Published: 18/04/2002, Volume II2, No. 5801 Page 28 29
Like it or not, local authorities are going to have far more say in the way the NHS is run, once new arrangements for 'overview and scrutiny'come into effect in January.
1NHS managers - not just chief executives, but directors and clinical leaders, too - will find themselves called to account before local authority scrutiny committees, made up of elected local councillors and meeting in public.Local authorities will have new powers to refer decisions about health service changes to the secretary of state and to the new Independent Reconfiguration Panel.
These scrutiny arrangements are intended to promote partnership and service improvement, but the risk is that they will degenerate into an exercise in blaming and point-scoring. So what should NHS organisations - trusts, primary care trusts and strategic health authorities - be doing to make scrutiny work?
2What is scrutiny?
Health scrutiny is a crucial component of local councils'statutory duty to 'promote the social, economic and environmental wellbeing of their areas according to the Local Government Act 2000'.
3New governance arrangements require councils to establish overview and scrutiny committees (OSCs) with a remit to hold executive members to account for the decisions they make and to secure improvements in local service provision.
Scrutiny arrangements in local government so far vary widely in approach and effectiveness.This reflects how well they have been resourced and whether backbench councillors and scrutiny committee members have been engaged effectively in the process.The wide variations in existing local authority scrutiny arrangements are likely to carry through into the new structures and systems being set up.
Though they now face abolition, community health councils have been the main form of community scrutiny of the NHS for almost 30 years.They have limited statutory powers - like the ability to visit NHS organisations and gather information, and to refer service changes to the secretary of state - similar in some ways to the OSCs.
But CHCs were always woefully under-resourced - some might say deliberately so - and while some made a constructive contribution, others were captured by sectional interests or were simply ineffective or marginalised.
The new arrangements for scrutiny by local authorities are different, for several reasons.Most obviously, they will bring the culture and dynamics of local politics into the NHS more directly than ever before.
4OSC members may not be well informed about health service issues, especially to begin with, but they will have an electoral legitimacy which CHCs always lacked, and could bring a more assertive and questioning style to their work than NHS organisations are used to.
They will be much better resourced, with stronger executive secretariat support to enable them to gather information and develop ideas.While CHC and HA meetings were already largely held in public, they were never well attended or reported on, and OSCs are likely to be better at getting public attention.The formal powers of OSCs - to call NHS managers and leaders to attend and answer questions, for example - look stronger and more significant.
It is interesting to speculate whether some major NHS changes would have been handled differently if the new arrangements for local authority scrutiny had been in place.Would the reconfiguration of acute services in Worcestershire, or the strategic changes in Manchester, have gone ahead in the same way? Almost certainly, the NHS organisations involved would have been forced to tackle the process of consultation differently - and the resulting changes might well have been different, too.
For NHS organisations, the scrutiny from local authorities will sit alongside an increasingly complex array of other bodies charged with regulating, inspecting or overseeing what the NHS does, like the Commission for Health Improvement, the National Institute for Clinical Excellence, the Audit Commission, the National Audit Office, and so on.
CHI is already leading a review aimed at cutting duplication and rationalising the overseeing process - but OSCs will add a new dimension to the problem.This can be seen as part of a wider move in the NHS away from bureaucratic direction by the Department of Health towards a more networked and multistranded approach to performance management.
5The key challenge for health scrutiny is to ensure that it adds significant value to the health and wellbeing of people locally, without duplicating the many other performance-management frameworks that exist within local government and the NHS.
Some councils - and indeed some NHS organisations - have placed emphasis on the early establishment of joint forum events to lay down initial priorities and styles of working within their scrutiny programmes.They say this has been important to share expectations and information, and to generate the scope and agenda for the programme.
If good relationships are to be created and sustained, NHS organisations and local authorities need to be willing to share information.The data would include reports of critical incidents or local problem issues, performance management reports, inspection findings from bodies like the Social Services Inspectorate and CHI, best-value reviews, and the results of consultations with patients, residents and others.
Scrutiny programmes need to be planned, and to cover a wide range of issues.A programme should be developed jointly to include specific service reviews, such as:
thematic, cross-cutting reviews on major issues or client groups (for example, a review on asthma might tackle issues from air quality to prescribing and health promotion);
major service reconfigurations (though there is a risk that these could dominate the agenda);
public health and health improvement challenges, such as drug abuse.
The programme should avoid overlap with other forms of performance management.
In some cases, joint scrutiny across local authority boundaries will be needed.
It is crucial that criteria for dealing with reactive issues in scrutiny are developed early on - how to deal with short-term, single issues which get a high profile in the local media and attract public and political interest.Scrutiny committees need to avoid getting dragged into every instance, otherwise the agenda will become driven by short-term, highly localised political considerations and strategic oversight will be pushed aside.
We need an agreed approach to scrutiny reviews with which NHS organisations and local authorities are comfortable.This might map out how information will be collected, who will be involved, how reports will be produced, what opportunities for consultation on recommendations there will be, how the public committee sessions themselves will be used, and how scrutiny findings should be published and disseminated.
Right from the start, the way scrutiny works needs to be kept under review.Local authorities and NHS organisations should not expect to get it right first time, and both should be willing to change the arrangements they put in place.A formative, developmental approach is needed.Some kind of evaluation of how it works needs to be built in and - crucially - what benefits it delivers.
Protests about the abolition of CHCs have perhaps overshadowed the arrangements for local authority scrutiny of the NHS.But in the longer term, this scrutiny could provide a much more powerful and effective form of community observation of the health service than CHCs ever could.
Making it work will not be easy.Challenges are presented by the cultural differences between local authorities and NHS organisations, elected councillors on scrutiny committees gaining a proper understanding of healthcare, and the potential for duplication with other forms of observation.
Perhaps most important, scrutiny needs to be a two-way process - complementing the best-value reviews which focus on local authority service provision.But for local authorities and NHS organisations just beginning to set up scrutiny, building good relationships and sharing information seem the best place to start. l On closer examination: scrutiny in context The legal context for scrutiny is set by the Local Government Act 2000, which separated the executive and non-executive roles in local authorities and created overview and scrutiny committees which hold the executive to account, rather like parliamentary select committees.OSCs are made up mainly of elected councillors but can have co-opted members or non-voting invited observers.
The healthcare scrutiny function is set out in the Health and Social Care Act 2001, which gives local authority OSCs power to scrutinise health services as part of their wider role in health improvement.NHS organisations have a duty to consult actively OSCs on developments in local health services.
The formal powers of local authority scrutiny committees have not been finalised, but will include the ability to require NHS organisations to provide information and to require senior managers and clinicians from NHS organisations to appear before the committee to answer questions.OSCs will be able to refer issues to the secretary of state or to the new Independent Reconfiguration Panel.
Their reports will be published.
Local authority scrutiny of the NHS, to come into effect in January next year, will bring health services into local politics more directly than ever before.
The scrutiny committees will be able to call chief executives and directors to account and scrutinise service decisions.
Health organisations should become involved in scrutiny arrangements now.
1 Department of Health. Local Authority Health Overview and Scrutiny: a consultation document.
2 Audit Commission. A Healthy Outlook: local authority overview and scrutiny of health. London: Audit Commission, 2001.
3 Local Government Act 2000. London: HSMO
4 Corrigan P.Here's looking at you, kid.HSJ 2001; 111(5741):30-31.
5 Walshe K.The rise of regulation in the NHS.British Med J 2002, in press.
Donna Bradshaw is a fellow and Kieran Walshe is director of research at the Manchester centre for healthcare management, Manchester University.