Camden Council is failing

It is not unusual for Liberal Democrat councillors to criticise the performance of Camden, especially when we think we ran the Council better during our time of leading the Council between 2006-10. However two entirely separate issues this week demonstrate our criticisms are not at all fanciful.

The West Hampstead Safer Neighbourhood Team asked the council to set up a dispersal zone covering the Lymington Rd and Lithos Rd areas of the ward in September. I attended a poorly advertised meeting at the West End Lane offices to discuss the boundary and helped to persuade the Council to accept a small change on the proposed boundary to include the area around Rowntree Close. A dispersal zone once in place gives the police extra powers to disperse gatherings of youths who are committing Anti Social Behaviour.

The zone was set up to run until mid-November and I secured a promise in September for a further consultation on a possible extension of time when we hit November.

Well November came and went without any kind of message from the Council, and last week's Safer Neighbourhood Panel meeting demonstrated that the police were not aware why the zone had ended in mid-November without consulting them.

It appears that the zone was a relative success because the extra powers were only used once. Local and no so local youths had read the notices displayed and decided not to cause any more trouble.

Nevertheless there was a need to evaluate the apparent success of the zone with local people. So I have today sent the following message to the Council -

"I want a full explanation why the Council officers feel it was appropriate to end this dispersal zone without consulting the Safer Neighbourhood Team, the local councillors or local residents groups. We have "policing by consent" in this country and if we are to use powers like these the Council needs to offer full engagement with the community so that we can all evaluate the relative success or failure of the dispersal zone and have a mutual agreement on a way forward."

My second concern is that I have been urging Council officers to work with Thames Water and Network Rail to find the source of a leak that has led to puddling water in Medley Road for over a year.

Two local residents and myself have had extensive e-mail correspondence with the Council and Thames Water for all this time trying to secure an answer to the problem.

I have discovered only today that the case file was closed at the Camden end last March with an officer failing to respond to an email from an affected resident. However, in the last couple of days Thames Water have identified a leak in West End Lane which is impacting on Medley Road. The leak is losing three litres of water per second!

This is now judged by Thames Water as an emergency (after a year of trying to shift blame onto Network Rail) and will involve the temporary closure of West End Lane, although as I write it is not known when this will take place...

The Council has a duty of care to its residents and should be making sure other public utilities carry out their responsibilities. Sadly Camden is simply not doing its job properly...

Getting a new school for West Hampstead will not be easy...

I attended Camden's Children, Schools and Families Scrutiny Committee last night and posed a number of concerns about Labour's plans to expand Kingsgate Primary School to provide more school places in the north-west of Camden. The Cabinet Member, and the Scrutiny Committee members had no answers to the points I raised.

I was sufficiently exercised about the lack of detail in the officer's report to the committee that then wrote a letter to the local press. The full text is below in case it does not get printed in full.

"Mike Katz likes to take credit for pressing for a new primary school on the Liddell Road site in West Hampstead, but perhaps he should first explain why the report to Cabinet on 18th July  stated that the Cabinet in December 2010 agreed to start the process for looking for a partner for a new school, but then nothing happened? Eighteen months later, when the shortage of places is getting critical, the Labour administration puts forward a proposal in haste which they might regret later. 

We certainly need to use the Council owned site at Liddell Road to create the places but the failure to act for 18 months means no actual new school building will be in place until 2016. 

The idea of extending Kingsgate Primary School could also backfire on them. If the Reception classes in the expanded school are established at the existing site, it is so close to the Brent border that many of the extra places will go to Brent parents on the proximity rule within the Admissions code. With Salusbury Primary School in Brent currently in Special Measures, Kingsgate becomes ever more attractive to parents living west of the Kilburn High Road. If on the other hand the Reception classes are placed at Liddell Road, then the proximity rule could work against Kilburn parents who live close to the existing Kingsgate site but too far away from Liddell Road to get a place. 

If in effect the proposal is to have two separate all age schools on the two sites, the DFE could oppose, as it will then be seen as a ruse to avoid a Free School or Academy. Such an idea would also be really difficult to manage. A four form entry primary school usually has year-group co-ordinators to organise the curriculum across four classes and to monitor teaching standards. Doing this on two sites several hundred yards apart would be time-wasting for all the staff involved. 

The paper to the Cabinet also indicated that no preliminary work had been undertaken on Option 2 (the Free school/Academy option). While I can understand local Labour members hostile to this in principle (forgetting  of course that Academies were the only option available for new schools under the last Labour Government),  the Council is still welcoming a new Academy primary school sponsored by Argent in Kings Cross. 

Getting the right sponsor is the key to this, but the blinkered Labour Council is not prepared to find a like-minded sponsor, such as UCL, which accepts the need for an inclusive intake and collaboration with others in the Camden family of schools. 

Voting for a half-baked proposal without exploring any other option is a knee-jerk reaction to Labour's own failure to act for 18 months while the Labour Group fought over the prize of the Cabinet position.  I sincerely hope that the latest incumbent Angela Mason hangs on long enough to make some sort of progress, and turns this proposal into something coherent." 

Content? Almost...

It has been an interesting five months for me. Having my wife return and getting used to married life again without the unwelcome interruption of the Home Office has had its usual ups and downs, but I am dangerously close to becoming content with my lot.

I have always believed until now that when one was "content" then you had actually started a slow decline. I have always believed in setting new goals, making plans and writing daily lists of the tasks to be completed. So although I still do all that and we have big plans for the next three years, I am actually quite content right here, right now.

