Published: 24/10/2002, Volume II2, No. 5828 Page 22

The power of local authority backbench members ('nonexecutive councillors' as the government now prefers them to be known) in relation to the NHS is set to expand.

The 2000 Local Government Act created a formal separation between executive and backbench councillors' roles, with overview and scrutiny functions undertaken by the latter.Overview and scrutiny committees (OSCs), modelled on Commons select committees, already attempt to hold the local authority executive to account, and have the power to scrutinise matters that extend beyond the council's statutory functions, but affect the economic, social and environmental well-being of the area.

From January next year, this remit will be further extended, as local authorities with social services responsibilities are given the power to hold their local NHS services to account. Under the Health and Social Care Act 2001, these authorities will set up OSCs to 'act as a lever to improve the health of local people'. The remit will include making reports and recommendations to the local health service, and requiring local NHS representatives to attend meetings to answer questions.

What are the prospects for scrutiny working effectively?

There will be those in the NHS who will look upon the prospect of backbench councillors scrutinising the NHS with a mixture of alarm and amusement. Amusement at the notion that the scrutineers can expect to have the necessary knowledge and understanding of the NHS; alarm at the prospect that they might ignite local populism where it is at odds with NHS priorities.

It is difficult to see how one OSC can call to account NHS trusts, or how the chief executive officer of a large trust can be expected to be accountable to all of the local authorities from which its patients come.

Scrutiny is a two-sided relationship which requires an effective contribution from both those scrutinised and those doing the scrutinising. The current model seems to be one in which both parties work in partnership - never a comfortable relationship where scrutiny is involved. The recent Audit Commission review identified four critical action factors the NHS needed to fulfil - to learn about local government modernisation and scrutiny; to recognise the legitimacy of scrutiny by elected members and respond positively; to contribute information and expertise to the process; and to increase accessibility and transparency.

1None of these can be taken for granted.

On the local authority side, the role seems doomed to failure without proper support. Simply tagging on the help of a committee clerk - the hallmark of the old committee system - will be untenable.All of this requires funding, and it is not clear that this will be forthcoming. The Local Government Association is seeking additional assistance of£22m - effectively the funding that currently supports the running of community health councils, which are planned to run alongside OSCs for a few months.

However effective OSCs may be, they cannot address the democratic deficit within the NHS; nor, indeed, do they constitute the only solution.

Local authorities are already taking a greater interest and role in health.Around 85 per cent have specified that health is included in the portfolio of at least one cabinet member. Therefore a more effective alternative to OSCs might be to give the NHS scrutiny function to the executive rather than the non-executive branch of the local authority.

While the centralising Blair government seems unlikely to entertain it, there is a much more logical way to democratise the NHS - to strengthen the role of local government more generally and incorporate at least some of the NHS role within it.

Municipal socialism not only cleared slums, built houses, laid out parks, provided unemployment relief, educated the poor and provided hospital and community health services.

It also developed a sense of civic consciousness which has long since been eroded as local government has become the client state of Westminster.

The possible emergence of regional government offers an opportunity to redress the central-local imbalance in NHS control.

In the absence of any of these alternatives, we are left with an uncertain scrutiny process that seems unlikely to do much to redress the democratic deficit.

Guidance and regulations due out in the summer now seem likely to appear only days before the system comes into operation, and non-executive councillors will need to climb a daunting learning curve.

As currently constituted, the prospect for effective scrutiny does not look good. l

REFERENCE 1Audit Commission (2001). A Healthy Outlook: local authority overview and scrutiny of health.

Bob Hudson is a principal research fellow at Leeds University's Nuffield Institute for Health.