A National Health Service - Locally Run
“Give people a real say on how their local NHS works by giving to locally elected people the powers currently held by unelected bureaucrats.”
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2. How does it fit with Compass’ core beliefs of equality, solidarity, democracy, freedom, sustainability and well being?
Three in particular:
Solidarity: making decisions together locally on the NHS would provide new opportunities to work together for the common good.
Democracy: local accountability could happen either by giving powers to existing local government, or to new ‘Health Boards’, but in either case, it would greatly democratise a system in which accountability is almost no-existent.
Well being: evidence from countries like Sweden and Denmark shows that localised decision-making leads to people being more spend more on for healthcare, through local taxes, and this has a positive impact on health outcomes.
3. How does it build the institutions of social democracy, like social groups and collective and cooperative forms of ownership and control?
Greater local control of healthcare would help people start to believe that we are all in it together. For example, if part of a hospital was due to close (and my local hospital has lost maternity services since 1997) due to costs, people could work together locally to keep it open. If money could be raised through local taxes, with a specific local result, then people would be less tax-resistant and would see that the only way of providing such facilities for all was to collaborate collectively. This would be a new form of ownership and control.
4. How much will it cost or raise and where will any cost come from?
The cost is what people want it to be. In the first instance, the NHS would cost the same as it does now, and money would be spent in the same ways that it is now. But instead of unelected bureaucrats making decisions on how to spend money in future, elected local people would do so. There could then be a rational discussion with local voters about how much they were prepared for their taxes to be for extra spending, with clear choices. As in other countries, an equalisation system would protect the poorest areas form losing out.
5. Which groups in the electorate are likely to support or oppose this measure? Is there any polling evidence you have on this?
This proposal should be popular with all who feel that the health service is too remote, and want to get more control locally. The clearest evidence of popularity is that of Denmark, which has a highly localised system and has the highest satisfaction ratings for its health system in the most recent cross-EU study (1998 Eurobarometer survey).
6. Is there a place or country where it’s worked? Please provide some information.
Yes - Denmark, which has a highly localised system and has the highest satisfaction ratings for its health system in the most recent cross-EU study (1998 Eurobarometer survey). It also has high ratings on health outcomes. Sweden also does well on health outcomes - across social classes - in a very localised system.
7. What are the three main arguments in favour/against it?
Spending works - since 1997 (and particularly the 2002 Comprehensive Spending Review) money has been poured into the NHS. Yet despite some obvious achievements on waiting lists, many are still sceptical about whether spending really works. Only if they can see local results for the money they pay in taxes will they be persuaded that spending works.
Democracy works - you can get specific results on issues that matter to do by turning out and voting.
Collectivism works - people can get the best public services by working together, not by going private.
The issue is not really the unelected bureaucrats. We will always have them. The real issue is who they are answerable to. In effect the only elected accountable people in the NHS are the ministers in each of the 4 countries. In Wales and Scotland and NI that seems to give a degree of local accountability, though in Scotland there is pressure to elect local health boards. But in England there is an issue about where to introduce democracy. A regional tier would be most logical, but we don’t have the infrastructure to support it. We could elect PCT boards. But maybe what we should be doing is giving the commissioning responsibilities of the PCT to elected local councils.
If real power is devolved to local bodies then differential provision is inevitable, no doubt followed by an outcry over the ‘post code lottery’ in health care.
Until local government re-organisation in 1974, primary health care was managed by a local ‘Medical Officer of Health’, who published an annual report and was answerable to a ‘Health Committee’ of local councillors. Sometimes, other members of the local community served as co-opted members. It was a system which worked well, but the government wanted to unify NHS services and create regional and local NHS bodies to manage all NHS services — which is how and why we lost democratic control. In return for this loss of control, we were given Community Health Councils, which worked well in some cases, but New Labour abolished CHCs ten years ago, since when we have had no real local input into NHS services, which is accountable to local people in any real way. Of course the local control of NHS services will bring local and regional variations in services, but different parts of England have different needs and priorities. Personally, I believe local communities and councillors, as our elected representatives, can be trusted to manage health services once again. As someone who worked in the voluntary health sector for over thirty years, until I retired, I am in no doubt that many ‘professionals’ believe they know best and regard councillors and local communities with patronising disdain. The NHS can, and should, be run by local people and local NHS staff.
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