But I am not sure I should be scared or pleased...

One of the plans on my list is to move from my present flat in Kilburn to somewhere bigger to allow for Nana's ambition to produce a mini-me for my old age. This led me to think about the furore that local and national Labour Party figures have stirred up about the upper limits for claiming benefits the Coaliton Government are bringing in.

Having researched the local property scene recently, to see what my realistic options will be, there are whole areas of Camden which are clearly beyond my reach.  I simply could not afford the higher mortgage payments. Market forces on property prices work against me.

However according to the Labour Party, these same market forces are not supposed to work against people claiming benefits.  So a couple like us, both working and paying taxes, who cannot afford a mortgage payment to live in Bloomsbury, is not supposed to complain about paying our taxes so that another couple with a family can afford to live in the same desirable area, while their astronomic rent is paid for by Housing Benefit.

The Labour Party likes to claim it's on the side of the squeezed middle, but by its actions it should be judged.

We all know they are comfortable about the filthy rich. They did little in office to close the loopholes which allow multi-millionaires to pay little or no tax, and we know it wants to protect those claiming Housing Benefit to stay in desirable parts of Inner London. But what does it promise for the working tax payer? When offered the chance of a coalition with the Liberal Democrats in 2010 it flatly refused to consider raising the income tax threshold to £10,000 because it wants about half the population dependent on state hand-outs for at least part of their income. It is this dependency culture they have always fostered which prevents so many from making the change back into work from a life of benefits.

Meanwhile I will have to find a place to live which I can afford after paying my taxes. And it won't be in Bloomsbury....

My personal criticism of the UK Border Agency

I have not blogged for several months because my last blog, about the joys of being newly married, were interrupted by the UK Border Agency which insisted my wife had to return to Ghana to apply for a settlement visa from there rather than from the Agency’s offices in Croydon.

This should have been a simple enough task, especially as the initial application was done online before my wife left for Ghana, and we had compiled an impressive list of original documents for her to present to the High Commission in Accra.

We had systematically found documentary evidence to support every assertion made in the application, managing to include my birth certificate, a reference to my flat purchase in 1998 to prove I owned a property, a copy of my last tax return to show how much I earned (with supporting bank statements), my wife’s degree certificate and journalism certificate plus a statement from NARIC, a recognised agency in the UK, that guaranteed that a degree from the University of Ghana was equivalent to a Batchelor’s degree here.

The most important piece of evidence was a job offer letter that my wife had received from an employer where she had volunteered for 5 weeks before returning to Ghana. The job offer was conditional, of course, on her obtaining a settlement visa.

The tone of the application form for such visas is one of hostility, with references throughout which imply “we hope you are not coming here to claim benefits”. Well no, I was earning enough to keep her anyway, and we had the proof that my wife wanted to work and had a job offer in an institution where her background and knowledge of community languages in Ghana could prove useful.

So we thought it should be plain sailing. But no.

The processing of settlement visa applications is done in a strict chronological order, and my request for my wife’s application to be fast-tracked because of the job offer was deemed to be “not a compelling reason for fast tracking”.

My wife had been told in Ghana it would be 12 working weeks from the time of submission to get an answer, which put the likely date for her visa to be processed into early January. The answer I got three times from a civil servant in Accra was that it would be resolved by 31^st December.

Extracts from an email exchange with this official in the High Commission in Accra are rather telling. I wrote - “You still have not responded to my email messages. Is it the official policy of the Foreign and Commonwealth Office to fail to respond to email messages from UK citizens?

The reply I got (eventually) was this - “For your information, the UK Border Agency’s publically (sic) available guidelines state that correspondence should be replied to within 20 working days of receipt.

I appreciate that this may not be the response you were hoping for.”

It was bad enough getting the same stonewall answer again, but to hide behind a pathetic response deadline of 20 working days at a time of electronic communication suggests that our old colonial outposts need to be dragged kicking and screaming out of the culture of the 1960’s into the 21^st century. In local government we have made great strides to improve response times to enquiries. Ten working days is often the target and the actual response times, such as in Camden, are often shorter.

However, not to be brushed off like this I tried to use the good offices of a number of local and national politicians to see if they could intervene on my behalf. Being used to intervening on behalf of constituents as a councillor I found it a frustrating experience asking for help in this way and finding a poor response from most. Glenda Jackson my local MP has very polite staff who tried to help, but when Glenda phoned me directly after a few email exchanges she appeared to me to be both unhelpful, and rather dismissive.

Various Members of the House of Lords who were listed as part of the parliamentary committee for Ghana were tried. David Steel, Navnit Dholakia and Paul Boateng were all either dismissive or too easily accepting of the status quo.

A letter to the office of the Deputy Prime Minister went unanswered for weeks until I get a composite reply, which referred to the other enquiries made on my behalf by others. The only politician who appeared to take the issue seriously was Sarah Ludford the Liberal Democrat MEP for London, who rightfully challenged the first response she received.

Why was I so angry? Besides missing my wife which was torment enough, applying for a settlement visa as a spouse of a UK citizen involves not only filling in an application form with supporting evidence, but a fee of around £850 payable in cash in the local currency. It occurred to me that if any Commission had a backlog of applications they also had a lot of fees collected which could be used to appoint more temporary workers to clear the backlog or to offer overtime to existing staff. But that it seems is too logical, too modern, too concerned about improving systems. That would be about an agency accepting that it is providing a public service rather than simply administering a legal procedure.

