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.

Reflections on Ghana - Four

My final blog about my visit to Ghana is about the politics of the country. While I was there the opposition New Patriotic Party (NPP) was choosing its next presidential candidate to contest the next elections due in 2012.

It appeared that party members were engaged in primary elections based on regional voting across the country. This resulted in a final gathering of party representatives in a public park on a Saturday evening in Accra for the final declaration of results after they had been faxed in from the regions.

The NPP is a centre right party whose avowed aims is to extend human rights and property ownership to Ghanaians while maintaining a strong sense of public accountability. The government party is currently the National Democratic Congress (NDC) which is a left of centre party with ambitions of socialism, but with weak Government machinery it cannot finds ways of implementing its lofty ideals.

As I travelled in taxis and minibuses during and after the final election day I was struck by the animated conversations my guide had with several taxi-drivers and the interest shown by fellow travellers when the bus radio was tuned into a talk station. The eventual runaway winner for the NPP was Nana Akufo-Addo who managed a resounding 79% share of the vote against four rivals for the role. His nearest competitor, Alan Kyerematen, could not even get a clear majority in his own region, and he along with the other losing candidates conceded gracefully.

It was the first time the grassroots members had been trusted to vote in such an internal election and all candidates appeared to be proud of the exercise and the way it was conducted. What struck me was that I was 3,000 miles away from England but the speeches made by the NPP's leaders could all have been made by any party's representatives here after an internal election of this type. For example it was reported in the Daily Graphic that Alan Kyerematen had "pledged to support Nana Aku-Addo in his bid to win the 2012 presidential election and urged all his supporters to also work tirelessly for the party's flag bearer to ensure victory".

The newspapers and airwaves were littered with such statements for several days. A sense of deja vu struck me. I had heard all this before. Politicians the world over still tell the same stories...

What was more striking though was the lack of policy differences between the declared candidates. This contest was surely concentrated on the personality of the contenders.

Although Labour back here in Britain is conducting a similar exercise, I can find little difference on policy between the competing candidates, and where there may be some there is little interest from the press or the public anyway. Only Diane Abbott appears to be trying to seriously broaden the policy debate but as she is favourite to lose we can predict now the "rally round our new leader" speeches at the final declaration. Was it ever thus?

Reflections on Ghana - Three

Once you get over the regular sight of people (mostly women but some men) walking around with goods on their heads on the streets of Ghana, one becomes ever more curious about what it is they are actually carrying.

Travelling in a mini-bus or taxi you are besieged at every traffic light stop or general traffic jam by an array of vendors hoping to catch the eye of the traveller interested in an instant bargain. Some goods on display are obvious and instantly useful such as bags of plantain crisps, nuts, a range of cakes, bags of chilled water and so forth. Given the slow speed of traffic at peak hours these instant snack items are useful and popular with travellers.

But what was more surprising and indeed almost surreal on occasions were the other objects carried by street sellers. It was puzzling why these people on the margins of society had chosen the goods they were hawking around the streets. Some of the more bizarre included a wardrobe collection of kipper ties, three pairs of garden shears, a full length mirror, a selection of discount vouchers, or a variety of combs and brushes. One woman had really taken the message of diversification from the marketing people to heart when she offered the option of packets of biscuits from her hands with a selection of girls' underwear from the basket on her head.

I reckon if you stayed in a car at a junction anywhere in Accra for long enough you could do your complete week's shopping, and renew your wardrobe, through your car door window. It might seem like the ultimate convenience store was coming to you but there is a dark side to this enterprising culture.

I learnt while I was there that many young people from the north of the country had left their villages to seek their fortune in the big city and ended up on the streets as vendors making as little as 5 cedis a day - worth about £2.25. Even in a cheap city like Accra that would give them only enough to buy food to keep them alive, but nothing for a room or clothing. What was even more telling was that the street hawkers were all of an age. I saw very few who I would guess were over 25 years old. Indeed I saw few people anywhere who would be of middling years or older. This is a young country certainly but one wonders what happens to people when they reach 30?

Reflections on Ghana - Two

I was determined to try out the local food in Ghana, and my guide helped me by interpreting menus and making recommendations. She also took me to restaurants which the locals patronised rather than the places designed for tourists.

One key feature of Ghanaian eating is that cutlery is not used. Fingers were made before forks after all, and eating food this way adds a further dimension to the pleasure of eating.

In one restaurant I went to the standard table setting included a bottle of liquid soap, as the adjacent picture demonstrates. The waitress delivered a plastic bowl of warm water so I could wash my hands at the beginning and end of the meal.

