Following the first direct elections of members of the public to Scottish health boards last week, Don Redding asks if England’s primary care trusts could soon follow suit

In pioneering direct elections last Thursday, 22 members of the public were voted onto two Scottish regional health boards.

In England, discussions about using direct democracy to increase the accountability of local health services have produced a distinct antipathy within both the NHS and local government

They included two nurses, a medical secretary, a health union convenor, five retired doctors, former councillors and advocates for patients, carers and disabled people. Four had previous board level experience.

If they join forces with the appointed councillor on each board they will be able to form majorities of elected members, making decisions about the running of health services for more than half a million people, with budgets totalling over £900m this year.

The coalition government has promised similar direct elections to the boards of England’s primary care trusts. Further details are expected in an imminent white paper.

In England, discussions about using direct democracy to increase the accountability of local health services have produced a distinct antipathy within both the NHS and local government.

An exhaustive commission for the Local Government Association concluded in 2008 that “there is currently no appetite for further major upheaval in the governance, structures or boundaries of the healthcare system”.

LGA senior policy consultant Alyson Morley said at the time that despite the widespread recognition of the need for service change in the NHS, the LGA “questions the wisdom of directly electing representatives of the public. Who are they? Who elects them? What’s their constituency? How do they relate to other structures such as local involvement networks?”.

Likewise a 2008 consultation of NHS Confederation members found almost none in favour.

“We can see potential benefit in giving more legitimacy to decision making,” PCT Network director David Stout tells HSJ. “But it was the risks people were focusing on.

“How do you avoid the risk of the NHS being politically driven and micromanaged at the local level, just when you are trying to reduce that at the national level? How do you deal with single issue campaigns?”

Counting the cost

Similar fears were expressed in Scotland, for example by the British Medical Association, whose spokesman Brian Keighley says: “The major concern is this won’t produce either the accountability or the engagement that we need.”

Cost has also been an issue. The Scottish pilots have cost £2.5m, including a two year evaluation, to bring 22 new members onto just two of the 14 territorial boards.

Dr Keighley argues: “There are better things we could be doing with the money at a time when we’re facing the cliff edge.”

NHS Scotland health service workers - who are facing 3,700 job cuts this year - and ordinary voters are also questioning the cost.

“I’ve had people saying this is a total waste of money and tearing up their ballot papers, they’re so angry,” says one candidate.

So did the elections prove the sceptics justified?

The fear of apathy was not borne out. In NHS Fife, 60 people stood, and in NHS Dumfries and Galloway, 70 - producing some of the longest ballot papers ever issued in the UK. Turnout was only 14 per cent in Fife - but around 38,000 people voted. In Dumfries and Galloway more than 26,000 voted - a turnout of 22 per cent.

The feared political manipulation did not materialise either. Although candidates could stand on a party ticket, most opted not to and were keen to emphasise their independence from politics. In Fife, around half the candidates were ordinary community service stalwarts, who saw this as an extension of their role.

Supporters of the pilots say that by bringing forward so many people who would not have come through a formal appointments process, the NHS elections have tapped a huge new pool of community spirited interest.

The two pilots differed where “single issues” were concerned.

In NHS Fife, hospital reconfigurations began in 2002 and are now close to completion.

“The board has settled strategies and financial plans,” says an insider, “so on the one hand it may be hard for new members to make a difference, on the other it gives them time to settle in and learn what they can influence.”

By contrast, NHS Dumfries and Galloway withdrew a consultation on its clinical services strategy shortly before the election, after local and political outrage that the board was backing the closure of five community hospitals serving the dispersed, rural population. Five of the 10 elected members are against that option.

It would be hard to classify those five members as “single issue” activists. Two are retired doctors and one is an ex-board member. A fourth, librarian and grandmother Lesley Garbutt, tells HSJ she had “made it clear from the start that I wasn’t standing on one issue”.

She says: “The whole point of this exercise is to open a highfalutin business to the views of Joe Public. A whole lot of changes could be brought that could improve the patient experience, that wouldn’t cost anything - patients and their families being listened to. As long as the existing members embrace this we can all benefit.”

Unlike English PCTs, the 14 territorial Scottish health boards remain part of a strongly integrated vertical health system. They run services directly - 12 hospitals in Fife, for instance - and are upwardly accountable to the cabinet secretary for health.

But similarly to England, the debate has recently focused on reconfiguration - particularly acute service centralisation.

Scottish Health Council director Richard Norris says the elected member pilots were “a direct response” to “a legacy of contested service changes, where boards have been arguing they need to centralise services.

“There has been too little challenge when controversial decisions were made. [Health] boards have not had a convincing story to tell about how they got to where they are.”

The minority SNP government’s legislation to introduce elected members was not opposed by other parties, after it accepted the need to run pilots first.

Scottish health secretary Nicola Sturgeon tells HSJ: “Elected health boards are the best way of ensuring boards will no longer be able to ride roughshod over community opinion, as has happened in the past. The voices of people whose taxes pay for the NHS will now have to be listened to and acted upon.”

The SNP government has reversed two major reconfigurations and set a national “presumption against centralisation”.

The question in Scotland now is whether directly elected members will change this picture. The two boards admit privately they do not know.

The question in England - amid uncertainty over the future scope and size of PCTs - is whether democracy is even relevant to them.

“If this is about patient representation, and PCTs are not responsible for the issues that are of concern to patients, such as reconfiguration, it’s not immediately clear to me how this helps,” David Stout says.

“The governance structure needs to be designed to follow the function PCTs actually have.”

The elected Scottish members are now central to operational decision making. Increasingly in England, as the NHS Confederation and the LGA point out, service change decisions will shift to GP commissioners. That raises the question of what, precisely, locally elected members will be making decisions about.

NHS FIFE

  • Population 360,000
  • Budget £618m
  • Area 500 square miles
  • Urban and rural mix
  • Major towns Dunfermline, Kirkcaldy, Glenrothes
  • Reconfiguration “Right for Fife” approved 2002, end date 2012 - Victoria Hospital, Kirkcaldy, becomes main A&E and specialist acute service and merges with a maternity unit; Queen Margaret Hospital in Dunfermline becomes generalist acute service. New community hospital, St Andrews
  • Job losses for 2010-11 Total 54
  • Board composition 12 elected members, one elected councillor, 12 appointed members including chair who appoints the chief executive

NHS DUMFRIES AND GALLOWAY

  • Population 148,500
  • Budget £300m
  • Area 2,400 square miles (60 people per square mile)
  • Mainly rural
  • Major towns Dumfries, Stranraer
  • Reconfiguration Clinical services strategy yet to go to minister for approval. Three options proposed in 2009 with board backing “option C” - closing five community hospitals - consultation now withdrawn until 2011.
  • Job losses for 2010-11 Total 32
  • Board composition 10 elected members, one elected councillor, 10 appointed members