Now for Health 10 Democracy in the Health Service

It cannot be emphasised too often that democracy in this country is not a permanently fixed system, but one within which any decision to change is made, after discussion, by the vote of the people as a whole ; and its essence is not the formulation of one single plan but the conscious selection of the plan, best suited to the job in hand. In spite of that elasticity, however, it is something that has to be zealously watched, and its twin principles of free discussion arid majority decision safeguarded.

All the new services now being discussed by Parliament involve administrative machines which have to be designed for the particular work they have to do. Everyone is agreed that we can no longer just use one of our present local government bodies to do the job, for local government no longer fits every case. We find, therefore, that for nearly every industry nationalised, and for every new service introduced, a new type of democratic structure is suggested. The National Health Service is no exception.

Parliament remains in all of these the supreme controller, the place where the responsible. Minister can be questioned publicly, where matters can be debated and changes effected. There is an understandable tendency for the public to be content to leave Parliament— younger and more active than it has ever been before— to settle the matter, satisfied that a good solution to any problem will be found even if the absolute best is not attained. But health is not only a communal problem, it is an individual question, and the care and attention the individual gets will depend on how and by whom the service is run. It is going to be run for the patient, but he has to be sure of where the responsibility lies and play his part in fixing that responsibility.

There are four aspects of democracy in the health service to which some attention should be paid. One feature of the debate in the House of Commons was that only one of them, the position of elected representatives on local authorities, was much discussed ; the others — the exact placing of democratic decision, the function of patients and the place of staff committees— all received scant mention. Parliament probably felt that it still held control and was content with that.

Indeed, that is the first problem. So far as direct election by the people is concerned, Parliament is the only level for all but the clinic services at which it is maintained. The Minister is given the power by Parliament ; and Parliament can call him to account for the service as a whole and in every detail. The Minister has control of the policies of the Hospital Boards and the Executive Councils, but the people have no direct access to these two bodies. True that one-third of the seats on the latter, and an unspecified number on the former will be county councillors or nominees of local health authorities, but there will be no direct election of them by the people.

It is clear, we think, that within the limitations imposed on the Minister of Health by our local government structure and by the attitude of the British Medical Association he has produced a workable compromise. Democracy should not be afraid of delegating these duties to the citizens who will sit on these bodies, but must be vigilant to see that the duties are fulfilled. In the localities it will probably be much easier to watch closely the work of the hospital management committees, and the structure of these has been left very fluid indeed. They will have considerable powers, including probably the acceptance of gifts to be spent on their own hospital apart from the ordinary budget, for rapid decision is to be a feature of the service. Their powers will make an interesting study, for they cannot override the Hospital Board and must not ignore the staff committees, yet they will have spending power and almost complete authority over the hospital they run.

It has yet to be clarified as to whether there will always be a “house committee” for every hospital, what its composition will be, and what its powers. It is at this level that the citizen as patient needs to be represented, but no method of ensuring this has ever been devised except in chronic hospitals and sanatoria. There is no statutory power to provide for patients’ representatives, and we shall probably have some spontaneous experiments in this matter at different hospitals.

So far as the staffs are concerned, there are many points of interest in democratic development. There is first of all the general question of political rights within a national service. It is claimed that the structure of this service protects all the political rights of those citizens who are employed in the service, but one point remains unresolved— can and should a person employed by a governmental agency be a member of the employing body ? For example, should it be possible for a doctor employed by the local health authority for the area in which lie lives to stand for election to that authority ? In the final analysis of the socialist state there is no question— he should be able to do so ; but in this interim stage many believe that he should not. There are still one or two cases in which a health worker employed in this new service might feel a slight restriction on his political freedom so far as membership of government bodies is concerned, but the service is probably as free as anyone would desire.

There is also the question of how much control the staff of the service are to have over day-to-day matters. This has long been a bone of contention, and professional opinion has varied from a demand for full control of the whole service to a claim for very big advisory powers. The Bill sets up the Central Health Services Council, with wide advisory powers, and it will probably deal with broad questions. At the periphery of the service, however, there is no advisory body, and the position of staff committees has been passed over.

Some method must be worked out which will provide for representative committees for each section of the staff, and for a Joint Staff Committee, at every hospital and health centre. It is much to be desired that the team-spirit in the care of the sick, which will be fostered by the new service, should find its outlet in collective responsibility within the institutions concerned.

Medical committees have been a feature of voluntary hospitals and of some municipal hospitals ; and nurses’ councils and committees of other staff have been developed in recent years. There must be machinery for discussion and representation within the hospitals and centres, and decisions on matters of urgency must be placed upon the shoulders of those best able to make them.

Here again an enlightened democracy must be on its guard, for it is upon such conceptions that the detailed success of the whole venture depends.