My guide was an expert in eating this way of course and could strip the flesh off a Tilapia fish (a local staple) using only one hand. I had to use two hands to strip the flesh away from my chunky portions of goat's meat. The sauce managed to spread up to my elbows, so I really needed a stand up wash after finishing lunch.

The standard dish was a portion of a starchy food, which looked like mashed potato, with a spicy soup and added meat or fish. The starchy foods came in different combinations. Banku was a blend of cornmeal with crushed cassava, and FuFu a mix of cassava with plantain. Both were excellent when dipped into the soup usually spiced with chilli.

Another delicacy was palava sauce which is a thick dark green potage made up of cocoyam leaves with palm nut oil, onions and tomatoes. It reminded me of Sag - the equivalent Indian dish made from spinach.

Although not a great lager drinker Star beer was the most palatable of the local brews, while wine was relatively expensive, being imported from South Africa.

Service in restaurants was friendly although the concept of eating courses in a particular order was obviously a foreign notion at my hotel because food arrived to the table when it was ready. So a portion of bacon and eggs would arrive before a portion of cornmeal porridge. (The latter incidentally was called Koko - so now you know what the famous club in Camden Town is named after!)

With locally sourced fruits making up part of my breakfast I ate well every day and very healthily too. The standard Ghanaian diet is low in fats, high in natural fibre and includes plenty of fish, so I think I lost a few pounds during my week.

Which I am sure won't do me any harm...

Reflections on Ghana - One

After spending seven mind-boggling days in Ghana this is the first of a short series of blogs about my impressions.The country is lively, welcoming and developing quickly but in a rather haphazard way.

The enterprise culture is embedded in the country and not just in the parts of the economy one would expect to be controlled by the private sector.

The transportation system is the first obvious example. The train system no longer operates. Although there is evidence of a single track threading its way through a market area of Accra, and also at its linked destination in Kusami, 272 kilometres north west of the capital, it is clearly and sadly redundant.

The roads in part are in a good condition with several dual carriageway roads and motorways within Accra carrying huge numbers of vehicles, but as you get to the outskirts of the city and on all major routes between towns, sections of road built to good European standards are suddenly interspersed with dirt tracks. The Ghanaians seem to have built their roads in sections but have yet to join them all up.

Another feature is the way that bus services have grown with little co-ordination by the city authority. Mini-buses are the most popular and the cheapest way of getting around. The vehicles are not always registered with the authorities, are often in poor condition, and run by teams of two, mostly very young men. One is the driver and the other is the fare-collector who manages the sliding-door access to the kerbside. This means in practice that he is bellowing the eventual destination to passers by, trying to attract custom as the bus makes progress. The standard fare is 60 pesewas (about 25 pence) which would be enough to take you several miles.

The city authority is trying to introduce a better standard of bus on recognised routes with a standard fare of only 40 pesewas, but when I took a trip on one of these I noticed that the bus stood at its stop for about 20 minutes to fill up with passengers before setting off.

The idea of keeping to a timetable appeared to be laughable...

The third option is to use a taxi. These are plentiful but again the condition of vehicles has much to be desired, and it's advisable to negotiate the fare before setting off. It's also better to use a local guide who can negotiate in the local language of Twi. Casual racism in trying to rip off white tourists persists. On one occasion a negotiated price of 6 cedis (about £2.75) suddenly rose to 25 cedis when the taxi-driver spotted me with my guide. His kind offer was refused and he lost the fare.

There and back...

I have just had an interesting week in the south of France, travelling there by train. This was my fourth trip on Eurostar and I must say the interior of the carriages are beginning to look a little outdated given the improved rolling stock on mainline routes within England.

This time I changed trains at Lille for my onward journey to Cannes. I had forgotten how long French trains are and the fact the TGV trains are double deckers. I had booked my tickets well in advance through the Rail Europe office in Lower Regent Street. This is highly recommended because whatever you estimate the cost will be after checking prices online, the staff at Rail Europe will always save you more even after taking account of their £8 commission fee. And you can guarantee your window seats too.

The one drawback of large double-decker trains is that while they get up some terrific speeds on the long stretches, they take at least 10 minutes at each stop to get everybody off and on with their cases.

The journey from Lille to Cannes could be described in two ways. The first half travelling through northern France is monotonous with a largely flat, factory-farmed landscape. The south is entirely different with a great deal of variation on the horizon. The only place we went through which looked seriously grotty was Marseille with huge tower blocks of poor standard social housing, and extensive ugly graffiti.

Travelling along the south coast, one saw no evidence of a recession and when I explored both Cannes and Nice on foot during the week, I could find no bordered up shop fronts or other vacant business premises. The main tourist centres were very busy of course and the main restaurants in Cannes were all packed to capacity by 8.00pm.

