Squaring the Circle – Democracy & the NHS

Improving the Public health and achieving Democratic Accountability 1996


The Socialist Health Association policy paper focuses on the current political opportunity to improve health by tackling the social, economic and environmental determinants of health and at the same time improve democratic accountability within the National Health Service by involving local government in the joint locality commissioning of health and social services. The consultation on the new health strategy “Our Healthier Nation” and the reform of the internal market in the NHS are the opportunity to square the circle by improving health and democratic accountability.

Important factors are :

  • Improving health depends on addressing social, economic, environmental and cultural factors
  • Local government and health authorities (HAs) should develop local Health Plans. Boundaries of local government and HAs should be coterminous.
  • Health and personal social services (PSS) have an important but subsidiary role in health improvement.
  • Personal social services and community health service budgets be jointly managed.
  • Formal democratic accountability by elected councillors at regional and local levels.
  • Participatory democratic involvement by involving individuals and commentates in informal and more formal ways.

To achieve this the Socialist Health Association proposes :

  • National accountability for “Our Healthier Nation” to be through the Prime Minister and Cabinet.
  • National accountability for the NHS and Personal Social Services through the Secretary of State for Health.
  • English regional government to be democratically accountable and include a remit for health and the NHS.
  • Local health authorities and unitary authorities to be conterminous and share responsibility for l ocal health and social service commissioning.
  • In “two tier” areas district councils have delegated authority and budgets for joint locality commissioning.
  • Hospitals and Community Trust to have more local representation on their Boards and be accountable to the region for their overall performance.
  • NHS workers remain part of the NHS and not become local government employees.
  • Community Health Councils should be strengthened with statutory rights to information about and access to NHS providers.
  • Citizens should be empowered to positively influence their individual health and the way services are provided in their communities.

Squaring the circle means addressing the wider determinants of health strategically within all levels of government, maintaining a National Health Service but making it democratically accountable at national, regional and local levels.


This paper develops current SHA policies on the relationship between health improvement and local democratic accountability in the NHS. It sets out the important distinction between policies for improving the peoples’ health and those to do with health and social services. The paper records how the SHA has over the past few years made an important contribution to our understanding of health improvement and inequalities in health.

It also reports on the development of SHA policies on democratic accountability in the NHS, why it is necessary and models for achieving it. The health service, unlike education and social services has little local democratic accountability. The proposed model takes account of the need for informal and formal democratic participation as well as the need for specialist and more generalist governance of the NHS. This needs to acknowledge the national, regional and local levels of governance.

The paper argues that local government, as the local civic authority, is well placed to contribute to the wider health improvement agenda as well as be a vehicle to provide more formal democratic accountability into local health and social service commissioning.


The SHA has a strong record in promoting policies for health improvement by influencing socio-economic and environmental factors. Our Towards Equality in Health series in the early 1990s broke new ground, offering for example, Richard Wilkinson an opportunity to draw attention to the strong association between income and health and the benefits of equity to all social classes. Other booklets on food, housing, accidents, carers and organisational change all contributed to a better understanding of the relationship between poverty and ill health and the underlying determinants of health.

Our most recent publication with the Socialist Environment Resources Association (SERA) on environment and health made the important link between ecological sustainability, environments and health. The 1992 World Our input to the development of Labour party policy before the 1997 general election repeatedly drew the distinction between policies for health and policies for the health and social services. Policies for improving public health imply the need for inter-sectoral working – horizontally in government as well as between different agencies -to address the wider determinants of health. This embodies ideas of positive health promotion as well as the more structural determinants of health listed in the Charter for Public Health (Appendix 1).

Health services have an important role in disease prevention as well as offering treatment for established disease; however in population health terms, this is an important but subsidiary role.

In our response to the Labour party’s Health 2000 policy document (1995) we set out the need for

  1. A national strategy to tackle the determinants of ill health.
  2. The NHS to be democratically accountable
  3. Involvement and empowerment of users
  4. A strong primary health care system
  5. Separate strategic and operational functions
  6. NHS staff need to be valued, rewarded and have a voice
  7. NHS should become greener assessing environmental impact.

All these seven points are relevant to the subject of health improvement and democratic accountability.

There is renewed interest in tackling the growing health inequalities by addressing the underlying social and economic determinants of health and illness. The new Labour government has made an important first step by appointing a Minister for Public Health and the new health strategy will hopefully begin to map out a process to systematically address the structural , educational and environmental determinants of inequality.

