An independent NHS board would be good news for ministers - but what about managers, wonders David Lock

An independent NHS board would be good news for ministers - but what about managers, wonders David Lock


The idea of an independent NHS board, floated last week by chancellor Gordon Brown, is that ministers would set the NHS budget and define its broad 'strategic direction' and then leave it to the board to make it happen (news, page 5, 28 September). Ministers would effectively give up their direction-making powers, and when operational things went wrong (as they always will do) they could haul in the trust chair for a dressing down rather than having to take personal responsibility.

It seems a good idea for ministers, but is it good for the NHS? How would it work in relation to, say, district general hospitals. Who should decide which are built up and which downgraded?

At present, acting on the advice of the independent reconfiguration panel, ministers have the final say. In practice this means that the strategic health authority puts up advice, local politicians have their say and the minister weighs the factors and makes a ultimate decision.

Those who complained that the health secretary may have glanced at a map of marginal constituencies when looking at the 60 DGHs supposedly under threat misunderstand the process. These are decisions taken by politicians which affect other politicians - so how could they be other than political decisions?

Under an NHS board, the decision would be entirely non-political and based solely on the objective evidence. This would, at a stroke, solve the politician's tension between maintaining short-term popularity and long-term strategic decision making. But this means that key final decisions affecting local services are taken by unelected 'bureaucrats'.

Those adversely affected - professionals and the public - will portray the board as out of touch, unaccountable and uncaring. It will bring NHS managers directly into the firing line where politicians presently stand. Do senior NHS managers really want local campaigners and press camped outside their houses at the weekend?

Those who do not like the board's decisions will say there is a democratic deficit in this type of decision-making. Taking decision-making away from those elected by the public means that there is precious little for MPs to do apart from join local campaigns. The sight earlier this year of former health secretary John Reid demonstrating against the proposed downgrading of his local accident and emergency services at Monklands Hospital is a case in point.

The decision was devolved to the Scottish Executive and so all Mr Reid, then defence secretary, could do was be a cheer leader for the local campaign. But perhaps this meant that the right decision was taken and the local MP, by not being part of the decision-making process, avoided the political flak.

So, properly staffed with high-quality and experienced decision-makers, an NHS board could therefore take the sort of long-term decisions which are so tough for elected politicians. But the key test will come when there is a scandal - and these come along regularly in an institution as large as the NHS - and ministers need the confidence to resist the 'something must be done' brigade.

Having given away the power to make immediate changes, when there is a baying press and a need to make a statement to the Commons, will ministers have the courage not to interfere? We will really know this has succeeded when the health secretary says: 'I share the Honourable Member's concern and will join him in drawing it to the attention of the chair of the NHS board. However he will appreciate that, as a result of the devolution of the power to the NHS board, this is not a decision for me.'

Now that would be progress.

David Lock is a barrister and head of health at Mills & Reeve.