The Health White Paper is flawed..

At the end of May I attended the Special Conference of the Liberal Democrats that endorsed, with an overwhelming majority, the Coalition Agreement.

As a Liberal Democrat I was supportive of the principle of democratising PCTs and pleased that this featured in the Coalition Agreement. It specifically mentioned stopping “top-down reorganisations of the NHS” and also promised “We will ensure that there is a stronger voice for patients locally through directly elected individuals on the boards of their local primary care trust (PCT). The remainder of the PCTs board will be appointed by the relevant local authority or authorities”. That appeared to follow the spirit of the manifesto we fought the General Election, so hats off to the negotiating team The Conservatives had made much of maintaining funding for the NHS above the rate of inflation whatever else happened to public spending, so bringing these two promises together made sense.

Two months later and the Health White Paper describes one of the biggest structural changes that the NHS has ever faced in its history, at a time of constrained budgets and after a General Election during which both coalition parties gave no messages that such a restructure was likely or indeed warranted.

So who then decided that the Health White Paper should propose top-down reorganisation, including the creation of an NHS Commissioning Board which will take decisions on the allocation of funding to GP practices, a centralisation of a power currently exercised by PCTs locally, and who decided that within two months of the Coalition Agreement that PCTs should be abolished?

While local authorities are given the welcome leadership role in conducting Joint Strategic Needs Assessments (JSNAs), the majority of decisions on commissioning services will be undertaken by GP Consortia. There is no proposal as yet to require GP Consortia to comply with the JSNAs when they commission services.

The needs identified through a JSNA in an authority like Camden would rightly consider the health needs of the many thousands of people who are not registered with GPs because of their transience within the area or because of their uncertain status in the community. These are the people who will attend A&E departments for treatment when necessary, but will not be part of the registered patient lists that GP Consortia will be commissioning for. So there could be a dangerous mis-match between what the Council believes is necessary and what is actually commissioned by GPs.

The White Paper talks about public accountability but proposes to absorb the functions of overview and scrutiny committees into the Health and Well-Being Boards. This new hybrid animal appears to have a mix of roles, which in my view are not compatible with each other. It will have strategic decision-making functions with regard to JSNAs, will be a body to promote “joined up thinking” between health and social care, and have scrutiny functions too. Who scrutinises the Boards is left dangling in the latest consultation paper - “Local Democratic Legitimacy in Health” for in paragraph 50 it states - “A formal health scrutiny function will continue to be important within the local authority, and the local authority will need to assure itself that it has a process in place to adequately scrutinise the functioning of the health and wellbeing board and health improvement policy decisions.”

So scrutiny committees are disbanded and then recreated to scrutinise the Health and Well-Being Boards. That does not look very joined up or logical to me. The separation of Executive and Scrutiny functions within local authorities eight years ago continues to have its critics but this latest proposal blurs these distinct roles, and the loss of effective scrutiny will, in my view, be the result.

Creating GP consortia to undertake commissioning on behalf of patients may have its virtues but there is no evidence that GPs have the inclination or the expertise to undertake the role successfully without themselves delegating many of the commissioning tasks to a range of unaccountable bodies from the voluntary or private sectors. I am not clear how this squares with the Coalition Agreement’s declaration that - “We will significantly cut the number of health quangos”. We might need to redefine what a quango is in this context but if something looks like a duck and quacks like one it will be seen by the general public, and by local politicians as their community champions, as another class of body which spends public money but is unaccountable to the local community.

The recent example CAMIDOC going into liquidation, the GP co-operative that ran out-of-hours services across four boroughs, is not a great example of GPs financial competence. Camden's Health Scrutiny Committee discovered this on 1st September, and this appears to have influenced the way politicians of all parties have grown more sceptical about the GP Commissioning role envisaged in the White Paper.

General Practitioners are the only part of the NHS that cannot be required under current legislation to attend health scrutiny meetings. So if the commissioning of a large part of the NHS is to be transferred to GP Consortia then their public accountability should be through a rigorous scrutiny process conducted by local Councils. Retaining Health Overview and Scrutiny Committees distinct from any decision-making bodies within Councils charged with carrying out public health functions is essential, and any subsequent legislation that flows from the White Paper should retain and enhance local Health Overview and Scrutiny Committees.

