Tribune March 2002
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Campaign for Health Service Democracy Why do we need a campaign? Hospital closures, high patient mortality, dirty and badly equipped wards, suspension of doctors and nurses who expose the failings at their hospitals: these are all issues that can be guaranteed to get a large and angry gathering at a public meeting. And yet the NHS is one of the public services with the least democratic accountability. When the NHS was founded the main reform was to make medical consultations and treatment free of charge at the point of use. This brought enormous benefits in making simple treatments accessible to everybody for the first time. The management model was local administration by ministerial nominees, with ministers in London accountable for the whole service. That made sense for a few years of centrally directed radical change. But the NHS has suffered from lack of local democratic accountability and from a succession of failed national reorganisations, which have taken away all effective accountability for local decisions. Bad management has been put right by the law courts more than by ministers. Patients who are injured can more easily claim compensation than change the policies that cause the injury. The local NHS bodies in existence in April 2002should all be made democratically accountable, starting with directly elected Primary Care Trusts, which would appoint representatives to the other bodies. There should be no more nationally led reorganisations of the local level of the NHS. There is much for local democratic bodies to do. The professional culture needs changing. There are many examples of patients and their relatives treated with contempt, whether that is shown by ridicule, threats or lethal injections. Subordinate staff are treated as badly, including dismissal for unprofessional conduct because a patient against instructions stayed alive. Consultants’ policies based on prejudice like refusing surgery (such as for a broken hip) to patients who are mentally infirm and arbitrary age limits for resuscitation need to be reviewed. Strategic decisions such as whether to concentrate specialist services for a large area at a centre of excellence need active public consultation that can best be achieved through a democratic body. Too often decisions are taken to close a hospital department, not because patients would get better treatment at a larger but more distant hospital, but for bureaucratic reasons connected with limited training opportunities for junior doctors at small hospitals. Such problems need to be resolved, perhaps by joint appointments, without imposing serious inconvenience on patients. Democratically elected local bodies should have both policy-making and scrutiny roles. The local policy making role can be reconciled with a national service with national entitlements, provided that individual patients can choose treatment in another area. This works for school admissions. Local democratic bodies would try to provide as far as effectively possible convenient facilities for consultation and treatment for their own residents, but are never likely to be able to provide every specialist facility. The Government is currently moving to devolving decision making to local managers, with scrutiny by existing elected local authorities and by Patients’ Forums linked to every Trust. This proposal is still untried. Community Health Councils, which are not democratically elected and have varied in effectiveness in their scrutiny role over the last quarter century, are to be abolished before the new system will have been operating for many months. To the extent that the same people will be moving from Community Health Councils to Patients’ Forums, the decision to abolish Community Health Councils virtually at the same time is understandable, but it has diverted attention away from how the new scrutiny arrangements will work. It is far from clear how representative of patients the new Patients’ Forums will be or how they will be able to claim a mandate for any stand they take. The new arrangements will still be too centralised. Appointed local managers will make policy on matters such as closure of hospital departments, and if the local authority’s scrutiny committee disagrees the decision will be referred to ministers for a final decision. It would be better for the final decision to be taken locally. Then if there are valid reasons for the patients’ benefit for a hospital department to close, the local democratic body will need to be satisfied and then to justify the decision to its electorate, whether through a referendum or at the next normal election. The new scrutiny arrangements need to be made to work. But local democratic control of the NHS must also be introduced. Campaign for Health Service Democracy. |
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Sheila
Porter-Williams |