Sea change in health scrutiny

As the future of health scrutiny grows increasingly complex, healthcare professionals and local government must ride the wave and forge new relationships, reports Sasha Strong

• The Health and Social Care Act 2001 gave local government the power to scrutinise local health provision through overview and scrutiny committees.
• A lack of guidance means there is some confusion about the committees' role.
• Experts recommend earlier involvement in decisions so they are better informed, and to reduce animosity.

In 2001 a citizen rebellion in Kidderminster prompted a fundamental change in the relationship between local government and health that is still finding its feet today.

People living in the town had been outraged at a proposed accident and emergency unit closure, so they took matters into their own hands and rejected their Labour MP and elected to Parliament local hospital campaigner Dr Richard Taylor. This sent a shockwave to central government as it realised healthcare decision-making needed an urgent injection of local democratic input to prevent reoccurence.

The solution came in the Health and Social Care Act 2001, which gave councillors in England's 150 top-tier councils the powers to scrutinise whether local health provision met local needs through health overview and scrutiny committees.

New powers

The committees gave councillors the power to summon evidence from health bodies about their plans, and oblige them to respond to (even if not accept) their recommendations. But crucially, the act made clear the NHS had to consult the committees on significant service changes - or face referral to the secretary of state for health.

Six years after their birth, however, committees are receiving mixed reports on their effectiveness.

In April, a Commons health select committee report on patient and public involvement claimed the committee activities were constrained by elections, manipulated by council executives and fundamentally ineffective while purse strings stayed centrally controlled.

The MPs said: 'Scrutiny committees can only be reactive rather than proactive. There is no lay or public representation; local councillors fill all seats and OSCs may not reflect the political make-up of the council (ie the majority party may choose to fill all seats). As a result, OSCs may not exercise rigorous scrutiny'.

A lack of guidance for health managers about how to deal with the committees has led to confusion around their role. Association of Directors of Adult Social Services president Anne Williams senses some NHS bodies 'think all the power is with the committee - and they work with them rather than the executive'.

Influence not aggression

In June, in-depth research by Manchester University looks set to report a more constructive picture, claiming committees are actually finding their feet and developing a collaborative style which helps councils and health bodies unite in their mutual task of public health improvement.

Tim Gilling, health scrutiny programme manager at the Centre for Public Scrutiny, commissioned the research as part of a Department of Health-funded support programme for the committees. He admits that in the function's infancy the term 'scrutiny' may have raised NHS hackles by 'evoking perceptions of yet more inspection'.

He says: 'The impact is largely achieved more subtly through influence rather than aggression, based on detailed questioning and evidence-based recommendations that bring the public voice to decision-making.'

NHS redesign

But despite obvious progress, the world in which the committee operates is about to become increasingly complex thanks to the changing landscape of both local government and health.

Scrutiny committees will gain an increased profile within the proposed comprehensive area assessment, currently at an early stage of consultation in preparation for introduction in 2009.

According to Audit Commission head of local government performance Ian Carter, the new system will assess the risk of achieving the desired local outcomes enshrined in the local area agreement. The process will draw on sources of local performance information, including scrutiny committees - if they are providing robust challenge, gathering a range of evidence and engaging well.

Inevitably the backdrop of massive NHS redesign will impact on scrutiny effectiveness. Continuity will be affected as new organisations develop and previous committees' recommendations become redundant.

As the health economy becomes increasingly mixed, committees will find they have to try to scrutinise a wider range of partners. For example, commercial confidentiality regulations restrict access to non-public sector contract information.

Recently one independent provider refused entirely to co-operate with Doncaster council's scrutiny committee, although the Confederation of British Industry's public sector directorate insists its members 'would expect to be under at least as much scrutiny as public sector providers'.

So how can the committees and the health partners with which they work ensure that future relationships hold firm?

Coping with change

The key message is to expect and manage change. Committees must be realistic about change, use it as an opportunity to forge new relationships: the key to successful scrutiny. Equally, primary care trusts need to be prepared to readjust relationships for the expected restructure of a handful of local authorities.

Sue Johnson, joint head of the Improvement and Development Agency's healthy communities programme, recommends all involved should 'expect change, and develop systems and processes to ride those changes'. But there are a number of practical steps that both healthcare and local government can take.

Scrutiny committees also look set to become overwhelmed with work, according to think-tank the Nuffield Trust. As a result, it is more than important that NHS and council executives ensure councillors understand services, say Ms Williams and Association of Directors of Public Health president Dr Tim Crayford.

Mutual benefit

Tim Gilling adds that health and social care professionals should work closely with lay scrutineers to agree priorities for work programmes. Anne Baxter, chair of the Association of Directors of Children's Services' health, care and additional needs committee, reflects this process has been useful in her council where early discussions between scrutiny and services ensure inquiries 'based on what is of mutual usefulness for the community'.

The centre recommends earlier involvement in service changes to ensure decisions are better informed and less acrimonious, particularly around reconfiguration plans.

Committees can give valuable input during pre-consultation engagement (known as section 11), says Mr Gilling, which may alleviate the need for a subsequent formal consultation (section 7).

Scrutiny committee involvement at an early stage ensures section 11 consultations are productive. NHS North West chief executive Mike Farrar says: 'The more people understand the more they can objectively analyse proposals for change and the rationale around them.'

Opaque finances

An important issue is that trusts need to become more open with financial information. Their reluctant approach has fuelled perceptions of an NHS stumbling from one self-inflicted crisis to another, according to the Nuffield Trust.

One scrutineer complained that her committee cannot accurately analyse the local trust's overspend because of opaque financial management procedures.

'We understand that services need to change,' she says, 'but we need better financial information to understand how much is available and whether social care is suffering'.

In terms of how best to cope with an increasingly mixed health economy, Ms Atkins says commissioners should manage contracts and relationships so that all providers are responsive to committees. However, Mr Gilling doubts such systems will be robust if accountability is contractual rather than legislative.

Improving life chances

Certainly the future for scrutiny looks increasingly complex and more reliant on relationships. But for those PCTs and scrutiny committees that are already working together well, the benefits are obvious.

The Healthcare Commission, for example, says the committees' commentaries on trust performance are already bringing valuable community-based perspectives to its healthcheck processes. Of the 69 trusts that received follow-up inspections last year, a commission spokesman says, 'eight would not have been selected without the committee commentary'.

Scrutiny committees are in many places showing a proactive role in investigating health topics of local concern. Improvement and Development Agency vice-chair Nick Chard comments: 'Scrutiny committees are bringing a lot to the table, articulating residents' concerns, accessing demographic details and highlighting things the health sector hasn't appreciated.'

Portsmouth PCT chair Zenna Atkins concurs: 'Scrutiny can magically improve the health-related life chances of the population if scrutineers take a really robust approach on top-line targets across public health,' she argues.

The benefits of getting this right are worth chasing: in Wigan, the scrutiny committee helped cut hearing-aid waiting times by 50 weeks, working with PCTs and acute trusts to see services from a patient perspective. Elsewhere, a review into health inequalities in a deprived ward in Stockport reached out to disenfranchised residents, including agoraphobics and asylum seekers, and stimulated community-based solutions. A walking group cleared the estate of litter and a fun run was introduced, improving the environment and encouraging exercise.

Ann Baxter says: 'We're all here to make services better. We should share that vision and realise we can work together in an environment of support and challenge.'