The UK Border Agency has been under attack a great deal in recent months, with one senior official resigning after a spat with the Home Secretary about apparently relaxing border controls in the summer.

In my experience it requires a serious root and branch review of all its systems.

To complete the story, my wife was asked to collect her documents, including the visa, on 28^th December. When she received her passport back it was clear the visa had been approved on 23^rd December, too close to the Christmas break to allow her to enjoy Christmas in the UK with her new British family.

My wife arrived at Heathrow on the morning of 2^nd January and I am now a much happier man, but my criticisms of the inefficient UK Border Agency are still legitimate and should be pursued by politicians in Government, or by those aspiring to represent us.

What I did on my holidays - got married...

I haven't posted for awhile because the summer has been taken up with preparations for my wedding to the lovely Nana who flew in from Ghana on July 30th. The fact that she did not turn tail and fly out again, lived with me for four weeks and then went through with our wedding, demonstrates either extreme foolhardiness, or amazing patience or her genuine love for yours truly. I suspect it's all three actually.

What has surprised me is that after a gap of 22 years of happy bachelorhood I appear to have taken to married life again rather well. So all those cynics out there who thought I was destined to be a crusty middle aged man for the rest of my days, will need to change their opinions fast.

It was an obvious surprise to many of our wedding guests on the 26th August that I had ever married again, but love (and the daily assistance of Skype video phone calls for 18 months) has conquered all. I have received a number of messages after the wedding to say we both looked gloriously happy. And yes we are.

Nana's subtle influences on our living arrangements are beginning to show. Early on it was decided that my business needed to move out of the flat, which took place in mid-August, and since then the use of a table-cloth, and the arrival of a bathmat in the shower room, offers a glimpse of the feminising touches to the flat that I accept will increase over time.

My large black and white mounted picture of a young Naomi Campbell (before her nose-job) which used to be on display above the bathroom wash basin has been banished and is now displayed in the office. I suspect some football related items might need to follow.

We are taking it in turns in cooking dinner, and the steady increase in exotic ingredients found in the kitchen cupboards proves Nana has found her way round some of the independent shops in Kilburn High Road and discovered the basics to produce some wonderful Ghanaian dishes. I have always enjoyed a wide range of food, and this simply offers further delights to my palate. It provides an extra bonus I did not take into consideration when deciding to marry, but hey, I am not complaining!

I used to tell a joke - "I believe in marriage. Everyone should get married at least once, because everyone needs to experience some misery in their lives..." As I said in my wedding speech - that one is being deleted from my memory bank.

Happy times.

Didn't we do well, or did we?

This is the latest article I have sent for publication to Liberator magazine.

"John Bryant argues that while the campaign led by the Social Liberal Forum has secured some significant changes to the Health and Social Care Bill there remain some lingering doubts...

Since my last article on the fortunes of the Health and Social Care Bill after the Liberal Democrats Spring Conference in Sheffield, we have had an official pause in the Bill’s legislative journey, a listening exercise, a report from the Future Forum, and publication of amendments to the Bill.

Liberal activists have also attended the Social Liberal Forum’s first one-day conference on 18^th June, which received feedback from Evan Harris, one of the key campaigners for change.

My own modest role in the campaign for change was to convince Camden’s Health Scrutiny Committee to make a submission to the listening exercise, setting out support for the 25 amendments that the Social Liberal Forum was promoting at the time. Since then there have been various claims that the vast majority of these suggested changes have emerged as formal amendments to the Bill.

So that’s all right then?

Well I think the gushing self-congratulations that have been published in recent weeks need to be tempered a little.

Not everyone in the NHS family of interests has declared its happiness with the result of the listening exercise. For the second time this year the BMA voted at its annual conference (following a critical emergency meeting in March) to support a motion calling for the Bill’s withdrawal, despite a call from its leadership not to be too critical now the Bill was to be amended.

At the SLF Conference Evan Harris was critical of the Future Forum’s report as it was littered with anecdotal references without a coherent analysis of the feedback it received from the many respondents to the listening exercise.

There was also an example of the classic bureaucrats’ answer to every problem by creating more committees. The Future Forum argues that, “there should be a strong role for clinical and professional networks in the new system and multi‐speciality clinical senates should be established to provide strategic advice to local commissioning consortia, health and wellbeing boards and the NHS Commissioning Board.”

A clinical senate may well be a useful adjunct to the more formal commissioning landscape, but something similar already exists outside of formal NHS structures. One example is “UCL Partners” which is a research body bringing together clinical leaders in Foundation Trusts in my part of North London to think through the best way of providing clinical pathways for specialist acute services. Its work in helping to shape the development of Hyper-Acute Stroke Units has led to the new “HASU” based at University College London Hospital. This is now reported to be the third best performing HASU in the UK with rapidly improving survival rates compared to the old regime.

So while such innovations as “clinical senates” may be useful I am not sure that giving them a statutory role will make their contribution even more valid than it is at present. The key to progress here is to ensure that clinical recommendations on patient pathways from such informal bodies are given effective scrutiny in public by scrutiny committees either at borough or regional level.

I am not entirely convinced by the Future Forum’s statement “We have heard many people saying that competition and integration are opposing forces. We believe this is a false dichotomy. Integrated care is vital, and competition can and should be used by commissioners as a powerful tool to drive this for patients.”

