, they may no longer be contracted to do so. Indeed, the existence and viability of local provider units and trusts is being threatened, irrespective of the opposition of local people to such reconfigurations of their local health services.
Local Choices
Local choices have always been made in the health service. As Ham has said, ‘This responsibility is not new to district health authorities, who have long been in the position of having to determine local priorities….’ 30 With the development of the local purchasing role this is now even more the case. Health authorities are no longer directly responsible for providing health services so that, for Ham,
What is different is that, as purchasers, district health authorities may be able to take decisions which depend less on the demands of providers than they have in the past. In so doing, district health authorities should be able to place greater weight on other factors, such as the views of local people and evidence on the cost effectiveness of different services. 31 (Emphasis added)
However, democratic accountability for such choices does not exist locally. Instead, it theoretically returns to the door of the appropriate minister. But, as has already been said, they are all too reluctant to accept responsibility for their appointees’ local decisions.
For some, it may be that too much democratic involvement could be to the detriment of the smooth running of the service since the involvement of elected local representatives may lead to a replication of the perceived disadvantages of local government, namely:
a common characteristic of local government is one of ‘committee-itis’ and stultifying bureaucracy, 32
which would get in the way of the smooth management of the health service, especially when the service is in the midst of making difficult decisions over acute services.
There is no guarantee that a local democratic process could help with the massive challenge posed by the major reconfiguration of acute services now taking place. 33
But this is precisely why a locally accountable service is needed, to ensure that those difficult decisions are taken in consultation with the community affected. This does not mean that difficult decisions cannot and will not be taken but rather that an intrinsic part of the process is that decision making needs to be taken openly and with the facility to call the decision makers to account.
The assertion that difficult decisions are fudged or obfuscated by local politicians is not credible. Local politicians have to close schools, make unpopular planning decisions, shut swimming baths; often in spite of local opposition. However, in these cases the community does have the opportunity of challenging, influencing and ultimately of removing the decision makers from office if they disagree with them.
It may well be easier for difficult decisions to be made behind closed doors with the community unable to call the decision makers to account. But ends do not justify means. Indeed, sometimes it may make for a more difficult life to have open and accountable decision making, but this more arduous journey makes the end more legitimate.
Possible Options: Local Authority Control or Directly Elected Health Authorities
Local democratic governance could be achieved by giving local authorities the responsibility for the commissioning of health services and this is something for which a number of people have argued. 34 Local authorities are responsible for commissioning social care and there is some logic to there being one body responsible for commissioning both health and social care. As NAHAT has said,
It is possible to see how in the future the division between health and social care will become increasingly blurred.35
Local authorities are also playing a key role in the attempts to improve the health of their localities. The Health of the Nation initiative is the latest to recognise the vital role that local authorities must play in ensuring that ‘healthy alliances’ take place. 36 Health gain is not going to be achieved simply by initiatives undertaken by health services. It is more likely to occur in the future, as it has in the past, with healthy alliances across a number of local public services, particularly those that are the responsibility of local authorities – environmental health, leisure, education, housing, and social services. As David Knowles has said,
It is increasingly accepted that improvements to areas such as housing and environmental services are often the most significant way to achieve better health. 37
The prospect of the responsibility for the running of health services returning to the local political arena is feared by some. But it is necessary to recognise that health services have always been political. Whenever choices are being made regarding levels of resourcing and levels of service, value judgements are being made. Presently, these choices are being made at a local level by locally unaccountable appointees.
The argument that it is inappropriate for local government to be responsible for a national service such as health is something that this article has demonstrated not to be the case. Local choices are being made, all be it within a nationally steered framework. Differences over levels of service, types of treatments available, and eligibility can already be seen between health authorities.
It would be both possible and legitimate for health services to come under the responsibility of local government. Decisions would have to be made though about the current lack of co-terminosity between health authority and local authority boundaries. Secondly, adequate resources would have to flow to local government with the transfer of responsibility for health services.
There is, however, another option. The directly elected health authority is frequently ignored as a policy option. A somewhat disingenuous leap is often made by opponents of local democratic accountability in the health service in that the arguments for democratic local accountability are invariably equated with arguments for local government control of the health service. 38 Whilst there are indeed strong arguments for expanding local government’s responsibilities, the arguments for democratic public accountability of the health service at the local level cannot be dismissed simply by arguing against local government control. Democratic local control of the health service can exist quite separately from local government and a major omission is often made by not even considering this approach.
The creation of directly elected local health authorities is one way of avoiding many of the concerns levelled against local authority control of health services as well as at the same time offering the opportunity for a real and focused debate on local health priorities. The ‘local state’ has already become fragmented, whereby there is now an emphasis on partnership between the various separate local players. It would be quite possible for locally elected health authorities to build ‘healthy alliances’ with the appropriate partners, including the local authority. A directly-elected local health authority’s sole concern would be for commissioning health services. This in turn would ensure that there was no opportunity for diverting resources away from health.