The Health of the Nation strategy is being reviewed and a new national strategy to improve health “Our Healthier Nation” will be out to consultation later this year. This new strategy will take account of environmental causes of health and illness and propose policies to reduce health inequalities.

We will also learn about the governments plans to reform the internal NHS market at about the same time and herein lies an opportunity to “square the circle” – to improve the public health and achieve greater local democratic accountability in the new NHS. This is why we need to weave local democratic accountability into the health improvement agenda

NHS accountability

The NHS as a national service obtains its political accountability through Parliament and the Secretary of State for Health. This is appropriate for the national level but the SHA has always been concerned about the democratic deficit at regional and local levels. The last government abolished regional health authorities that despite their limited democratic credentials were statutory authorities responsible for the NHS services in a geographical region. The regional offices are now part of the central government function.

Scotland and Wales have their own Secretary of State and own Chief Medical Officer. With devolution their autonomy in managing and resourcing health services will increase. The concept of subsidiarity is important for English regions and local government too.

The issue of democratic accountability has always been integral to wider socialist policies and not isolated from the social-political context Over the past 20 years the SHA has been developing practical models to improve democratic accountability in the NHS that took account of the changing political context. The models range from direct election to health authorities to the integration of NHS commissioning with local government.

Models for improving democratic accountability

At the 1990 Labour Party conference the SHA had a resolution passed which stated 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”

This resolution reflected our view at that time which involved direct elections, staff elections and voluntary sector involvement. This was at the time when the concept of electoral colleges was prevalent and the need to address the interests of the various stakeholders.

Following the Tory reform of the NHS in 1990/91, which led to the internal market, our 1994 resolution to Labour party conference on the Future Governance of the NHS stated:The SHA re-affirms its commitment to democratic control of the NHS at all levels and calls for:

  • The health service to remain a national service, free at the point of use, accountable through the appropriate ministers and funded from central taxes in accordance with national standards.
  • Democratically elected regional government structures would have a role in planning, the monitoring of standards and quality control.
  • Local authorities to be given the planning and commissioning function for their populations. This would involve assessing the health needs of their areas, planning how to meet those needs, commissioning health care provision from separate NHS units with the involvement of GPs, and monitoring outcomes.
  • Trust status in its present form to be abolished and replaced with groupings of provider units rendered accountable to the NHS through the regional tier (as in (2) above), but with management bodies representative of the communities they serve.
  • CHCs to be retained as independent bodies, providing a voice for local communities and service users separate from the commissioning and service providing authorities, given statutory rights to enable them to exercise their functions properly, and with sufficient resources.

This reflected the new purchaser/provider separation of the internal NHS market and articulated the potential local government role in local commissioning as well as describing the national, regional and local structures.

In our response to the Labour Party policy document Health 2000 in 1995 we had a section on democratic accountability which identified five levels of democratic input which is still relevant today

We believe that there are five levels

  1. The centre through the Secretary of State needs to be accountable to Parliament
  2. An intermediate regional tier based on recognisable and geographically consistent boundaries that have co-terminosity with local government structures. These should be the location for regional government and the NHS strategic functions be part of their responsibility. They will also have a developmental and regulatory function (including NHS providers)
  3. Local NHS commissioning and planning needs to become a revitalised local government function and derive their local democratic accountability through locally elected councilors. Local commissioning would be constrained by a ring fenced NHS budget determined by a national formula and the responsibility to work within the national NHS framework and attain minimum quality standards.
  4. Hospitals and Community Units will need to be run by boards that have representatives of local government, health professionals, user groups, staff and other relevant interest groups. Providers will be part of the NHS and accountable upwards through the regional health authorities and to their local commissioning authorities.
  5. CHCs should be strengthened by developing their statutory rights in obtaining information and providing a regulatory role. Their boundaries should be coterminous with relevant local government and health authority boundaries. They also need to develop links with neighbourhoods where local organisations and people can be involved and participate.

Formal and informal democratic participation

These models depend on empowering individuals themselves by raising self-esteem through full employment, sound educational achievement, citizenship and opportunities for participatory democracy. A bottom up approach starts with the individual and integrates this into a social/political hierarchy with the individual, their family and social network, the neighbourhood, local area, region, nation state and international/global connectivity.

In such a hierarchy, which starts at a personal and neighbourhood level, informal democratic forums will be common and community development an important vehicle for health improvement. Empowering individuals and strengthening communities lie at the heart of “Health for All” policies. These personal and community levels allow for participatory and informal democratic inputs. Above the community level the structures become more formal representational democratic structures as in local and national government.