In developing an integrated care pathway for Stroke patients in North Central London the clinicians presented a case for UCLH to be the HASU, while other hospitals such the Royal Free in Hampstead would develop and expand their rehabilitation service for supporting patients in the period following the first three critical days after a stroke. Had a competitive approach been followed both UCLH and the Royal Free would have had good claims to be the HASU and a lot of time and money would have been wasted to judge between competing bids. So in my own local example working together to create a well-organised integrated care model produced the desired improving health outcomes, without competition being involved.

The Future Forum report later backtracks on the competition issue with this -

“Most importantly, the Bill should be changed to be very clear that Monitor’s primary duty is not to promote competition, but to ensure the best care for patients. As part of this, they must support the delivery of integrated care.”

Without specifying clearly how integrated care models are to be created by using competition, it begs the question that this report was surely designed to please both Conservative and Liberal Democrat members by providing a fudge between the different forces in favour of either competition or integration.

The more detailed report on Choice and Competition sets out some principles for a new Framework which are - Delivering choice; Encouraging collaboration and integration; Market making; Improving outcomes; Personalising care; Reducing health inequalities; Enabling informed citizens.

The most worrying of these for me is the principle of “Market Making”. The later section devoted to this talks about new entrants to the market, but concentrates on the creation of new social enterprises rather than admit the existence of the elephant in the room - the possibility of many more services being commissioned from the independent sector.

The Government’s formal response to the Future Forum appeared to take on board of many of the fears of Liberal Democrats, ruling out cherry-picking and competition on price. However it is noticeable that the summary on Choice and Competition also states “we will phase in the extension of Any Qualified Provider”. What the “extension” might entail could be anyone’s guess, but if you are naturally sceptical of anything the Tories put forward with regard to competition in health services I would remain alert to future interpretations of this throw away line.

One of the big worries regularly expressed by both providers and patients is that competitive tendering by clinical consortia (even on quality rather than cost grounds) could put some well-loved institutions such as Foundation Trust hospitals out of business, because without a certain level of core business they may become unviable.

So even assuming that most of the new amendments to the Bill are supported across the Coalition and are welcomed in the Lords, there is still more that Liberals should be doing.

As this Liberator was being prepared, Liberal Democrat conference representatives were being urged by SLF activists to put their names forward in support of a new motion for the Autumn conference. This was drafted by Charles West and calls for all the new NHS structures created by the Bill to have a common duty when commissioning services to “avoid the risk of a transfer of such income or case-load as to undermine the ability of existing providers to provide emergency, complex case and intensive care services, and to provide education, training and research.”

It also suggests that Monitor's duty to prevent anti-competitive behaviour, which is against the interests of patients, is matched by a duty to prevent anti-collaborative behaviour for the same purpose.

So what else should Liberals be doing? Besides supporting SLF motions at conferences Liberals can be doing some useful work at a local level too. Many principal local authorities have created shadow Health and Well-Being Boards and it is through these that Liberal Democrat councillors can argue for better integration of health and social care providers as they redefine patient pathways. They can also argue for much greater transparency of decision-making by all local providers, including Foundation Trust Boards.

Members of Scrutiny Committees could also challenge Board members of emerging clinical consortia to avoid engaging arms length organisations from the independent sector to carry out commissioning functions. PCTs were forced to shed around half their staff this year because of Andrew Lansley’s decisions to cut management costs, but the remaining postholders should be those with the expertise to understand the intricacies of health contracts. Retaining the transactional task of commissioning as an in-house function of consortia by them directly employing their own (hopefully ex-PCT) staff is something that Liberal Democrat councillors could and should be arguing for.

Liberal activists not serving on Councils should continue to make their voices heard through their local press, urging local editors to spend some time on investigating the various interests that are hovering in every community to get a slice of the NHS cake.

I ended my last article on these issues by alluding to a “reasonably managed muddle”. I am not yet convinced we will achieve anything better than this, despite the good work done by campaigners on improving the Bill. The Future Forum report attempts to look in two directions at the same time and while many of the amendments to the Bill are welcome, it is the behaviour and motivation of the key players in every locality which will need to be closely monitored over the coming months.

JOHN BRYANT

(John has been a member of the Liberator Collective as “William Tranby” for about 20 years. He is currently a Camden councillor and Chair of its Health Scrutiny Committee, and is also Vice Chair of the North Central London Joint Health Overview and Scrutiny Committee.)"

People already vote preferentially

The arguments advanced by both the Yes and No campaigns in the AV referendum concentrate on the perceived benefits of both systems currently under scrutiny, but neither of them consider the evidence of what people actually do when they have the opportunity of expressing different choices on the same ballot paper.

In a minority of Councils there are all-out elections every four years. This is the case in London, and last year on the same day as the General Election the 32 London boroughs held elections, usually for three councillors in each of their wards. Electors are told they can vote with crosses for up to three candidates that are listed alphabetically by surname.

Most of the parties nominated three candidates in each ward and encouraged their supporters to use all three of their votes for their listed candidates. No party campaigned on the principle that voters can and should vote for candidates from different parties on the same ballot paper. However, although no party made this suggestion, thousands of voters across London made the decision to split their votes for candidates for two or even three parties.

In my own ward of West Hampstead in the London Borough of Camden voters had to make a single choice for their preferred MP, but on the same day and within seconds of completing their ballot in the parliamentary election, many voted for a "pick and mix" slate of Council candidates. In West Hampstead our Liberal Democrat campaign managed to secure 1,316 supporters who voted for the three Lib Dem candidates. But the counting of the Council election voting papers then went into the more complex procedure of counting the split ballots, where voters had decided to vote for a combination of candidates (or only one or two) which did not match the party slates.