Elected health authorities would not necessarily lead to the party politicisation of health at a local level. Representatives of health professionals and other health staff, user-representatives, individual members of the public, members of the local CHCs could all stand for election. An advantage of directly-elected health authorities as opposed to the local government option, is that people would be able to vote specifically on health issues. There would be no necessity to weigh up the strengths of a candidate’s position on a number of issues.
The criticism that it would be inappropriate to have local accountability for health services which are financed in the main from national funds is not a sufficient argument against change. Local government presently finds itself in such a position, yet few would seriously argue that elected local government should be completely abolished.
Tinkering With The Current System
There is a view that rather than creating even more upheaval in an otherwise basically sound health service, all that needs to be done is to make a number of improvements to the current situation. In this vein, one has witnessed the ‘Nolan’ recommendations concerning appointments to non-elected public bodies (including health authorities) and, for its part, the Labour Party’s proposals to revamp health authorities (which would be renamed ‘supervisory boards’) by including local community representatives along with patients groups and health professionals. 39 In addition, the Department of Health has also emphasised the need to involve Local Voices and has also implemented, amongst other codes, a Code of Practice on Openness in the NHS for health authorities, trusts, and GPFHs. 40 There have also been calls to strengthen the role of Community Health Councils. However, none of these initiatives tackle the problem of the lack of democratic accountability at the local level. They merely tinker with a flawed situation.
The ‘Nolan’ recommendation to set up an independent commissioner to oversee the appointment of members of QUANGOs, and the desire for members to be more representative of their communities is surely an improvement on the present situation. 41 The Labour Party’s proposals to set up supervisory boards of non-executive directors representing the local community are also an improvement but remain inadequate for the reason that there is a continuing failure to address the local democratic deficit. 42 Even if the methods used to appoint future non-executive board members are seen to be more open and even if the members are more representative in a demographic sense, the need for democratic accountability at the local level remains.
The recent emphasis on health services involving Local Voices, whether through the use of locality purchasing, surveys and opinion polls, focus groups, standing panels and citizens juries, is to be welcomed as a way of informing decision making and decision makers. 43 However, there is a risk that what is created is an even less accountable situation in which unaccountable health authority members end up listening to individuals who represent no one: ‘the unaccountable in pursuit of the uninformed’. 44
Community Health Councils (CHCs) too have a role to play. However, the existence of CHCs does nothing to ensure that the democratic deficit at a local level is addressed. Their role is one of local watchdog. Anyway, it can be argued that CHCs themselves are problematical because of the difficult juggling act that they have to perform. They have to strike a balance between on the one hand not to being too confrontational with their local purchasers and providers, in which case they would risk losing the power to influence, and on the other not to becoming so cosy that they lose their independent voice. Indeed, as CHCs are re-established with the restructuring of health authorities in April 1996, they may be further compromised. Local health authorities will be responsible for holding contracts of employment for CHC staff and hold the leases or deeds for CHCs’ premises. 45 As the Institute of Health Services Management and the Association of Community Health Councils for England said in a joint report ,
There are concerns that the CHC whose health authority holds the contract for all CHCs in that region might be vulnerable to particular pressure from that health authority. 46
Measures such as codes of conduct and involving local people, along with a continuing role for CHCs, are useful additions to other mechanisms in ensuring that health authorities operate in an open manner. But, no amount of tinkering with the present arrangements can act as an adequate substitution for local democratic accountability.
Conclusion
In terms of its responsiveness to local needs and opinions the health service is deeply flawed. Public accountability for health services should involve more than simply allowing for the periodic questioning of the appropriate Secretary of State. Such a process does not allow the public to hold those responsible to account when hospitals are being closed, bed numbers are being reduced, specific waiting times being shortened or extended irrespective of the seriousness of the clinical condition, budgets exhausted before the end of the financial period. By choosing one option a health authority is denying another. Such decisions affect the health care that the public hopes to receive. These are not management but governmental decisions.
Those responsible for decisions must be held to account for their actions on a regular basis and in a public arena. Where decisions are about local needs and local priorities, this should be at the local level. The inescapable conclusion must be that there can be no effective substitute for the local ballot box. There are a number of ways that this could be achieved, such as through local government being given the responsibility or through the creation of directly elected health authorities.
Accountability at national level for local decision making is inappropriate and no longer sustainable. Political decisions over the allocation of resources are made by members largely unknown and inaccessible to the majority of us. Tinkering with the system is no longer a credible response.
References
1. see, for instance, House of Commons Public Accounts Committee, The Proper Conduct of Public Business, HMSO (January 1994).
2. NHS Management Executive, ‘Local Voices: the views of local people in purchasing for health’ (1992).
3. quoted in Financial Times, (26 October 1993).
4. cited in P.Hunt, ‘Accountability in the National Health Service’, Parliamentary Affairs, Vol.48, No.2 (1995), p298.
5. The argument presented is a development of those contained in the mimeo: G.Daly and H.Davis, Public Accountability in Today’s Health Service, University of Birmingham (1995).
6. see, for instance, G.Daly and H.Davis, ‘Give Us Democracy’, Nursing Times, Vol.84, No.23 (1988), p.62.
