At their recent conferences all three major parties made proposals to devolve more power from the centre. Would this help bring structure and consistency to policy, or are they solutions without a problem? Daloni Carlisle takes a closer look

At their recent conferences all three major parties made proposals to devolve more power from the centre. Would this help bring structure and consistency to policy, or are they solutions without a problem? Daloni Carlisle takes a closer look

At their recent conferences all three major parties made proposals to devolve more power from the centre. Would this help bring structure and consistency to policy, or are they solutions without a problem? Daloni Carlisle takes a closer look

It was ironic that this month's unified three-party call to take the politics out of the NHS should come during the partisan tub-thumping of the party conference season.

At Labour's bash in Manchester, chancellor Gordon Brown made a bid to define his leadership style by proposing an independent NHS board. Meanwhile, health minister Andy Burnham proposed his NHS constitution - apparently approved by Number 10 - and former health secretary Alan Milburn mooted directly elected primary care trusts.

A week later at the Conservative conference, leader David Cameron's speech set out to claim the NHS as his own. He proposed to remove bureaucracy and pass power to the front line. Shadow health secretary Andrew Lansley wants to hand power to GPs and hold managers to account through a proper commercial framework.

The Liberal Democrats, meanwhile, were in the throes of a policy review but reiterated the general theme of giving power to locally elected people.

Lib Dem health spokesman Steve Webb told HSJ: 'We cannot go on with the Whitehall meddling. We are very strongly in favour of localising public services wherever possible.'

If the politicians are aligned on the need to take politics out of the NHS, then so are policy analysts on the fundamental impossibility of doing so. The position was summed up quite simply by King's Fund chief executive Niall Dickson, whose response to Mr Brown's independent board proposal was that 'those who have this idea of taking the politics out of the NHS are living in cloud cuckoo land'.

This is not to suggest everyone is happy with the way things stand. The issue at the heart of a general dissatisfaction is accountability.

Richard Brooks, associate director of think tank the Institute for Public Policy Research, says: 'There are two big problems. We have the wrong kind of accountability at the top and a lack of bottom-up accountability.'

The same examples come up again and again in discussions. Health secretary Patricia's Hewitt intervention in the debate on prescribing the breast cancer drug Herceptin; the ability of PCTs to refer unpalatable local reconfiguration decisions to Ms Hewitt; the move by the payment by results board earlier this year to shunt technical decisions on the level of the national tariff onto ministers.

Meanwhile, ministers are not held to account for the one thing that really is a national concern: the health of the nation.

'Patricia Hewitt cannot go anywhere without someone making a personal appeal to her for a particular drug or treatment,' says Mr Brooks. 'That shows the lack of sensible debate about priorities or the right kind of accountability.'

Accounting practices

Work by the NHS Confederation based on information from MORI polls shows the gap between patient experience (generally good) and public perception of the NHS (an institution in crisis). 'The public do not trust politicians when it comes to the NHS,' says confederation policy director Nigel Edwards.

But would Gordon Brown's independent board solve these problems? The idea is not new. The NHS Alliance put forward the idea in a paper in 2000, meeting with ministerial opposition. Chief executive Mike Sobanja says: 'Our argument was about the role of politicians. They have to decide on policy and national priorities and resource allocation. Then they say to an independent board &Quot;these are the policies and this is the policy framework; here is the money&Quot;. The board then says either yes, we can deliver with these resources or no we can't. In principle there's a contract.'

Free market think tank the Adam Smith Institute also proposed an independent board in 2005. Its president, Masden Pirie, says with evident glee: 'I wonder if he [Mr Brown] got the idea from us.'

The ASI vision of an independent board would be a panel of experts who 'command universal respect' appointed by parliament to decide what proportion of the budget is spent on, say, health education, public health or treatment.

It is doubtful whether Mr Brown's independent board would look much like this. The trouble is that detail is so thin on the ground that it is hard to tell.