On the split ballots I received an additional 745 votes which placed me at the top of the poll with 2,061. But that means around 36% of those who voted for me also voted for a candidate from another party. And don't forget this was at a time when every party was saying "only vote for us". No one was advocating splitting votes. No one mentioned this in conversations on doorsteps or in campaign leaflets. This was the electors making their own sophisticated judgements about the mix of parties they preferred.

I think this demonstrates there is a clear appetite for voters to choose to vote preferentially for candidates from different parties. Just think what would happen when candidates in an AV election had to reach out to attract "2nd preference" votes from other parties' supporters.

The appetite for preferential voting is already there and it's about time the politicians learned a lesson from the voters.

Why the Secretary of State has damaged our health

(The following article has been submitted for publication in Liberator magazine)

The Liberal Democrats Spring Conference in Sheffield was much enlivened by a first class debate on a motion entitled “Updating the NHS: Personal and Local”. The Liberal Democrat Health Minister Paul Burstow was forced to accept two amendments to avoid the humiliation of losing a vote by an overwhelming margin. Both amendments in their different ways aimed to increase the accountability of local institutions and were in line with the party’s manifesto commitment to democratise local PCT’s.

Strengthening the role of scrutiny by local Councils had been a message heard loud and clear by our Health Minister in official submissions from local authorities to the earlier White Paper and from individual councillors (like myself) at the Liverpool conference. Paul has listened to this point and the Bill now does provide greater scope for scrutiny as a separate function from that envisaged by Health and Wellbeing Boards within Councils. The motion at conference stressed this by welcoming the proposals to enable local authorities to effectively scrutinise “any provider of any taxpayer funded health services”. So far, so good.

The amendments at conference wanted to strengthen all this further by making sure that democratically elected individuals were involved in every stage, not just in scrutiny, but through “councillor-led” Health and Well Being Boards and with places on GP Commissioning Consortia too.

The debate in Sheffield also highlighted a widely shared hostility to the concept of “any willing provider”, which is possibly the most controversial concept in the Bill. There is a great concern that private operators will cherry-pick the routine operations to make money out of high volume work, leaving complex and serious conditions to be catered for in the public sector.

The last Labour Government had already promoted this private sector entryism into the health market by guaranteeing fees to private operators that were above the standard tariffs agreed for NHS hospitals. The conference was relieved when this was criticised by Paul Burstow but one has to remember that the fixed tariff system only covers around 30% of current procedures, so there is still room for the profiteers from the private sector to make money in any newly created health market.

Openness and transparency was another theme highlighted by the amendment sponsored by the Social Liberal Forum. This called for meetings of GP Consortia to be open to the public. But one has to remember in calling for changes of this sort that we have secretive GP practices now. Each practice acts as a separately traded business with no openness with regard to its business operations. While General Practice accounts need to be registered with their local PCT they are private and confidential and no one really knows how much the partners are paying themselves, and how much they are re-investing in their practice facilities, except the PCT which is not at liberty to reveal all. (There may be some principled GPs in the country who are willing to reveal their accounts but it is not the norm in my part of London.)

Paul Burstow and Nick Clegg might well feel emboldened by the clear messages from conference to seek major changes to the Bill, bearing in mind this top down reorganisation was specifically ruled out by the Coalition Agreement, but I fear the real damage to our health service has already been done by another decision of the Secretary of State which I presume had Paul Burstow’s blessing.

My local PCT in Camden was ordered by Andrew Lansley to make 54% cuts in management costs this year. That meant that by the end of the financial year about to close as I write this, 54% of the staff were to be made redundant. There would be some natural wastage and some voluntary redundancies of course. But anyone reading this with any experience of local government efficiency savings, where 10% cuts in staff in one go are just about manageable, could only describe cutting out half your staff in one go as anything but “slash and burn” on an epic scale.

There are several risks involved in doing this. Some staff with commissioning experience might jump ship and start working for the “any willing providers”, helping them to find the corners to cut. Others might be so disheartened by yet another health reorganisation that they seek employment in another field entirely or retire to look after their gardens, their expertise lost forever.

The remaining staff are required to soldier on with the specific task of helping the GP Commissioners take on their responsibilities while at the same time looking forward to losing their own jobs by 2013, which is hardly a great incentive to go the extra mile.

Health if anything is a people business. For successful commissioning we need to have the right people with the right skills carrying out the right tasks to secure good and improving health outcomes, while achieving good value for the taxpayer.

This will not be achieved in my view by a bunch of well-meaning GPs with little training, without a team of experienced commissioning staff who know and understand the intricacies of health contracts. What cannot be guaranteed by this imposed revolution from the centre is that we will end up with commissioning teams that secure both improving health outcomes for patients and good value for the taxpayer because the transfer of the right people in an orderly fashion from the PCTs to the GP consortia is not guaranteed.

It does not matter if the final Bill passed by Parliament establishes that the award of contracts will be on quality rather than cost, because if the contract specification is not written correctly the snags will emerge after the contracts are in place. Anyone with local government experience will know that out-sourcing contracts for services like refuse collection and recycling, or housing maintenance, are fraught with dangers. The so-called “best value contractor” will often be commissioned but when the operation appears not to be working the contractor nearly always has an excuse along the lines of - “what you have now requested is not in the contract but we can now do it for you, but it will cost you extra...”

Having councillors added to commissioning boards might bring some worldly wisdom to these decisions, but it is whether commissioners secure the expertise of those who can write watertight contracts which will determine whether this whole experiment will succeed or fail, and with half the available staff already lost from PCTs I think the die is already cast.