Building up democratic participation and democracy

NHS Population Governance
Specialist Formal
DOH 50 Million National
Region 5-10 Million Regional
DHA 500,000 Unitary/County
Locality 100,000 District
Practice Generalist 10,000 Informal Neighbourhood
Patient 1 Citizen

Fig 1. Building up democratic participation

Local government and NHS governance

There have been concerns about the risks of local government becoming involved with a National Health Service that might lead for example to conflict between national and local priorities. In addition NHS trade unions and others have been concerned about NHS workers becoming local government employees.

In assessing the risks and benefits of any change we need to consider the overall socialist objective which we outlined in our policy statement “Putting People First” – a socialist health service for the 1990s.

“The overall objectives of a socialist NHS should be to create a system which reduces social and geographical inequalities, provides equal and good access to services, is publicly funded, is free at the point of use, is effective and efficient, ensures equal opportunities, is democratic and responsive and is a good employer. Moreover the NHS should increasingly work with local and national agencies to help create a healthier environment and to eliminate poverty in order to reduce health inequalities”

Our more recent policies have argued for an NHS provider system, which employs 99% of NHS workers, which would be part of the NHS Trusts not local government. There would still be an NHS with funds flowing through regional authorities, health authorities and local commissioning groups. The NHS would set minimal standards and the provision would be monitored through the provider networks, health authority and regional levels.

Local government however would have an input into local commissioning including client group plans involving health and social services e.g. mental health, older people, learning disabilities, and children. This would ensure that local care in the community strategies would be jointly developed and owned. The integration with local government would allow the pooling of personal social service budgets (PSS) with NHS budgets (HCHS and GMS) and thus defuse much of the health/social care divide. GP locality commissioning groups would be coterminous with local government boundaries and their budgets be part of the local level.

This more local focus also offers opportunities to knit in with primary care commissioning groups and achieve co-terminosity within local government boundaries. The public health function needs to be part of this locality based commissioning process providing generic corporate support as well as having links with more specialised public health resources.

Generalist and specialist commissioning

The NHS however is a complex system and local government populations are too small to commission the specialist services needed in a modern health service. The local health authorities, at county or metropolitan city levels, and regional level will therefore need to have responsibility for ensuring specialist health services, integration with locality commissions and have a public health specialist capacity at each level to help strategically plan and monitor services. This will need to tie in with regional government, and in the first instance with regional offices. Co-terminosity wherever possible is an important principle for inter-sectoral working.

In this way the integrity of NHS hospitals and primary care providers are safeguarded; local government is able to plan and commission local generalist services and integrated health and social community care. Health authorities commission specialist hospital services and regional level strategically plans specialist services, regulates local provision against national standards and has the necessary specialist knowledge and skills. National accountability is assured through the Secretary of State and Ministers to Parliament.


This policy paper has identified the differences between policies for health and health services. It has described how both these streams can be integrated through a system that improves the democratic input accessible to our citizens in such a way that the NHS is safeguarded and local government can play its role.

We are promoting these policies at a time when the structure of the NHS and the health improvement are being determined, and when the concept of democratic renewal has achieved wide acceptance for other areas of public service. There is a historic opportunity tosquare the circleto achieve improved health and enhance local democratic accountability in the NHS.

The SHA Council recognises that the model we propose is a framework which requires further detailed work to enact and also that as the social/political context changes it will need to evolve. We believe however that it is a good foundation for much needed debate and invite responses to it.

Appendix 1 – The Public Health Charter for Public Health

The following are the essential basis of every citizen’s right to good health
which provides the material means to remain healthy
that are safe, warm, dry, secure and affordable
that is safe, nourishing, widely available and affordable
that permits accessible, safe travel at reasonable cost and encourages fuel economy and a clean environment
that is properly rewarded, within or outside of the home, which is worthwhile and free from hazards to health and safety.
that which are protected from dangerous pollution and radiation, and planned to preserve and enhance our quality of life.
which provide care for those in need and support for carers, clean safe water and water disposal, adequate childcare and recreation facilities.
which give all the necessary information to keep us healthy, and the confidance and research to tackle the causes of ill health
properly resourced, free at the point of use and sensitive to our health needs
to good health regardless of class, race, gender, physical ability, age or sexual orientation
which gives freedom from war and from the threats of crime and violence
which recognises the importance of self-fulfilment and supportive social relationships and promotes these through the provision of domiciliary support and other services.