More questions than answers

Mr Edwards is sceptical about what Mr Brown has revealed so far. 'It seems to be a solution without being clear what the problem is,' he says. 'This is fairly classic in terms of policy making.'

Presumably, he says, the idea of an independent board is to do away with politicians getting involved where they shouldn't. 'The starting point, then, is to define the rules of engagement. If they don't, the board will find itself interfered with.'

Another missing detail is whether the board would hold funds. 'I am assuming it would be a commissioning board, a sort of national insurer,' says Mr Edwards. 'That would mean everyone else in the NHS becoming providers so at least it would solve the PCT provider problem. They could keep the provider role but manage it at arm's-length.'

Questions also remain about the other expertise in the Department of Health. Where would the chief medical officer's department fit? 'There's a lot of expert knowledge and clinical expertise,' says Mr Edwards.

Not only is the idea poorly worked out, he says, but existing models show it does not work.

Extreme reluctance

Hungary, Poland and Slovakia have very similar independent boards to that proposed by Mr Brown, he says. They were set up at the behest of the World Bank and operate as independent self-governing organisations responsible to parliament.

'On the whole they have been extremely reluctant to use their commissioning powers to manage any service change,' says Mr Edwards. 'That's partly because they are responsible to parliament.'

His third criticism is that the independent board idea does not begin to solve the accountability issues. 'How do you get accountability for£100bn of taxpayers' money? Is it conceivable for local people to say &Quot;the board is shutting my hospital&Quot; and a local MP to say &Quot;it's nothing to do with us&Quot;? People would ask &Quot;what the hell are you there for then?&Quot;.'

Mr Brooks is also unconvinced by the independent board. 'We do not want to reduce the accountability of ministers. We want a change in the nature of accountability,' he says. 'The problem with the idea of the independent board is whether you would solve the problems of accountability or simply replicate them in another organisation.'

Handing over 10 per cent of the national budget to an independent agency would be completely without precedent in this country.

However, something needs to be done. 'If we continue as we are we will end up with an unsustainable pattern of care.

'We cannot continue to take decisions one by one, like Herceptin. There is a problem that needs careful structural thinking.'

Both Mr Brooks and Mr Edwards come down on Andy Burnham's side, citing the idea of a constitution for the NHS as the most interesting of the current crop of ideas.

Mr Brooks says: 'It would be helpful to have a constitution that sets out in more detail the principles behind the NHS. If we were going to do that we would need a proper debate or conversation about what we want from the NHS.'

The final area of agreement is that structural changes must run the length of the NHS. It's no good tackling the top without reforming the bottom. Jon Glasby, senior lecturer at Birmingham University's Health Services Management Centre, addressed this recently in a book on creating what he calls NHS Local by crafting a 'new relationship' between the NHS and local government.

Local legitimacy

'We are arguing for local government to do the healthcare commissioning,' says Mr Glasby. 'In a very real sense this would take central politics out of the NHS and transfer it to local democracy.'

He argues that PCTs need more legitimacy for decisions through local democracy. 'What kind of
local legitimacy do PCTs have?' he asks. 'You could never imagine merging Devon and Cornwall
county councils, but you could merge the PCTs and no-one would notice.'

There are various ways of tackling the lack of local democracy - elected PCTs, for example, or beefing up overview and scrutiny - but Mr Glasby argues that handing commissioning powers to local government would be the most powerful solution.

'Local authorities are good at managing cash-limited budgets,' he says. 'They are very good at working with a mixed economy. They are being asked to shape their local areas and to do that they need influence over the local services.'

To achieve this would require a change at the top, too. 'Local government would not be interested in administering an NHS with as much central, national control as is currently the case,' he says. 'There would need to be a letting-go of control.'

Examples exist already, he argues. 'We have a model with the police and education. There are ways of setting a central framework that allows local control.'

Amid all the talk and the rather confusing picture of just where politics is taking the NHS one thing is sure: it's not taking politics out of the NHS.