Another area which is fraught with difficulty is the way in which specialist and low volume treatments will be commissioned in the future. In recent years in London the treatment of cardiac arrests, major trauma and strokes have been significantly improved through commissioning on a regional basis. For example one of the great success stories now emerging demonstrates that creating eight Hyper-Acute Stroke Units in the capital has radically improved survival rates. The proposals were developed by Healthcare for London, an off-shoot of the strategic health authority which was answerable to the joint committee of PCTs in London and scrutinised by a pan-London Joint Health Overview and Scrutiny Committee (JHOSC) on which I served as Camden’s representative.

How will proposals for improving specialist acute services be developed in the future? It may be that the NHS Commissioning Board might create local outposts to lead on these developments, but where will the boundaries lie with GP Commissioning Consortia? And how will these developments be scrutinised? Local authorities are increasingly stretched for resources to undertake their scrutiny duties as they are now. If the Government is serious about strengthening scrutiny, and to create quality pathways for acute services, then there is more work to be done and more resources are needed.

I suppose the summary of what I am saying is that if the conference decisions lead to real improvements to the Bill then that is to be welcomed. But, as the saying goes, “if I wanted to get there I wouldn’t have started from here”. Sacking half of the PCT staff before embarking on this change to the commissioning arrangements was clearly the wrong step in the wrong direction at the wrong time.

We might be able to muddle through. The NHS has made great improvements in the past, often despite the meddling of Secretaries of State and not because of them, but does the service have the capacity to do this one more time?

And do we as Liberals in Government for the first time in 70 years want our first term legacy to be a reasonably managed muddle?

Stop the World I want to get off..

Since the turn of the year, I cannot believe how busy I have been. January is usually a slowly paced month, planning for school meetings that normally become congested in March. But I had a rude awakening on 4th January, the first day of the spring term with a succession of phone calls and e-mails announcing the suspension of my friend Alan King as the headteacher of Furness Primary School.

This set off a flurry of activity for the Governing Body with three special meetings in quick succession and a protracted correspondence with Brent's Director of Education. Not only was the headteacher suspended (and at the time of writing still is), but the Director decided to apply to the Secretary of State to dismiss the Governing Body as well. I had already decided that if that happened, I would not offer myself to clerk the Interim Executive Board that would succeed the Governing Body, and so it is with some regret that I now believe I have ended my association with the school after being its clerk for 22 years.

It is a great pity. I do not believe the current investigation into the headteacher's management of the school will uncover anything of any great seriousness and I reckon the Governing Body's performance was no worse than many others in this area. Alan King always had a great line in conspiracy theories, which always appeared to become more outlandish as the rounds of drinks quickened at his local. And so after knowing him for over 20 years I usually took a lot of what he said with a pinch of salt. This time perhaps his theory was right all along.

Anyway that is what kept me busy in January, and the ever complex health agenda also provided a lot of extra work in the opening months of the year. I confess I also took my usual winter break in February to my favourite hotel in Lanzarote and managed to read five hefty novels of varying seriousness while I was there. But one downside this year was the impact of now owning an iPhone on which I can now screen my e-mails. A holiday is not quite the same when you are still in contact, on an hourly basis, with work and colleagues back home.

Since being back, I have returned to a frenzy of work with the more usual high number of governing body meetings taking place. The Council's budget-setting process created a flurry of activity within the Liberal Democrat Group, so much so that I was checking a suggested budget amendment at midnight while standing at baggage reclaim in Gatwick after returning home.

Is the world speeding up? It certainly feels like it. Many people tell me they think the years get faster as you approach retirement. But why do we have this frantic obsession with activity that keeps us moving like manic hampsters on spinning wheels?

Why indeed do I have massive feelings of guilt when I sit idly for 20 minutes? I have always juggled a number of plates in the air, keeping my schools business, Council work, and social life on track through careful diary planning, but what I have never done is build in "lazy time".

Should I now begin the slippery slope towards deliberate downsizing? Not in the sense of moving down the property ladder, because anything smaller than my flat would be a bedsit, but downsizing the number of things I intend to do and plan for in the diary? But could I ever get used to a diary page with blank spaces in it? And what exactly is being lazy? Is that the first step towards staring vacantly into space, and falling asleep in the afternoons? My grandparents used to do this, leading to low sniggering from the rest of the family, but now my parents do too.

How soon will it be my turn?

The Minister listened!!

I have been a particularly ebullient critic of the Coalition Government's White Paper on Health in the last few months. (see earlier blog entries.)

Today the Government published its formal response document to the consultation process. I was involved directly, taking part in a Consultative session with Paul Burstow at the Liberal Democrats annual conference in Liverpool and in a private session with him later on, and I also helped to frame the official consultation response by Camden Council.

In the published response today Camden get a specific mention -

"Some respondents, for example Camden Council, wanted the Government to “require local authorities and health commissioners to pool resources”. Although we do not think this is practicable, we understand the sentiment. As Solihull Care Trust suggested, “local authorities will struggle to co-ordinate commissioning without a commitment from partners to joint/pooled budgets”. However, we agree with Suffolk and Great Yarmouth LPC when they say that “integrated working depends on the quality of local working relationships and although the Department can outline areas where integrated working is required this should not be too restrictive to prevent local innovation to occur”. This is backed up by the Lesbian and Gay Foundation’s suggestion that “lead commissioning and other flexibilities should be explicitly promoted and supported by the Department for the delivery of high quality community based specialist services”. Staff at Norfolk PCT echoed the views of many NHS respondents when they welcomed “the opportunity to increase dialogue between services and join services together for the good of patients”. The Bill will therefore place a duty on GP consortia and local authorities, through the health and wellbeing board, in drawing up the joint strategy, to consider how to make best use of the flexibilities they have at their disposal, such as pooled budgets. To reinforce this duty, the Department has also decided that the NHS Commissioning Board should be placed under a duty to promote the use of flexibilities by consortia. These duties do not require flexibilities to be used, but they signal the importance of maximising the use of the tools available.

