Local democratic accountability via local authorities to replace local quangocracy. The appointment of members to PCTs and NHS Trusts is we consider entirely inappropriate. The substitution of local accountability via local representative democracy for non accountability via appointed Trusts is key to both making the NHS more sensitive to local needs and more owned by local people.
This could be achieved either by having existing Trusts – PCTs and NHS Provider Trusts – composed of members elected specifically for this role on an NHS ticket; or by transferring the PCT role to local authorities. We opt very firmly for the latter option and consider that it is Unitary local authorities and, where these to not exist, County Councils, which should take on the PCT commissioning, community service provider and public health roles.
How the NHS commissioning function is structured within local government would be up to the local authority concerned but we envisage that there could be:
a separate NHS Committee analogous to the Education Committee
supported by a NHS Directorate
with a Director responsible to the Chief Executive.
or better still, a joint NHS and Social Care Committee
and supporting NHS and Social Care Directorate.
With integrated healthcare and social care commissioning from the new style local health and wellbeing authorities integrated services and individual care packages should be readily deliverable based on :
Existing Local Area Agreements (LAAs)
Links with neighbourhood management
Appropriate joint commissioning and joint provision of services between health and social care
Pooled healthcare and social care budgets with clinicians and patients responsible for spending decisions and with incentives to increase efficiencies with reinvestment of savings.
Financial incentives to improve compliance with care pathways, similarly for QOF
We have also considered whether the NHS commissioning function should have its own councillor representatives elected purely on a health ticket or whether existing “all purpose” councillors should take on this role. The sheer complexity of the healthcare environment suggests that having separate “specialist” councillor representation would be appropriate.
Health (and Social Care) would be commissioned to meet the defined and measured health (and social care) needs of the relevant catchment populations as determined regularly by the Director for Health and Wellbeing assisted by other Directors.
Dental and ophthalmic services would also be commissioned directly by the new style local health, social care and wellbeing authorities.
Having those responsible for NHS governance elected rather than selected is a necessary step towards local democratisation of healthcare; but it is a very small one and needs to be accompanied by means to involve the public in a real and truly representative way in policy development and planning. In other words representative democracy via councillors must be supplemented by direct democratic involvement.
The arrangement for health would mirror that for Education and would have the immediate effect of reducing the DoH role to that of Monitoring, Strategic Planning and Policy, as with the DES. It would also render nugatory any consideration of the arms length NHS Board concept.
An NHS Executive, separate from the DoH, staffed by NHS employees, would remain to fulfil those functions such as procurement and some aspects of human resources, which are best done centrally on behalf of the whole NHS, rather than at regional or sub-regional level.
The NHS function would be revenue funded by a central grant within the overall local authority support grant. Whether these revenue funds could be enhanced with funds raised through local council tax, as with other local authority services, is open to debate but we consider that it should be permitted.
In respect of capital funding we envisage that this would be done from Exchequer funds, possibly supplemented by a Peoples NHS Bond issue, by the regional planning authority against agreed capital programmes.
A price to be paid for this level of localism would be the continued existence of the postcode lottery. We consider that this price is worth paying – it already exists after all for other local authority services and has never been eliminated from the current NHS in spite of NICE etc.
Possible problems with this model relate to the competence of local authorities and their officers and elected members; and the intrusion of local politics rather than national politics on the local health scene.
Taking the competence issue first it is undoubtedly true that some – possibly many – local authorities have not demonstrated great competence in tackling the many problems that confront them with their existing array of services. But then this is equally true, probably more true, of PCTs. Undoubtedly, to add the health commissioning role to local authorities existing functions would be a challenge to their competence but we envisage that any move to increase the role and autonomy of local government would make the role of councillor and local authority officer that much more attractive to competent people.
On the issue of political intrusion on health issues it is our view that this is inevitable and in fact entirely appropriate bearing in mind the resource consumption of healthcare and the importance accorded to it by all members of the population.
Reintroducing strategic planning to the NHS. Strategic planning on a 5-10 year time frame would be reintroduced at local and regional level. We see no necessary incompatibility between having a strategic planning framework and retaining commissioning rather than direct management. This function would be carried out be Strategic Health Authorities. Such authorities would initially be constituted as health authorities with members nominated by local health and wellbeing authorities within their boundaries. If elected Regional Assemblies were established these would take over the strategic health authority function.
