Healthy future?

Seven months ago, the LGA set up an independent commission to look at how health services can be made more locally accountable. Karen Thornton reports on the health commission’s key recommendations.

The NHS celebrates its 60th birthday this year, and in one respect at least it hasn’t changed much, according to independent experts. Established as a national service funded through general taxation, the NHS remains highly centralised – with performance targets and policy priorities set by central government, and little or no accountability to the public and patients at the local level at which services are delivered.

Devolution consensus
These predominantly national mechanisms for holding health services to account “sit uneasily with the growing political consensus that more responsibility should be devolved”, to take account of local circumstances and the views of local people. So says the final report from an independent health commission set up by the LGA to look into these issues.

The commission says it has “serious concerns” that health services are not being adequately held to account locally – especially given local variability in services (for example, spending on cancer care) and local decision-making already exist, despite strong central control. Local accountability is weak, even non-existent in places, it says.

Its report argues: “For local accountability to be effective, the people who run health services should be obliged to explain and justify their decisions publicly; the local population (or their representatives) should have the right to interrogate health service managers about those decisions; and there should be a formal process whereby the local population (or their representatives) can pass judgement, and possibly impose sanctions, on those it decides have underperformed.”

That level of accountability and public involvement is hard to develop when most people have little knowledge of how local health services function – never mind how decisions are made, it concludes.

According to an opinion poll carried out for the commission, half the public don’t know what primary care trusts (PCT) are. The fourth most popular answer chosen by those who felt they did know was that they are responsible for emptying bins. In fact, they commission local health services and control more than 75% of the NHS budget.

“If you don’t know what an organisation is and what it does, it would be difficult for it to be accountable,” says Niall Dickson, commission chairman and chief executive of the King’s Fund. “The fact that more than half the public doesn’t even know what PCTs are is a shocking indictment of the system.”

Improving systems
But equally, the commission also found no appetite for major structural changes in the NHS or local government to address accountability issues – and has instead recommended a series of improvements to current systems (see below). A key priority is beefing up the role of local authority health overview and scrutiny committees – via joint training, more jointly funded secretarial support, a right to take concerns about local services direct to the strategic health authority and to respond to PCTs’ annual reports.

Local government should have a role in selecting PCT board members and appraising PCT performance. And more should be made of local area agreements, to set joint health improvement priorities and hold PCTs, councils and others to account for delivering them. The commission sees a particular role for councillors and councils in public health and improving the health of local people. Councillors should be encouraged to apply for PCT board member vacancies. And the full council should debate their PCT’s annual budget and commissioning plans.

If local accountability of health services has not improved in five years, then the commission does not rule out more radical reforms – including shifting the commissioning of health services to local government. Paul Coen, LGA chief executive, said the report was an important contribution to the debate, and that the association would respond to it in full in due course.

“There is very little opportunity in the NHS for people to influence decisions that impact on their lives. We at the LGA consider that unsatisfactory, and something that needs to be corrected,” he added. “We are very keen to help health colleagues produce better outcomes. We believe the health system as a whole will be better able to achieve its objectives and increase its standing and reputation in the public mind if it is seen to be actively engaged with other organisations in the locality.”

Health commission – key recommendations

• Pilots and trials of joint commissioning of health services by local authorities and PCTs should be encouraged, but also fully evaluated.
• Where there is local agreement to do so, pilots involving the transfer of some PCT public health responsibilities to local government should also be encouraged, via the pooling of budgets and joint commissioning.
• PCTs should show they are working with local authorities to facilitate involvement of local people in health services.
• PCT chairs should attend council cabinet meetings on healthrelated matters, and the council executive member for health and social care should attend PCT board meetings.
• Councils need to ensure a strong working relationship between their health oversight and scrutiny committees and new ‘local involvement networks’ involving patients.
• Strengthening the independence and status of public health directors jointly appointed by PCTs and councils.
• All contractors providing NHS services should be required to provide information to, and to attend, overview and scrutiny committees, if requested.