And the views of Southampton City Council were identical to ours on the need for "compliance" of GP Consortia to follow the Joint Strategic Needs Assessment (or JSNA). The relevant sections in the response paper today are these -

"In the reformed system, the process and product of the joint strategic needs assessment takes on much greater importance. The health and wellbeing board will have a role in helping meet the need - expressed by the NHS Confederation and others - for GP consortia to have “access to public health expertise so that they can take a population health viewpoint, in particular access to epidemiological advice and insight into parts of the population that are either unregistered or invisible to general practice”, through for example the Director of Public Health being a member of the board. As Southampton City Council has suggested, the focus on the JSNA will help “ensure that GP consortia take commissioning decisions based on the overall needs of the population in future rather than the needs of their current set of patients”.

5.20 The Government fully agrees with the view of the Association of Directors of Adult Social Services that “all commissioning should be driven by the JSNA or shared assessments across local authority boundaries, whether these are GP commissioning, council commissioning or joint commissioning”. Many respondents, for example the Association of Directors of Public Health, Nottingham City Council, Oldham PCT, and Peterborough City Council, felt that the value of the JSNA could be enhanced by clearer expectations about its use within commissioning plans. The point is well made. At present JSNA obligations extend only to its production, not its application. To remedy this lacuna, the Government is therefore introducing in the Bill a new legal obligation on NHS and local authority commissioners to have regard to the JSNA in exercising their relevant commissioning functions.

Added to this was a commitment to strengthen the distinctive role of Scrutiny Committees, including the ability to scrutinise the decisions of GP Commissioners.

So we made some progress. And it's good to note that the Coalition actually listened to the responses and adjusted their approach accordingly.

JOHN BRYANT

Let's stage a World Premiership instead!

The huge disappointment of England not being chosen as the 2018 host for the World Cup has led on to some angry criticism of FIFA and it's internal workings. Corruption of officials appears to have been fully uncovered by the Sunday Times and BBC's Panorama programme.

However the argument that investigative journalism should be restrained out of patriotic interest is in itself suspect. If we had won the nomination through a corrupt process, then how could we then be proud of the outcome? England offering a friendly against Thailand in exchange for a vote is as corrupt in my book as a brown envelope stuffed with cash to a FIFA representative.

The exhaustive ballot process is also inefficient and suspect. I noticed that in the vote for the 2022 tournament Qatar actually lost a vote between two stages. Use of the Alternative Vote would stop all attempts of later stage tactical voting, as the losing country's votes would automatically transfer to later pre-registered preferences.

Given the total lack of confidence many nations (at least of a democratic variety) now have in FIFA, it is time for English football to replicate its own previous rebellion when the leading clubs rebelled against the Football League and set up their own tournament.

Surely it is time the English FA formed a World Premiership tournament to take place in England during one summer when the Olympics and World Cup will not be taking place - perhaps in 2013? We already have the stadiums and training facilities to stage a tournament. It could be by invitation only to the world's top 16 footballing nations, taking account of the most recent regional tournaments such as the African Cup of Nations, Euro 2012 and the South American and Asian equivalents.

For some countries it might prove to be a useful trial run for the Brazil World Cup in 2014, but it might find its own momentum as a genuine alternative to FIFA's suspect package. After all we had significant splintering of the world titles in boxing some years ago and so the precedent is set for staging an alternative to the "official" tournament.

If FIFA threaten to exclude the top nations who choose to take part in the World Premiership then the top nations should walk. The TV companies know where the money will be and they will choose to show the best football they can to their subscribers.

So does anyone in the English FA have the guts to lead on this?

Who is ready for a public meeting?

It was curious to note that although we had around 80 residents who turned up on a cold night for the Area Forum in West Hampstead on Monday hardly anyone had been attracted to come by reading about the event on Twitter or Facebook. While most of our citizens are using e-mail these days there still seems to be a generation gap between those who are attracted to attend a traditional public meeting to keep up to date with current affairs, and those who aren't. The latter appear to be under-45, and are ready to post their opinions on social networking sites, but won't push through the doors of a community hall of an evening.

The same generation gap is sadly affecting the active membership of traditional residents and amenity groups too. I attend a fair number of community meetings as a councillor but I know there is a significant demographic I rarely come across. Within the boundaries of West Hampstead ward we have a higher than average number of people in the 25-34 age group compared to the population as a whole, but these are precisely the people we don't see taking part in community groups.

Many will be transient because of their work, so do not settle in the area, and therefore take less interest in local affairs. Those who put down their roots by buying a property or by having permanent tenancies are those who tend to join in. The only exceptions to my thesis are those who have children of primary school age and get involved in the local schools as Parent Governors or members of Friends Groups. But I suspect these are also the "settlers", and given the trend to have children later in life, many of these will be approaching 40 before they get stuck in to organising the school tombola or joining the Governors' Finance Committee.