So if nothing changes when the White Paper is converted into legislation GP Consortia are to become compulsory in that every GP will have to belong to one to secure a new GP contract. The existing PCTs are expected to ease the transition to the new structure at a time when they have been told to reduce management costs by an average of a third and in NHS Camden's case by 45%. No stress there then.

Another feature of the top-down restructure clearly proposed by the White Paper, (although rigorously denied by the Coalition Agreement), is the creation of the NHS Commissioning Board, which will carry out the function of commissioning specialist services.

In London the recommissioning of stroke and major trauma services across the capital, which has led to 4 identified major trauma centres and 8 Hyper-Acute Stroke Units (HASU’s) followed a rigorous scrutiny of the plans by a pan-London Joint Health Overview and Scrutiny Committee (JHOSC) on which I served. The resultant report highlighted a number of issues that the commissioners needed to take account of when proceeding to implement their proposals.

The reported health outcomes after the first few months of the HASU’s being in place show a significant improvement in survival rates. So how under the new system of commissioning would the important role of scrutiny be undertaken to examine regional or sub-regional proposals for change? Without existing scrutiny committees in place to come together to form JHOSCs, how would such proposals be examined in public?

The title of the consultation document “Liberating the NHS: Local Democratic Legitimacy in Health” suggests that there might be a real democratisation of health functions at local level. Sadly the proposals fall far short of this.

The document openly admits the following - “The Coalition Programme proposed directly elected individuals on the primary care trusts (PCT) board as a mechanism for doing this. However, because of the proposed transfer of commissioning functions to the NHS Commissioning Board and GP consortia, the Government has concluded that PCTs should be abolished.”

I have already commented on the blurred roles undertaken by Health and Well-Being Boards but their composition cannot be described as an advancement in local democratic decision-making. Like the previous Government which created the separate roles for Children’s Trusts and Safeguarding Boards in which the membership is overwhelmingly made up of appointed officials rather than elected representatives, the Coalition Government has fallen into the same trap. The Boards will have some elected councillors but they will be joined by a range of appointed officials

The consultation document states, “the boards would bring together local elected representatives including the Leader or the Directly Elected Mayor, social care, NHS commissioners, local government and patient champions around one table. The Directors of Public Health, within the local authority, would also play a critical role. The elected members of the local authority would decide who chaired the board. The board would include both the relevant GP consortia and representation from the NHS Commissioning Board (where relevant issues are being discussed).”

Later it states, “For the board to function well, it will undoubtedly require input from the relevant local authority directors, on social care, public health and children’s services. We also propose a local representative from HealthWatch will have a seat on the board, so that it has influence and responsibility in the local decision-making process. We recognise the novelty of arrangements bringing together elected members and officials in this way and would welcome views as to how local authorities can make this work most effectively.”

Novelty indeed. This hybrid arrangement has little to do with democracy. If it was ever proposed that key decisions of the National Government’s cabinet would be undertaken by Cabinet Sub-Committee with a mix of ministers, and a built in majority of senior civil servants who had equal voting rights it would be deemed unacceptable by democratically accountable MPs and rightly so. I have no problem with key service Directors having the duty to attend Board meetings to provide proposals and advice but democratic decision-making should mean that only elected councillors should have voting powers on Boards.

Finally the transformation of LINKs into HealthWatch bodies with changed powers (another top-down reorganisation proposal) is not accompanied by any detail on how these bodies can be seen to be truly representative of patients. Presently those who want to be registered as members of LINKs can do so and local committees are largely self-appointed because of the lack of widespread membership. The White Paper suggests a HealthWatch representative would get a seat on Health and Well Being Boards. Most members of Camden’s Health Scrutiny Committee had to convince over 2,000 constituents in their wards to vote for them this year to get elected to the Council for an opportunity to serve on the Committee or become a member of the Council’s Cabinet. How many votes would be needed for a Health Watch representative to gain a place on a Health & Well Being Board?

In conclusion I would strongly argue that the White Paper fails on the twin tests of increasing localism and democratic decision-making. It is a top-down reorganisation which will create more quangos than it abolishes, and it proposes that decision-making powers should be concentrated in the hands of GP Consortia which will not be publicly accountable or subject to the priorities established by Councils’ Joint Strategic Needs Assessments.

Without significant changes when the expected legislation is laid before Parliament this will be a great opportunity missed, and the first example of a Government Department specifically ignoring the Coalition Agreement so successfully negotiated between the coalition parties only two months earlier.