The Welsh NHS is about to be reunited with local government. But, asks Patrick Butler, how democratic will things be?

After years of centrally controlled insularity, the Welsh NHS could be in for a shock.

Local government is back in the health business, fuelled by devolution and popular hatred of unelected quangos, and driven by politicians' apparent desire to reduce the 'democratic deficit'.

First, ministers plan to create a statutory responsibility for the NHS and local authorities to work together. Local authorities will have powers and responsibilities to 'promote community well-being'.

The key buzz-words are 'partnership', 'integration' and 'collaborative approach'.

Second, local authorities will have a place on local health groups - the Welsh equivalent of primary care groups. LHGs - which are co-terminous with the 22 local authorities in Wales - will advise the principality's five health authorities on priorities and objectives.

But how 'democratic' is the new approach? Will it give local communities - and their elected representatives - a real say in health services? And - dread question for many NHS managers - how much influence will councillors have on health policy and provision?

The Welsh Institute for Health and Social Care recently published two commentaries addressing some of these issues. Its answers to the above three questions are, respectively, 'not very', 'probably not' and 'not much'.

WIHSC notes that the NHS has in the past 'sat uneasily within the local democratic process'.

It calls the government's plans 'an admirable attempt' to drag health policy towards greater democratic control.

But it also suggests that, without radical changes to those plans, local authorities' principal role in the Welsh NHS could end up being little more than a 'democratic fig leaf'.

Although local authorities will sit on LHGs, says WIHSC, Welsh Office guidance 'carefully avoids setting out a role for elected members' - referring only to a role for 'officials'. It says there is little to indicate that democratic processes will have an impact on decisions over local priorities.

For a start, LHGs will be HA sub-committees, firmly establishing a 'top- down' accountability framework. And their advisory nature - at least for the first two years - may 'discourage' innovative primary care practitioner- led purchasing decisions.

Although LHG executive committees will be chaired by GPs, they will be packed with HA and local authority officials. This, suggests WIHSC, could be a ruse to provide 'clinical respectability' to a tight, politically and managerially driven process.

According to WIHSC: 'The guidance as written clearly intends to deter any democratic involvement in the resource allocating and service monitoring processes.

'Given that LHGs have... been deliberately aligned with local authority boundaries, this clear message is worrying, signalling that oversight of the delivery of care, and debates about prioritisation... are matters for the professionals alone, unmoderated by local politicians...'

It adds: 'This is at odds with the clear statement in the white paper (Putting Patients First) that local representatives would be involved in taking decisions about heath and social care.'

It also points out that LHGs will have local authority 'officials' rather than elected members. This 'suggests that the democratic deficit is not to be resolved by LHGs utilising their potential place in the democratic process'.

WIHSC concludes: 'As currently proposed, the danger is that LHGs will suck local professionals into a bureaucratic machine designed to implement government policy, thereby stifling local initiative behind a facade of local accountability.'

This is likely to cause problems for local authorities, which will be required to 'share in and defend those difficult allocation decisions facing the NHS' while seemingly having little leverage over the setting of priorities.

'Is it realistic to expect a local authority with minority representation in the health decision- making process to defend those decisions against its own electorate?' asks WIHSC.

It would like to see HAs made more accountable both to LHGs and the democratic process. This would effectively make LHGs a forum for 'bottom-up' policy making.

The response of local authorities to proposals for joint working have been enthusiastic, but not unconditionally so. The Welsh Local Government Association has made it clear it wants to establish 'appropriate member mechanisms to engage with the local health agenda'.

It also calls on the Welsh Office and the new national assembly to 'acknowledge the value of democratic accountability at a local level and provide specific opportunities for elected representatives to be included in strategic planning structures'.

The NHS has similarly welcomed joint working but is reluctant to see itself hampered in its attempts to implement strategic plans, according to Fiona Peel, who chairs NHS Confederation Wales and Gwent HA.

'You do not want the Welsh assembly saying we want a modernised system and at the other end LHGs arguing against closing or changing things,' says Ms Peel.

'At the moment local authorities very much want to be more involved. To be successful we need better partnerships than we have had in the past. But I think we have to be clear whose responsibility running the NHS is.'

WIHSC commentary number four The Welsh Assembly and Reinvigorated Local Government, and commentary number five Local Health Groups: what are they used for?

Welsh Institute for Health and Social Care, University of Glamorgan, Pontypridd CF 37 1DL. Free.