Making the NHS locally accountable
by Paul Gosling
Councils’ health overview and scrutiny committees were supposed to act as a system of local NHS accountability and improve co-ordination between local NHS bodies and council services. But a series of just published reports casts doubt on whether this working effectively.
A Health Commission formed by the Local Government Association proposes a range of new initiatives designed to drive accountability deeper. But it warns that accountability must start with a better public understanding of how the local NHS works, with few voters at present have much awareness. Less than half of people surveyed knew even what a PCT (Primary Care Trust) does. The structure of the local NHS is too complex for people to comprehend, concludes the report, ‘Who’s Accountable for Health?’.
Niall Dickson, chief executive of the health think-tank the King’s Fund, who chaired the health commission for the LGA, says: “It is not the general public’s fault that they are unclear who is responsible for providing their local health services – the system is complex and in the past has been almost entirely focussed towards national accountability.
“The government is now committed to devolving decision-making in health to local organisations, which makes it vital that they become more locally accountable. That’s not to say that most members of the public want to become health service planners, but that does mean local NHS organisations must be scrutinised effectively and be required to report to the local population and their representatives. The public does want to feel it is being listened to about how local resources are being used and how local services are run. As they stand the arrangements now in place will not achieve that.”
Dickson and his colleagues agree that local authorities are the main route to achieve local NHS accountability. But to be effective, more resources need to be given to councils’ health overview and scrutiny committees, along with allocating them a formal role in reviewing PCTs’ annual reports. Local authorities should have a formal role in strategic health authorities’ assessment of PCTs and they should be involved in the appointment of PCT chairs and non-executives. There should be encouragement of councillors applying for PCT non-executive positions.
The commission also proposes ways of getting PCTs and councils to work better together. This includes increased integration of service commissioning; attendance of the council and PCT at each other’s meetings; and local authorities debating PCTs’ budgets and commissioning plans. Perhaps controversially, the report also suggests that PCTs should use the foundation trust model of governance, despite the fact that earlier this month a joint report (‘Is the Treatment Working?’) by the Audit Commission and the National Audit Office criticised foundation trusts for also not being, in practice, sufficiently accountable.
The Local Government Information Unit has also just published a report proposing stronger NHS accountability through local authorities and their overview and scrutiny committees. The report – ‘Out of Control? The case for better health accountability’ – similarly casts doubt on the effectiveness of existing arrangements, pointing out that 59% of elected members do not think their local NHS is locally accountable. But nearly as many – 56% – believe that it should be, with elected members given responsibility for the design, delivery and monitoring of local health services.
Alyson Morley, author of the report and a policy analyst at the LGIU’s Democratic Health Network, argues that the overview and scrutiny function of local government works well “against all the odds” and that the health scrutiny function probably works best of all. But her report argues the committees need more resources, to become more respected and be more strongly connected to councils’ performance management systems for them to be a really effective system of accountability.
As the local NHS evolves, with a stronger focus on commissioning, so the challenge becomes greater for councils’ scrutiny of this process, points out Morley. “They are learning and getting to grips with the process,” she says. “But the focus on commissioning is a major challenge for them.” They also have a problem, she suggests, in intervening sufficiently quickly to have real influence.
Critics suggest that often the scrutiny function also needs to be better resourced in terms of the quality of membership, with the strongest councillors typically taking on the portfolio and shadow portfolio roles. “It’s true that most of the more ambitious local politicians do not see a long term future for themselves in scrutiny committees,” Morley concedes. “That said, I have known a lot of effective and committed chairs of scrutiny committees.”
Ross Willmott, leader of Leicester City Council, is one of the few councillors who already sits on the board of his local PCT, and is convinced that it helps the two organisations operate together more effectively. “It makes a significant difference,” he says. “I feel it has improved communication and the way we work together. I now understand how the NHS works – and I suspect very few do – and how we can work together on the health improvement agenda. It’s not like the one meeting a quarter that you would have as a leader, which is not enough to have an influence.
Willmott says that he wants this connection to be strengthened by other local initiatives. “We [at Leicester City Council] have set-up this ward community meeting structure and we are looking with the PCT about this fitting together with their own accountability structure,” he explains.
Andrew Cozens, strategic adviser for children, adults and health services at the Improvement and Development Agency, suggests there is much that the NHS can learn from local government – and much more where the sectors must work closely together. “There is a growing realisation that the previous approach that the NHS has taken has not narrowed the gap on health inequalities,” he says. “You can’t performance manage your way into better health. The NHS can’t deal with this until it is dealt with in a partnership approach which local government is involved with.”
Cozens makes the point that health secretary Alan Johnson admitted earlier this month that not enough was being achieved in tackling health inequalities. Cozens argues that the clear conclusion is that extra funding for the NHS has not affected health inequalities, which can only be tackled by cross-sectoral partnerships – particularly with local government. He stresses that the more ‘public’ aspects of public health policy are things that local authorities are best able to address – such as getting more people to use swimming pools and promoting the use of cycling to work, and also through lifestyle and parenting advice.
“The second area,” continues Cozens, “is in managing the market, where local government is streets ahead of the NHS because of the diversity of suppliers that local government has – there are about 30,000 suppliers of social care. The real difference between adult social care and the health service is that 60 or 70% of [social care] transactions are bought by the users themselves. So local government action really has been about making sure there are sufficient suppliers in the sector.”
Cozens believes that persuading local NHS bodies that they can learn much from local government could help bridge the local divides that remain. But the LGA and LGIU reports also make clear that if councils want to be listened to by local NHS bodies, that change will need to start from within – by giving their overview and scrutiny committees more resources to do their jobs.