What do you mean by greater local accountability? Health Policy Today, 17th September 2008

The Labour Party want to devolve power in the health service to those best placed to make decisions.  The Conservatives criticise the centralizing tendencies of the government and favour greater localism.  The Liberal Democrats remain strong advocates of local accountability and decisions made locally.

Today’s HPT wonders, what are we all arguing about? All united in a common desire to empower local people, it should be straightforward to achieve.  No? Just what do the parties mean by achieving greater local accountability and is it the same thing?

LOCAL HEALTH WATCHDOGS – THE CONSERVATIVE APPROACH

The Conservatives' notion of greater local accountability is to enhance local local consumer rights.  Their community creation, HealthWatch, would create local consumer councils who would influence local providers on the needs of consumers.

The Conservative conception seems to be that the centre should set the reform agenda – involving taking the Blair agenda to its logical conclusion: greater competition and more choice.  Local consumers would hold managers to account over their ability to implement the national reform agenda.  Despite their language, the Conservative vision is quite centralist.  The difference from now?  Instead of central government haranguing local managers over their implementation record the local population will do it instead.

The risk for the Conservatives is that the evidence suggests that local populations do not always have the same priorities as central government.  They are unlikely to play their part as consumer agents, acting as economic agents in a quasi market for health services.

Of all the political plans, it is the one that seems least thought-through, yet it could be argued it is the one most in tune with the Blairite reform agenda, which despite all debate is still dominant. It is one that could logically fit with the current reform programme, yet it is unlikely to be effective as it would recreate the problem of the (once they had demised) much loved CHCs.  They would be dependent on the dedicated local middle-class to lead it and not necessarily engage the whole of society, especially with few resources.


LABOUR AIMS TO EMPOWER COMMUNITIES

Labour say they aim to empower communities.  A green paper that was published in June is peppered with statements reflecting this ambition.  The introduction to the paper contains an analysis which would be strongly shared by both Conservatives and Lib Dems.

'Labour say they now wish to devolve power to those who can use it effectively, but in order for this to work, they need to strengthen local accountability.'

The gist of it is that government in the late eighties and nineties, in order to respond to perceived poor performance in the public services, intervened more regularly and over time the mechanisms for delivery became centralised.  The first Labour government continued this trend, they say, because they needed to establish a strong national architecture and a platform from which to move forward.

Labour say they now wish to devolve power to those who can use it effectively, but in order for this to work, they need to strengthen local accountability.

So far so good; in fact, this analysis would be shared by many, though Labour’s motivation for devolving might be questioned, particularly in the face of a consistent critique from the opposition parties that Labour is addicted to intervention and incapable of letting go.

Critics point to the measures suggested in the Green Paper, describing them as ineffective posturing.  The main stay of the policy proposals are petitions.  If a set number of signatures are gathered, then the local authority is forced to respond.  Never mind that a lot of time may be wasted responding to duplicate, time-consuming and irrelevant requests (think of the petitions on the Numer 10 website).

The real problem is the body being held to account is not responsible for the delivery of the service.

Labour would defend itself by saying there is little appetite for elections to health boards.  It has lots of initiatives to try and improve local accountability and part of its reputation for weakness in patient and public involvement is that these initiatives are seemingly unconnected.

It is possible to feel sorry for Labour and Gordon Brown at this time.  Everything it does is interpreted negatively.  It was possible for Nick Clegg, in yesterday’s speech yesterday to extol the virtues of government policy, while taking credit for it.  Nick Clegg talked about the empowering qualities of personalised budgets.  He told a story about a constituent who has benefited in important ways from having a personal budget.  He could have been promoting Labour policy, as it was this Government that introduced the initiative.

But Clegg doesn’t need to fear praising Labour policy, because in the current climate, almost nobody is prepared to give them credit.

The reason Clegg can get away with it is that few seem to have faith in what the Government say.  Some don’t think the Government mean what they say – in some cases rhetorically following the Blairite agenda without really believing it.

This seems to be the view of Alan Milburn,  writing in the New Statesman today .  He says that though Brown says he wants to place power in the hands of people, a number of initiatives point in the opposite direction.

