Paul Stanton on local legitimacy in the NHS

Paul Stanton

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In the first article of this series, I began to explore the nature and the scale of the challenges that confront NHS organisations and those who govern them in the first quarter of the 21st century.

I concluded by making reference to the tacitly recognised paradox of a system staffed and governed by those who care but which, far too often, is perceived by those who turn to it when in need (and indeed by many NHS staff themselves) as being impersonal, impenetrable and inhumane.

Here I will begin to consider some of the factors that conspire to generate and sustain this paradox.

From the outset, an unintended byproduct of the progressive principle of "free" provision is that it has profoundly changed the nature of the relationship between those who provide and those who receive care. The patient/consumer is not the "customer" and lacks the fiscal leverage and influence that customers exercise.

The "customer" of NHS care is and has always been government. As a result, the NHS and its constituent organisations have been driven by national (party) political diktat - even though, at local level, there is a singular and persistent absence of democratic accountability. 

Command and control

Targets, political imperatives and priorities that originate from ministers, having been translated by the Department of Health, have been imposed by NHS senior management upon the service. Inevitably, governments of whatever party think in a foreshortened time perspective, are reflexively risk averse and seek short-term "good news" results that they can parade before the electorate as evidence of their successful management.

The NHS, in other words, has been a classic Stalinist command and control economy. It has never been a true marketplace.

As the "welfare consensus" of the post-war decades gave way to the bitter ideological conflicts of the last quarter of the 20th century, the NHS became a chosen battleground on which both political parties fought pitched battles in pursuit of electoral advantage.

If Lord Warner is to be believed, the NHS, alongside other public services, suffered from catastrophic and cumulative underfunding to the tune of some £30bn. NHS organisations were compelled to live hand to mouth in their attempt to keep abreast of escalating need and expectation and were utterly starved of the investment and development funding that any industry or sector needs if it is to remain "fit for the future". 

Barrage of reforms

There is no doubt that the current government has injected real and vitally needed resource into the NHS, but much of the additional resource has been misapplied.

Instead of a clear, consensual and realistically timelined strategy for the development of NHS 21C, resource has been squandered on premature, piecemeal, uncoordinated and incoherent tactical "advances" that have been launched from the centre and then been abandoned or petered out on the ground in the face of the inertia that is an inherent characteristic of any complex interconnected system. 

Under the banners of modernisation, market pluralism and reform, the NHS has had to endure restructuring, subsequent primary care trust separation of function, Connecting for Health, payment by results, choice, choose and book, practice-based commissioning, improving health and well-being, world class commissioning and its attendant assurance handbook - a seemingly endless torrent of centrally driven "policy initiatives".

The government's investment in the NHS has been vital. It is even arguable that the choice agenda when taken alongside payment by results could begin, in time, to place some leverage back into the hands of the individual consumer of care and make care providers more attentive to their preferences (as well as to their clinically defined needs).

Local legitimacy

However, I do believe that there is still a profound democratic deficit at the heart of healthcare - a deficit that is highlighted, rather than being resolved, by the current emphasis on a "commissioning-led service" and "new localism".

Through no fault of their own, primary care trusts lack a local democratic mandate from the people and communities on whose behalf they act as definers of need, procurers of sustainable illness management supply and promoters of health and well-being. Their profile in their local communities is significantly lower than that of the majority of the trusts and the independent contractors from whom they commission care and their function is, from the perspective of the ordinary citizen, opaque.

This is compounded by the fact that, as commissioning-only organisations, it is impossible to see how they will "do what it says on the primary care trust tin".

In a rational world, the separation of provider arms would have preceded the last structural reorganisation so that the new bodies could, from the first, have been local health investment trusts with a clear focus and function. This should have triggered a fundamental reconsideration of their accountability and the democratic legitimacy of the vital decisions that they must now make on behalf of local communities.

In my next column, I will return to the theme of local legitimacy and the urgent need to decouple health care from national party political conflict.