As a sole traveller this time, I did my usual trick of walking into my restaurant of choice as they opened at 7.00pm. While everyone was friendly and obliging the waiting staff knew that a table for two converted into a table for one is one less cover for the evening, and so my service was often rapid so they could get their table for two ready for service again. Fine food can be fast food when it is in the restaurant's interest!

I had done some research before I went. One restaurant - Mere Besson - had been highly praised by one reviewer, and after my visit on the Monday I could see why. So much so that I planned my last dinner on the Friday to be a return visit. Sadly a stomach bug took a grip straight after Friday lunch and I was confined to my room for the rest of the day. What was even more annoying was the cheery disposition of my hotelier who asked me on the Saturday morning whether I had enjoyed the civic firework display on Friday evening, an event I had slept right through!

Travelling back I was mightily impressed with the time-keeping of my train from Cannes to Paris Gare de Lyon, a journey of 5 hours 10 minutes, which it completed exactly to time. I was also impressed with an announcement at one station when the station staff apologised for a train running 5 minutes late. It wouldn't happen here.

My final journey was from Paris Gare du Nord to St Pancras. What really needs updating is the passenger facilities at the Paris Eurostar terminal. There are too few waiting room seats and the refreshments on offer are pathetic. They are a disgrace given the usual French hospitality standards, and the gents toilets were the worst I have encountered since my childhood.

The train back was only half full surprisingly. Perhaps those that had packed into my outgoing train were staying longer on the continent than my one week.

Back in the flat I had nearly 200 e-mails waiting for me, mostly instantly deletable, but a few will need proper digestion and response.

So I have been there and back and it almost feels like I have not been away at all...

Gove is getting it wrong..

The Coalition Government has already done a lot that traditional Liberals like me would welcome, and not just from the Liberal Democrat side of the Coalition. Theresa May's cancellation of the ID card scheme and Ken Clarke's utterances about the effectiveness of short prison sentences compared to community sentencing demonstrate that this will be a genuine Liberal Government in terms of extending and defending our liberties.

Michael Gove's rush to introduce a new cohort of Academies, converting existing community and voluntary aided schools by September, is foolish, unnecessary, and undemocratic. I attended a meeting of the Education Law Association on 14th June shortly after the Academies Bill was published and I have to say that the Education lawyers were shocked by the minimalist detail contained in the bill, and were privately rubbing their hands with glee at the possibility of making money out of judicial review proceedings to question the first few school applications.

The Bill lacked sufficient detail on the transfer of staff to the school's governing body when a community school converted, no detail about the level of financing that was guaranteed as a minimum funding level for the new institution, and no requirement for the school's governing body to consult either staff, parents or pupils before making their applications. All that was required was a single resolution of the governing body to say yes.

Under existing school government regulations there are requirements for governing bodies to consult parents and staff on forming a Soft or Hard Federation from existing schools, including the publication of the proposed size and make up of the new governing body.

There are no such requirements to consult in the Academies Bill. It would appear Gove does not understand that schools are learning communities in which all voices should be heard and indeed that the best schools are those that have open and interactive forms of communication between all those who make up the school.

Pushing through a status change with so little information immediately available (or now being made up "on the hoof") does not bode well. And pushing it through half way through the financial year is fraught with difficulties for both schools and and their local education authorities. They need to extricate their accrued spending, their bank accounts, and future funding arrangements straight after a summer break. Well that will mean chaos, and quite a few school staff will no doubt not get paid properly and in time for the first month under the new regime. That will be good for morale!

It is not surprising that only a tiny number of schools have broken cover in either Brent or Camden to even register any interest in becoming Academies. I don't blame them. Until we see the detail no school headteacher or governor should respond to Gove's kind invitation to join his silly revolution.

I am afraid both New Labour and now the new Conservatives have become obsessed with structures, believing that by changing these you drive up standards. No, it is the quality of school leadership, the quality of the teaching in the classroom, and the adequacy of the facilities available that have the biggest impact on learning outcomes. Who funds the schools and by what formula, who holds the cheque book for schools' spending, and who oversees the quality of the service provided, are all secondary to the what happens in the classroom.

Leave the existing structures alone and provide a loosened grip on the curriculum from the centre, and cut the number of mind-boggling initiatives and circulars from the DFE, and heads and their staff might just come up with the goods.

The Liberal Democrat contribution to the Coalition Government's education policy is to insist on the pupil premium to give extra to schools providing for disadvantaged pupils. That in itself will do more good in Brent and Camden than any structural change offered by the Academies Bill.