Broadening the remit of local authorities. The new style local authorities would be given a specific responsibility to promote the health, social care and wellbeing of their populations as is currently the case in Wales
Democratising Provider Units. We see the adoption of cooperative principles in the governance and management of Provider Units as an important step towards democratic control replacing the current system of selection of members by election from an appropriate constituency. This is the institutional equivalent of replacing PCTs by democratically elected local authorities.
Foundation Trusts were much vaunted as applying such cooperative principles. We consider that in fact they represent a travesty of cooperative working and do not provide a template that we would wish to replicate.
The form of cooperative working we propose for Provider Units is a mixed worker and user model with the Governing Body and Managing Body both comprising worker representatives and patient representatives elected by the relevant
staff/professional representative bodies within the Unit and via the new local LINKS arrangements, respectively. Importantly, we see clinician representatives making a major contribution at both Governing and Managing Body levels.
Also, crucially, the catchment population’s voice – distinct from the patients’ representative voice – would be manifest through elected councillors of the relevant local health and wellbeing authority, ie via local representative democracy.
We are conscious that this proposal is very much an outline only and requires development taking account of experience of cooperative working in other sectors outside the NHS, in other countries such as France and Spain, and in consultation with those more familiar with the cooperative modus operandi and ethos than the current authors.
Creating a truly patient centred NHS
The NHS must be a patient-centred service responsive to users at both an individual and collective levels. Patients should be seen as co-designers, should they so wish, both individually of their own care, and collectively of their local health services. What drives the whole system should be defined by patients to meet their needs and wants. This has significant implications for structure and function.
Patient choice is important at the individual consultation level and is a necessary component of the equal co-producer, partnership relationship between healthcare professional and patient. But, just as important, is public voice whereby the public as citizens can have their say and influence through local representative democracy. Thus patients also have a key role in defining quality in healthcare and commissioning and in developing and monitoring performance measures.
What patient-centredness means in practice at various levels of the Service is set out below:
1. At Individual, consultation level.
- Shared decision making for all patients who want it when they want it.
- Patients to be given full access to their medical records
- Patients to have ready access to Decision Aids to help them participate in clinical decision making.
- The Expert Patient Programme to be expanded outside the current franchise
- Patients and patients to be involved in the training of healthcare professionals at all levels of training. Patients as Teachers is one approach
- More outreach to those currently not accessing services such as the young, men, some BME groups, homeless people, refugees and asylum seekers who may have specific health needs?
2. At General Practice level:
- Elected Practice boards to work with the partners to run the practice should be offered as an option to practices
- patients are encouraged to work with staff to select new doctors and clinical staff
- Every Practice should be encouraged to have a patient participation group or panel.
- The Practice is incentivised to become responsive by:
- The HCC/CQC demanding evidence that the practice has changed in response to patients’ views
- QOF incentives increased to do the same
- Quality of care is in part defined by patients
- the patient experience part of QOF to take up a larger proportion of the points
- Working with local community development workers
- Community development workers are placed in each group
- Practice participation groups link up to advise the cluster
- Patients are involved in:
- Choosing priorities for investment and disinvestment
- Monitoring quality
- Identifying problem areas and successful areas of service provision
- Deciding on how to spend any savings
3. At PCT level :
PCT Boards are elected and subsumed into LAs
HCC/CQC demands evidence that the local commissioners and providers have taken on board patients’ views in the areas specified above
PCT Boards have a NED who has a specific brief for PPI
Review the role of NEDs to ensure that they are accountable to the community
Every PEC has lay representation. For instance, half the Board could be patient leads within PBC clusters
Citizens’ views to be incorporated into the commissioning process in the following areas
Choosing priorities for investment and disinvestment
Identifying problem areas and successful areas of service provision
Determining the shape of service development
Deciding on how to spend any savings
4. Hospital Trusts:
Foundation Trust governance is made more effective to ensure that members become more involved in the running of the Trust. Non-FTs take on similar governance.
5. At National level:
Patient interests should be safeguarded by appropriately funded and supported Local Involvement Networks ( LINKS) with defined rights (including unannounced inspection) and duties
Community Development will become a significant approach for LINKs.
Liink LAs and LSPs to adopt a community development approach to wider well-being agenda.
A national body comprising LINKS representatives to promote the sharing of experience and good practice and to influence national policy and strategy.