I am not sure whether I should be worried or not. We have gone twenty years or so since a younger generation was catching the headlines with direct action with demonstrations and sit-ins. More recently the demonstration against the Iraq war also caught the imagination although this was across all age groups.

The recent unrest about student tuition fees, although in my view largely misplaced (See my earlier blog) at least shows us that when the right cause comes along the young can still get worked up about it. They are the ones who do use the social networking sites to organise their activities, but it tends not to be an invite to a public meeting in a draughty hall...

The NUS has got it wrong

I have not been blogging for a while because a lot of work has got in the way since last month. In that time the tuition fees issue has taken the headlines in a big way.

I am one of those fortunate enough to have enjoyed a free university education in the 1970's and an almost complete maintenance grant. Grants were means tested then according to your parents' income, and coming from a modest background I qualified for the full grant for my first two years.

Since then we have had the introduction of tuition fees, the withdrawal of grants except for a very small number of poor applicants, and the introduction of top-up fees too, each change made by a Labour Government following manifesto pledges against such moves.

So am I arguing that because Labour reneged on manifesto commitments it's all right for the Liberal Democrats too?

Well there is a big difference between the two parties. Each time Labour made a promise they failed to keep they had secured a working majority in the House of Commons at the General Election that preceded their decisions. So they had the power to fulfil their promises but chose not to do so.

In 2010 the Liberal Democrats did not win the election.

They did not secure the power to implement their manifesto in full, which included in case any reader has forgotten, to phase out tuition fees over six years. Not immediately, but over longer than a parliamentary term.

At the election we secured around 23% of the vote and got about 10% of the seats. Both Labour and the Tories support tuition fees, so whether the Liberal Democrats had done a deal with either party, securing a phase out of tuition fees just wasn't going to happen.

The Coalition Agreement secured the option for Liberal Democrat MPs to abstain on any vote to increase fees, and in practice I expect many will vote against the increase. This is the position taken up by our new party president Tim Farron who was my choice for the role.

However our instincts for fairness has led to the party securing a better deal for graduates than the Browne report (commissioned by the last Labour Government) envisaged. The repayment scheme now being proposed makes sure that the third of graduates taking on the lowest paid jobs (such as in Social Care) will actually pay less back than they do now, and those graduates in the top third of jobs on the highest pay (such as those in financial services) will pay back more. It is the closest one can get to a Graduate Tax without calling it such.

So why is the NUS trying to unseat Liberal Democrat MPs?

I don't think they have thought this through. If we have fewer Lib Dems in the next Parliament we are likely to have more Labour and Tory MPs who actually believe in fees and are not interested in making the system fairer. Labour is very publicly split over the concept of a Graduate Tax already, and as they are a party that has twice reneged on tuition fee commitments when in power they cannot be trusted. The Tories are waving the flag of fairness at the moment, because while they are in coalition with us they have to. But give them a working majority and the fairness principle will soon be lost.

So by supporting the NUS campaign to unseat Lib Dem MPs students will be making sure the opportunities for their fellow students from poor backgrounds are diminished further for another generation.

In fact the opposite would be a better way forward. If students actively campaigned for the Liberal Democrats to win more seats we could extend the fairness principle further.

Whether we can ever recreate the conditions that applied when I was a student, when I was the first person from my family to ever go to university, will always be difficult given the higher proportion of students now qualifying for Higher Education, but it's still a campaign worth pursuing.

So I think the NUS needs to reconsider its position. It would be usual for students to blame the older generation for mistakes that impact badly on them, but this time they could be making it worse for themselves....

We were right, the other parties wrong

Before the General Election Chris Philp, the Tories' candidate for Hampstead & Kilburn led a silly campaign which he described was to save the closure of the Stroke Unit at the Royal Free Hospital. He changed tack several times when the fact of the proposals from Healthcare for London were explored. Rather than shutting, the Royal Free's unit was to have an increase in beds. The excellent rehabilitation work was in fact to expand there. However the new "Hyper Acute Stroke Unit", or HASU, was to be centred on the UCLH site to serve a large part of North Central London rather than at the Royal Free.

Philp was determined to keep his campaign on the road so he managed to get a resolution passed at a full Council meeting, with the support of the Labour and Green parties, critical of the proposal to use UCLH as the HASU.

The Liberal Democrats stood alone in support of the new HASU, largely because we had done enough to study the proposals in detail and recognised they represented a step change in future survival rates from strokes.

Now we have the first figures after the new HASU has been in operation for six months. Some 2,675 patients have been taken by the London Ambulance Service to HASUs across our area. The transport time from home to HASU is less than 30 minutes in 93% of cases. The HASU established in UCLH in April is now ranked second best in the country in the recent RCP audit.

The number of people receiving thrombolysis in our area of London has doubled due to centralisation. Thrombolysis is a lifesaving treatment which can only be given within a strict time period. Previously patients waited up to 72 hours to see a specialist- now they are at the specialist unit in 30 minutes. The in-hospital mortality rate for patients treated through the UCLH HASU is now strikingly low - 6% against the national average of 27%.

This means in practice that if these proposals to centralise emergency stroke care in the HASU at UCLH had not gone ahead, as the other parties wanted, dozens of local people would now be dead. So those that whipped up a stupid frenzy of petty parochialism earlier this year should now hang their heads in shame. Their views were not even supported by key staff at the Royal Free, the hospital they purported to support.

There are times when politicians should properly examine the clinical evidence for change and show leadership on matters of health policy. I am proud to have to got this one right...

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.