A Democratic Deficit
Last week I attended Surrey’s Health and Wellbeing Board. This committee contains representatives from patient organisations, Clinical Commissioning Groups, (CCGs), the SCC Cabinet (represented, I have to say, by three councillors who are really effective and know their brief) and Borough and District Councils.
Its remit is to take a strategic view of health issues in the county, and for strategic, read high level. I make this point because it is there to cover the democratic deficit which leaves health policy and provision unaccountable to any democratic body. Even the police have a Commissioner who is elected (a post which replaced a committee of local councillors- and which has, as yet, failed to grab the public’s attention.) Surrey’s Police and Crime Commissioner, a former County Councillor, also sits on the Health and Wellbeing Board (HWWB.) The Statutory role of Director of Adult Social Care sits on the committee (also the Director of Public Health), as does the Director of Children’s Services.
This well stocked committee should be very effective. It works to ensure that services which different agencies deliver are as well co-ordinated as possible. But it all feels very bland and anodyne, and you sense that it is going through the motions.
If residents were looking for a body to take significant decisions and which enabled them to hold individuals to account I am afraid they would be disappointed. For years, no elected individual has been accountable for decisions on health spending, and since the 2012 Health and Social Care Act, neither has the Secretary of State. Commissioning decisions- the way our taxes for health are spent, is the business of Clinical Commissioning Groups, made up of clinicians and civil servants, rudely dubbed “managers”, (often said with a snarl), with some lay Board members, who take all the decisions.
They are usually heavily leaned on by the NHS England, a sort of Politburo without the politicians, (again, there are lay members on the board, but they and the Chair are political appointments, and the CEO, Simon Stevens, is effectively in office at the pleasure of the Prime Minister.) NHS England, which is in a constant state of being re-structured, has at its disposal NHS Improvement, a hit-squad. A visit from them is the equivalent of a late-night knock on the door.
With me so far?
So, which elected person can you shout at if, say, the Walk-In Centre at Weybridge Community Hospital is not re-instated after last year’s devastating fire? Who can you shout at if your mum was on a trolley for twelve hours in a Surrey A&E? Answer, no-one. MPs always champion a popular cause- “don’t close the much-loved memorial community hospital”, but in fact they can only brief behind the scenes. If the CEO of a CCG attracts a lot of bad publicity, local MPs might persuade NHS England to send the boys round, but otherwise they are powerless. Closure, or significant amendment to a health services, by statute, have to be the subject of a public consultation, but as we all know, most consultations are constructed to deliver the outcome that the commissioners want- the current consultation on the future of drug and alcohol services in Surrey is a case in point.
So, to pretend to fill this gap, the democratic deficit, top tier Authorities can have a HWWB to take the “strategic overview” and have elected members sit on it.
I set all this out because today’s Times reports that a majority of the population is now in favour of a dedicated (hypothecated) tax to support the NHS. I support the option myself. But in the context of the democratic deficit I have set out above, is it not time for a change in the accountability of the people who spend this dedicated tax? Should they not be accountable, in some way, to the people who pay the tax?
The most successful period of the NHS in my lifetime was the period 2000-2010. Spending was significantly increased, systems were streamlined, and staff morale improved, especially in primary care, as there was significant investment in it. That period was characterised by strong ministerial control. The office in Manchester where the project I then worked for was based had a banner in huge letters setting out our objectives- “Happy patients, Happy doctors, Happy Ministers!” Those were the days. What should have happened following that period should have been a move to a system more accountable to the people. Instead, the change of government meant the opposite happened- the Health and Social Care Act even exempted the Secretary of State from any responsibility for the delivery of services. The NHS was a market, loosely managed and dysfunctional and heading for a crisis- the winter of 2017/8. Today, 12th April, the news reports that March had the worst A&E performance on record.
The NHS survives despite itself, despite the systems that often conflict, the constant lack of money, the bullying of staff to deliver targets and the serious exploitation of the many staff who hardly make a living wage. It survives on the eternal good will of so many who, despite the systems they constantly have to fight, strive to make a difference. Time to support them with an electorally accountable system methinks.
Twenty-one years at Tandridge and a year at County Hall. What have I learned?
Most people who are elected care about residents. There are a few egotists who are self-serving. Some seem to be very lazy and there for the wrong reasons. They seem to get away with it and I think that is because their record is not really subject to proper scrutiny and elections are confusing.
I welcome the webcast of meetings from County Hall and look forward to its introduction in the coming months at Tandridge. Residents need to see how councillors behave, what they say and don’t say. I just wished more people had the time to witness the behaviour of their representatives.
I was very shocked at a recent Tandridge committee. We were discussing a potential investment property (I can’t reveal which as it was a confidential item- rightly). We had a detailed report on the proposal in front of us which we had the opportunity to interrogate both before the meeting and during the discussion of the item. Whereupon one councillor decides to google the site on her phone and proceeds to regale the committee, and more insultingly, the very senior officer who had written the report, with the contents of her google search.
The officer remained calm. The councillor clearly had no shame, but I was embarrassed. Local government can’t work like that. I know it is fashionable to distrust “experts”, but councillors who traduce not just the integrity but also the very intelligence of an officer in this way really should have no place in public life. Imagine if the council were run by people who used google for their policy making. Councillors are there to challenge and hold officers to account, testing their recommendations and making decisions on balance. It is a serious business, not one that can be conducted as if it were a pub quiz.
For a number of years, I used to be very challenged by the party political nonsense which infects council debates from time to time, but that aspect of behaviour, which used to leave me feeling as if I was swimming in foul water, has diminished of late. It still rears its ugly head- there was a party political defence of the way the Highways budget is spent at the last County Council meeting. Obviously a system based on parties opposing each other will produce some of that. But it does not further the work, the interests of residents, or the quality of decision making.
Councillors can only truly be effective if they firstly command respect across the Chamber, secondly build a consensus around a position by drawing opposing councillors into compelling arguments, and thirdly by demonstrably working hard. Those are the three tests that matter. As we go into local elections I wish those were the tests that candidates were subject to.