England & Wales

local health services and accountability


Feedback from our big debate on health accountability last week, hosted with the All Party Parliamentary Local Government Group. We had a mix of local authorities around the table, represented by Councillors and officers working in the health field, with health practitioners and national health organisations such as the NHS Confederation and the Kings Fund, and a cross party turnout of MPs and Lords.

We set the scene with an LGiU perspective on health accountability arrangements, too much central control, and at local level, weak accountability, with most parts of the system, such as Primary Care Trust boards, representing provider interests. More broadly we asked about service integration, how far this is developing in communities, how well local councils are working with health providers, and the extent to which (jargon alert) ‘joined-up’ commissioning is happening. To see more of our analysis, here is the LGiU’s ‘Out of our control’ pamphlet summarizing the debate, and our ‘Getting to the heart of accountability’ paper which sets out our overall model to strengthen local democracy and improve public services through better commissioning.    The key themes that emerged in the discussion were: 

The impact of geography – how the areas covered by health providers and local councils (including two-tier issues) are so variable that it makes joint working more complex and creates problems in trying to hold health services to account in e.g. local scrutiny processes.      Some in the room, mainly the MPs, proposed structural changes to address this, such as a wholescae shift to unitary local government and PCTs on the same boundaries, but the consensus was that structural change is a distraction and what is really needed is a pragmatic approach at the local level to improving communication and collaboration.  The LGiU was asked to help by sharing good practice ideas, which we will be doing in our seminar series.   The Councillors in the room were particularly strong on the need to concentrate on people not structures, with the message that people don’t particularly care who is providing the service as long as they get the service they want.  

On accountability there was a predictable divide between the local Councillors, who think accountability is weak, and the health organisations in the room, who argued that the current models broadly work.    Councillors and local officers gave examples of how they are currently influencing health service provision for the better, through local strategic partnerships, local overview and scrutiny, and some joint appointments and joint commissioning, but the general feeling was that there is an accountability gap.   Local health boards, such as the primary care trust board and the hospital boards, including new Foundation Trusts, give very little opportunity for local people to have a real say in shaping health services.   The new LINKs services, which replace the Patient Involvement Forums, which in turn replaced the Community Health Councils, are not seen as a success.   All of these changes took place within five years, which is part of the problem.   Central government too readily interferes and shifts the deckchairs around.   The councillors who commented on these issues when I asked on twitter were unimpressed by LINKs, but some thought they have more power than council health scrutiny committtes, which some say the PCT won’t even attend.  

As for some of the national organisations in the room, particularly the health sector, I could not agree that decision making in the NHS is too complex for the people to have more of a say.    I would argue that if people want to retain a local community hospital, even though the NHS says it should be closed, then that should be an option, but in the current system it seems that Whitehall always knows best.   The ‘postcode lottery’ debate needs to be turned around to a positive approach to local diversity of provision.  Everyone knows that health services vary greatly from one area to another, what is missing is the chance for local people to shape their local services so that they meet local needs, particularly as variation is only going to increase with the combination of tighter funding, rising demands, new medicines and technology.    

So what is the answer?   Directly elected health boards have been proposed by some, but the LGiU opposes this mode because we believe it will fragment and weaken local democracy.    There was an idea that PCT Boards should be reformed with half the membership being local councillors, similar to a police authority.    I was interested in this idea and will be looking at it further, do comment if you have views either way.