Chris Leslie, Director, NLGN
Whitehall and Westminster World

There were two shooting stars across the Government’s public service fermament in July; the Darzi Review on health and Hazel Blears’ White Paper ‘Communities In Control – Real People, Real Power’. Both were complementary in some respects, emphasising the importance of user empowerment, choice and the positive benefits of citizen activism in the information age. Yet there was a strange dissonance between these two arms of Whitehall, leaving those of us who campaign for power and decision-making to be decentralised not entirely satisfied. Of course, it is possible that the campaigning think tank community are completely insatiable when it comes to public policy, always wanting more and accusing Ministers of never going far enough. But in these two cases I think that it is reasonable to give two cheers for the small steps along the journey while politely pointing out that more boldness could have been achieved.

My point is a simple one: why is there timidity when it comes to the extension of democratic accountability over local PCT commissioning activities? Primary Care Trusts hold the stewardship of comparable sums of taxpayer money as democratically elected local authorities these days. Why should those in charge of local social services policy be subject to election, but those in charge of local health policy not?

The creation of the National Health Service 60 years ago envisaged minimum standards of decent care available to all nationwide according to need and not ability to pay. Over the years the professional dominance of clinicians has – rightly – witnessed massive improvements in patient treatment and the NHS has been firmly steered by the collective judgement of its workforce. Managerial improvements have occurred, sometimes painfully, but there is now a recognition that basic budgeting, business planning and challenge adds rather than detracts from the service. The national underpinnings of the NHS have been consistently strong, including the apparent political consensus today on fundamental principles and the centrally-driven financial uplift delivered by Labour’s decade in power. In short, centralism and central planning have been in the driving seat, while local variation and citizen accountability have been second order considerations so far.

Lord Darzi’s top line conclusion may represent a turning point. He argues that, to date, NHS reform has been about ‘quantitative’ issues of investment, reducing waiting times, increasing capacity. Now, he believes, ‘quality’ must come to the fore and in the 21st century care needs to be personalised and tailored. Expanding qualitative care inexorably means greater localisation. Communities are more diverse than ever, the consumer wants convenience and local provision, and no central model can possibly cope with the variation demanded. The NHS was forced to create a degree of decentralised PCT decision-making a decade ago precisely because of the limited capabilities of management from the centre. Today, the challenges of ‘nudging’ public behaviour - whether on obesity, alcohol or broader preventative health and well being approaches – all require local leadership and creative thinking. There is no doubt, therefore, that delivering Darzi’s vision of smart community commissioning and NHS partnering with other agencies requires a new phase of local management.

It must surely be an accepted rule of sound public management that everyone should know who is responsible for making decisions, and that there should be a dialogue of constructive challenge to ensure those in charge are kept on their toes. Yet does anyone know who sits on the board of their local PCT? And even if you were able to find out their names, how on earth can we benchmark the values, principles or general ideas that those individuals bring to those PCT boards? Centrally appointed according to ‘objective’ merit-based criteria, PCT board members have no motivation to interact with the general public other than their altruism; they are appointed from on high and rationally are pre-programmed to respond to central direction. There are honourable exceptions, but the power held by PCT board members is not matched by any rationale to respond to wider community interests. Yes, patients and today’s health service users do have some rights of scrutiny and redress, but what about the rest of the taxpaying public, the potential patients of the future, who also have a vested interest in the best local services for the longer term? Health service consumer views are important, but all citizens and their representatives should be involved in shaping the future.

The argument for local NHS accountability is gathering speed, as is the pragmatic hard-headed case for greater local authority involvement in PCT management. A decade of greater exposure, stronger audit practice and accountability has transformed councils into discernably better managers than many other corners of the public sector including PCTs, as the New Local Government Network pamphlet ‘Healthy Places’ published in June 2008 points out. The NHS needs local democracy not only for sound reasons of high principle, it also needs the positive management skills that local government now have to offer. PCT boards should be amalgamated within the strategic overview that local authorities bring, allowing local people to elect councillors to fulfil their commissioning functions in full glare of the local media and with a healthy degree of policy competition.

Despite this obvious future for PCT accountability, the Government has not yet chosen to step in this direction. “No more structural change!” cry some Ministers. But no structural change is required to merely replace the Secretary of State’s appointment of PCT board members with local democratic appointment instead. It was a great shame that the Department of Health could not be persuaded to play ball with the Communities and Local Government White Paper on empowerment, and perhaps they felt that the Darzi Review went far enough without needing to open the door on greater accountability. The trouble is, if one corner of the public realm is talking the language of putting power in the hands of citizens, it seems peculiar if this fails to extend to other corners too. Eventually the penny will drop and Whitehall will realise that letting go and trusting local democracy is shrewd managerial practice as well as the right thing to do.