England & Wales

Democracy, accountability – warm words but do health reforms live up to their billing?


The coalition says one of the main objectives of their health reforms is to make healthcare more accountable to local people – one of the tests must be, therefore, whether democratic accountability will be strengthened. No-one could argue that the NHS is a paragon of accountability currently. It looks upward to the Secretary of State and to regulators and auditors, but that’s it really. Local people hardly get a look in and councils have an important, but not really that powerful, scrutiny role.

As our forthcoming Local Health Learning Network suggests, there is bound to be growing debate about whether boosting the marketisation of healthcare will add to or weaken scrutiny and accountability. There are already patient advocates suggesting that the accountability to patients is actually weakened. For local government, however, the key questions are more about the proposed commissioning arrangements and the new role for councils in bringing health, social care and public health together at the local level.

For once, there does seem to be consensus here – over the principles anyway. The reforms give councils and, crucially, elected councillors a stronger role – with increased influence over commissioning plans and in promoting integrated working across health, social care and public health. The main vehicle, the Health and Wellbeing Boards, are statutory bodies and there are duties on GP consortia to work with the council on preparing joint needs assessments and health and wellbeing strategies.

Yet there are concerns: Although the boards are statutory, it is questionable what real powers they will have to challenge commissioning decisions. The Bill creates a new, powerful economic regulator (Monitor, which has massively increased its powers). The powers of Health and Wellbeing Boards are much weaker than Monitor’s. The NHS Commissioning Board will also be extremely powerful with wide ranging powers to direct and influence commissioners. How strong will the boards be in demanding engagement from powerful foundation trusts and independent GP consortia?

GPs will be, in many cases, delegating commissioning to private organisations which will make the task of local authorities and the new boards even more difficult. There are also wider questions over how GP consortia will be scrutinised and held to account.

Going back to the original question – whether local democratic accountability will be strengthened by the reforms that directly affect local government – the answer is not black and white – the framework will exist for significantly increasing elected councils’ influence over local commissioning and over joint working to improve health and wellbeing outcomes for local people, but there are barriers to making this work effectively. The reforms as a whole are a risk and unpredictable: the changes to local government’s role are far less contentious – it is up to the government to make sure they work as intended -and to local authorities to make their voices heard in the debate around the Bill: these issues aren’t marginal and need to be taken seriously, and they could be critical in improving the wellbeing of local communities, not to mention in bridging the current democratic health gap.

Local Health Network 2011

In healthcare we’re about to see a big transformation in the way services are provided. Local authorities will have new responsibilities to bring together health, social care and public health at the local level. All local agencies will be expected to contribute to reducing health inequalities. There will be real opportunities, but also significant challenges, for everyone involved.

Councils will be required to make rapid, informed decisions about strategic issues. The aim of the Local Health Network (LHN) is to prepare those affected for the changes happening in health provision and to plan for healthy local communities. LHN will build knowledge, facilitate workshops and spread learning through face to face meetings and through social media.

LHN will meet four times between April and December 2011 in London.Subject to demand, the meetings will be repeated in the North and the South West. The programme will be shaped by the participants; an initial programme is set out below.

Take part

Download more information about the Local Health Network. If you have any further queries or would like to take part in the network please contact Laurie Thraves, laurie.thraves@lgiu.org; tel: 020 7554 2800.