Democracy and "postcode prescribing"

Standards in the health service have never been uniform. Inner London Teaching Hospitals were traditionally better resourced than the rest of the country, and in the 1960s any increases in resources were gradually shifted away from those hospitals. Meanwhile it was possible for patients to be referred to the hospitals specialising in particular conditions or treatments or having shorter waiting lists. This was useful for patients with the knowledge where to go needing treatment for conditions they regarded as critical, but was less useful for conditions that were uncomfortable or inconvenient, where traveling long distances would be a bigger deterrent. Referral outside the local area became more difficult about 1990 with the introduction of the Internal Market. Since then purchaser health authorities have made contracts for their residents, often exclusively with particular hospitals, giving much less opportunity to shop around for a short wait. Purchasers have also established different policies on expensive drugs and treatments, leading to criticism of "postcode prescribing".

One example of inconsistency of policy is the availability of homoeopathic medicine.  Homoeopathy has been available on the NHS since 1948.  Many patients have experienced beneficial effects from homoeopathic treatments, which are invariably much cheaper to provide than conventional treatments.   However individual patients often experience difficulty in getting homoeopathic treatments for two reasons.  Only a minority of general practitioners have any practical knowledge of homoeopathy (other than saying in general terms that they don't believe in it) and only a minority of health authorities are prepared to pay for homoeopathic treatments in the few NHS hospitals that provide such treatment.  A patient who drew attention to this inconsistency received in August 2001 a letter from the NHS Executive, saying:

"... However it is important that at local level decision-making should reflect priorities of local people in the provision of services.   The availability of complementary medicine treatments within the NHS therefore reflects decisions taken by Health Authorities, Trusts and Primary Care Groups as to the clinical and cost effectiveness of such treatments, and the priority given to their provision in the light of local health needs. ..."

This would be a persuasive argument if the local bodies were democratically elected and democratically accountable.  Then the responsible bodies would need to justify their decisions, and anybody aggrieved would be able to produce their own evidence of clinical and cost effectiveness and get flawed policies changed through press campaigns and ultimately by changing political control through elections.  But the existing bodies are appointed by the Secretary of State.  If they are accountable to the Secretary of State, he should be held accountable for every flawed decision or local inconsistency.  Otherwise the local health bodies are accountable to nobody.  It makes no difference if the members are local residents, or even if they are also local councillors, if the local council is not able to appoint them or to remove them.

Peter Lilley in The Guardian 19 June 2000 suggested restoring patients' right to be referred to the hospital and consultant of their choice, regardless of local boundaries and contracts, just as parents can send their children to local authority schools outside their area.

Although some patients will travel long distances for life-saving and other critical treatments (and the fact they are doing so will provide local health authorities with useful information of shortfalls in their own services), for health education, preventive work, and treatment of chronic or less critical illness and disability, adequate local provision is the only way of meeting local need. Ensuring this, and making the people providing services locally democratically accountable, are sufficient reasons for electing local health authorities.

The proposal for Foundation Hospitals to earn greater freedom will cause inconsistency.  As the greater freedom will apply to management, the test of democratic decision making is failed.  Even if Supervisory Boards include local politicians, the Government is not proposing that they should be directly elected in that role, so there is no democratic accountability.  In any event, democratic accountability needs to be to communities.  Hospitals work with a fluctuating group of patients, often from wide areas, and usually for a temporary period of treatment.  They need to be accountable to the community through elected Primary Care Trusts, and any delegation of management fredoms should be by those bodies and not by ministers.