7. Department of Health, The Health of the Nation: a strategy for health in England (Cm.1986), HMSO (1992).
8. National Association of Health Authorities and Trusts, ‘Securing Effective Public Accountability in the NHS’, NAHAT (1993), p.2.
9. P.Hunt, ‘Accountability in the National Health Service‘, Parliamentary Affairs, Vol.48, No.2 (1995), p.301.
10. Department of Health, Working for Patients (Cmd.555), HMSO (1989).
11. see, for instance, H.Davis and J.Stewart, The Growth of Government by Appointment: Implications for Local Democracy, Local Government Management Board (1993)
12. National Association of Health Authorities and Trusts,’Securing Effective Public Accountability in the NHS’, NAHAT (1993), p.5.
13. J.Stewart and H.Davis, ‘A New Agenda For Local Governance’, Public Money and Mamagement, (October-December 1994), p.32.
14. House of Commons Public Accounts Committee, The Proper Conduct of Public Business, HMSO (January 1994), annex 2.
15. J.Stewart, ‘Defending Public Accountability, DEMOS , Winter Quarterly (1993).
16. The Observer, (30 January 1994).
17. W.Waldegrave, The Reality of Reform and Accountability in Today’s Public Service, CIPFA (1993).
18. P.Hunt, ‘Accountability in the National Health Service’, Parliamentary Affairs, Vol.48, No.2 (1995), p303.
19. P.Hunt, ‘Accountability in the National Health Service’, Parliamentary Affairs, Vol.48, No.2 (1995), pp.301-302.
20. Department of Health, Working for Patients (Cmd.555), HMSO (1989).
21. House of Commons Public Accounts Committee, The Proper Conduct of Public Business, HMSO (January 1994), para 1.
22. H.Davis and G.Daly, ‘Codes Of Conduct Are Not Enough’, The IHSM Network, Vol.2, No.4 (1995), p 3.
23. ‘Study claims inner cities policy is unjust’, Health Service Journal Vol.105 , No.5477 (2 Nov 1995), p.6 J.Hacking,’For Richer, For Poorer’, Health Service Journal Vol.105, No.5463 (27 July 1995), pp.22-24.
24. House of Commons Health Committee, Priority Setting in the NHS: purchasing. First report sessions 1994-95, HMSO (1995). Department of Health, Government Response to the first report from the health committee session 1994-5 (Cm2826), HMSO (1995).
25. J.Jones, ‘Should We Save Only The Young?’, The Observer, (29 October 1995).
26. C.Ham, ‘Health Care Rationing‘, British Medical Journal, vol 310 (1995), p1484.
27. R.Zimmern, ‘Insufficient To Simply Be Efficient’, Health Service Journal, Vol.105, No.5467 (1995), p.19
28. J.Stewart, ‘Defending Public Accountability’ DEMOS , Winter Quarterly (1993).
29. ‘Welsh GPs to move contract to England’, Health Service Journal, Vol. 105, No. 5480 (1995), p.4.
30. C.Ham, ‘Priority Setting In The NHS: Reports from six districts’, British Medical Journal, vol 307 (1993), p435.
31. C.Ham, ‘Priority Setting In The NHS: Reports from six districts’, British Medical Journal, vol 307, (14 Aug. 1993), p435.
32. P.Hunt, ‘Still Open To Question’, Health Service Journal, Vol.103, No.5383 (1993), p.21.
33. P.Hunt, ‘Still Open To Question’, Health Service Journal, Vol.103, No.5383 (1993), p.21.
34. see, for instance, N.Willmore, ‘Hands On Health’, Local Government Chronicle (7 January 1994), p10.
35 National Association of Health Authorities and Trusts, ‘Securing Effective Public Accountability in the NHS’, NAHAT (1993).
36. Department of Health, The Health of the Nation: a strategy for health in England (Cm.1986), HMSO (1992).
37. in: N.Willmore, ‘Hands On Health’, Local Government Chronicle (7 January 1994), p10.
38. see, for instance, P.Hunt, ‘Accountability in the National Health Service’, Parliamentary Affairs, Vol.48, No.2 (1995)
39. Standards in Public Life: First Report of the Committee on Standards in Public Life (Cm.2850-1), HMSO (1995). The Labour Party, Renewing the NHS (1995).
40. NHS Management Executive, ‘Local Voices: the views of local people in purchasing for health’, (1992). NHS Executive, Code of Practice on Openness in the NHS (1995)
41. Standards in Public Life: First Report of the Committee on Standards in Public Life (Cm.2850-1), HMSO (1995).
42. The Labour Party, Renewing the NHS (1995), p.20.
43. NHS Management Executive, ‘Local Voices: the views of local people in purchasing for health’, (1992).
44. N.Pfeffer and A.Pollack, ‘Public Opinion and the NHS: the unaccountable in pursuit of the uninformed’, British Medical Journal, 25 September 1993.
45. NHS Executive, Report of the Working Group on the Implications of the Change in the Establishing Arrangements for Community Health Councils (1995)
46. IHSM, ‘Back from the Margins’ (1995).