26 April 1998

The Health Strategy Unit,
Room 535,
Department of Health,
Wellington House,
133-155 Waterloo Road,
London SE1 8UG.

Dear Sir/Madam,

I am writing on behalf of the Campaign for Health Service Democracy to comment on the Green Paper, Our Healthier Nation.

We are pleased that many of the disappointing features we identified in our response to the White Paper: The new NHS have been put right in the Green Paper. Nevertheless the Green Paper fails to recognise the fundamental need for accountability to communities through their democratically elected representatives at all levels of the Health Service. This will impact on the questions in Chapter Three: A Contract for Health, especially (i) Obstacles and (viii - xi) which all relate to working across institutional boundaries or barriers.

Ministers’ accountability to Parliament works for issues of national policy. For issues of local policy and administration, Ministers cannot have the attention span or the political incentive to second guess decisions made by local managers. When Ministers do involve themselves personally at local level, it is too frequently to set headline targets, such as "Reduce waiting lists or be sacked", that can be met by perverse means such as by rejection of prospective patients or by use of quick and cheap but ineffective treatments.

Consulting patients and communities is an essential ingredient in democracy, but it is not sufficient. Consultative processes leave the initiative with health professionals and managers habituated to the culture and blind spots of the NHS organisation. Questions to which professionals and managers have not thought of answers are difficult to ask, and it is even more difficult for the community to promote research aimed at finding answers to those difficult questions.

A democratic Health Service is needed for at least the following reasons:

as an aspect of the general principle of communities governing themselves;

to secure communities’ acceptance and ownership of short-term priorities and longer-term strategies for health care, including difficult decisions;

to co-ordinate interdependent public services which may (but for democratic intervention) be managed from a narrow professional perspective;

to ensure that Health Service employees are accountable to their communities not only for their actions but also for their refusing to act.

The first three of these points are inter-linked. As the Green Paper clearly recognises, improving any aspect of the community is likely to need action from several directions - employment, environment, housing, education, domiciliary, residential and health care - through different administrative units. Success is likely to depend on the whole community owning the strategy and on the people governing the administrative units being democratically elected and having overlapping knowledge and interests which collectively cover the spectrum of the community’s concerns.

The fourth point is very much linked to my own experiences. My mother has Alzheimer’s disease, and over eight years two surgeons gave that as the reason for refusing different necessary surgical treatments. They were operating a discriminatory policy for which they were accountable to nobody. Both conditions in my mother’s case were treated eventually: the first when she moved to a different Health Authority area; the second when the responsible Unit General Manager arranged a second opinion after I had involved my MP and broadcast on local radio.

But both surgeons are probably still following the same discriminatory policy. To stop them will, I believe, need legislation, which could take either of two forms. It could be made law to stop the specific mischief by preventing the use of mental illness or infirmity as a reason for refusing treatment for a physical condition. Or, much better, it could be made a requirement on every Health Authority to issue binding policy statements (probably including national core elements) on criteria for treatment or non-treatment of medical conditions; as the Health Authority would be democratically elected, anybody aggrieved by the policy would be able to use the normal political process to get it changed. Either way, it is imperative that professionals should be responsible just as much for their decisions to refuse or postpone treatment as for the treatments that they perform.

A further obstacle to partnership and to improving performance is the culture of the medical profession working in hospitals, in which consultants almost own their patients. This is most obviously perverse where a consultant disowns a prospective patient, who then becomes nobody’s responsibility. It also prevents effective service when a local out-patient service is tied to consultants at one remote hospital. To take one local example, when the Rugby maternity unit closed, the community was advised that ante-natal classes would still be provided at Rugby. and that prospective mothers would have the choice of maternity care at Coventry, Leicester, Northampton or possibly other hospitals. Later, after the key decisions had been made, the news slipped out that the ante-natal classes would be restricted to prospective mothers planning a delivery at Coventry. That is not the sort of decision that would be made by a democratic body accountable to people of the Rugby area and seeking to minimise the inconvenience of closing the local maternity unit.

Regarding Chapter Four: Targets for Health, we are concerned that, while it is appropriate to target particular conditions for special attention nationally, the way it is done could create perverse incentives. This could apply both to the age ranges proposed for the national targets and to the treatment of conditions not subject to national targeting.

There may be good statistical reasons for recognising age in targets for reducing deaths from specific diseases; if everyone dies of exactly the same diseases five years older than they would have done ten years ago, that is a significant improvement which needs to be measured in some way. But a cut off at age 65 appears to devalue older people, and statistically it is too crude, and could lead to diversion of treatment resources, or, more insidiously, insufficient attention to screening, for older age groups. These problems could be reduced by targeting significant improvements for a series of age bands (0-50, 0-65, 0-75, 0-80, etc). Where a single measure is needed for national comparisons, all the data should be used and inversely weighted by age.

As for the conditions which will not be targeted for special attention nationally, it is important that they should all be monitored, if only to confirm that they do not get worse as a result of diversion of resources. Local targets should seek the biggest improvements for the conditions which locally are worst relative to national norms, and in extreme cases local targets should take precedence over the national targets. This will be much assisted when Health Authorities are democratically elected and in the best position to exchange views on priorities with their residents.

I will also send an electronic copy of this letter to the Department’s Internet site.

Yours sincerely,

Sheila Porter-Williams