He writes, ‘Interestingly, all three main political parties are toying with the notion of moving power from one to the other. Nick Clegg wants a "People's NHS" to realign the Liberal Democrats as less big-state and more individual-citizen, but many in his party oppose such talk. David Cameron talks of "shifting power from the state" to charities and communities, but they simply lack the capacity to deal with the modern challenges brought by a globalised economy and a diversified society. And while it is welcome that Gordon Brown embraces "a new politics that places power ... in the hands of people themselves", a splurge of Whitehall initiatives seems to point in the opposite direction. This half-in, half-out approach won't work. Uncertainty has to make way for clarity.

Milburn doesn’t offer any detailed solution.  But he says both the police and health services should be accountable to local populations via the ballot box.  He seems to be on the same page as the new Liberal Democrats.

LIB DEMS PUSH FOR GREATER LOCAL ACCOUNTABILITY OF DECISIONS

In Monday’s speech to conference, Norman Lamb littered his speech with references to giving local communities more power.  Lamb said he would change the name of PCTs to health boards.  These would either commission independently, with advice from the local authority, as is currently the case, or if there is a local preference for a local authority to take on these functions, they would allow this too.

Norman Lamb praised Sweden and, as I mentioned here on Tuesday, this is a country that all politicians use to evidence their particular ideas.  They can do this because a variety of approaches are evident across the country.  From Stockholm, with its strong purchaser-provider split, to Norbotten (in the far north) where large hospitals are few and far between and located in the larger towns.

I mentioned as well yesterday that the Swedish people I have spoken to are not exactly enamored by having elected health boards.  The voter turn out isn’t very high and there is a sense that these bodies lack power.  The same appears to be true in New Zealand, according to this week’s BMJ.   An editorial by Robin Gauld explains that New Zealand’s centrally funded district health boards were created in 2000 to facilitate local accountability.  But the boards have suffered from problems of ‘low voter turnout, a lack of public interest, and the inability of these boards to challenge national policies have undermined the spirit of the system’.

These accounts beg the question, should local accountability be more firmly embedded in local government, to provide a stronger democratic link between local elections and the delivery of public services?  Is the problem in Sweden and New Zealand that the elections are not taken seriously because they do not believe that elected boards have the power to make changes to services?


ENSURING LOCAL ACCOUNTABILITY COULD BE AT ODDS WITH SOME CENTRAL POLICY INITIATVES

The King’s Fund report earlier this year, Should primary care trusts be made more accountable locally? says that reform in local accountability should be taken forward without clarity on the objectives reform is designed to achieve.

The difficulty is that local accountability does not exist to fulfill central policy objectives.  As Robin Gauld’s editorial says, success depends on what accountability is aimed to achieve.  Is it about taking people’s views into account? Gauld says, if the aim is to hold local decision makers to account then the direction of travel should be to transfer health decisions to locally elected officials.

The lesson is an important one.  Policymakers should be clear about what they intend to achieve by increasing local accountability.

Would the Lib Dems have local communities overthrow national decisions?  If Labour’s plans are to gather a wide-range of voices, what will be done with these views?  How will differences be squared?  And, if the Conservatives’ HealthWatch gather examples where consumers are being given poor service, how will providers be forced to respond?

With an emphasis on consumer feedback, who will provide the collective voice of a community on the development of local health services?

The problem with all the main political party solutions to the enhancing localism is that they are all keen to avoid a local political process, for facing different views towards one another and aiding better understanding of the complex trade-offs involved in spending financial resources.  Although it is often said that there is too much politics in the NHS, it could be argued that there are not enough.  A cause of local anger and frustration is an ability to be able to talk about and debate issues about the distribution of resources.

THE RISK OF DUAL ACCOUNTABILITY

One of the problems in both Sweden and New Zealand, it seems, is that there is confusion about who is being held to account, local managers of resources, whose hands are tied by the budgets allocated to them or central government who will say it is up to local decision makers to take difficult decisions with precious resources.

The problem with dual-accountability is that neither central nor local government is effectively held to account.

The problem of dual accountability will never be removed. The challenge is to achieve political clarity about what local authorities should be held to account for and where their hands are tied, with the legitimate target being central government.  For example, central government might be responsible for setting out the treatments which are part of the comprehensive and universal services available on the NHS.  There is then a need to clarify whether national rules determine who receives available resources or whether this is determined locally.

The point that the political parties seem to miss is how to effectively engage patients and communities with political perspectives.