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Health Policy Today, 13th July 2008 - Local authorities to hold PCTs to account

Health Policy Today, 13th July 2008 - Local authorities to hold PCTs to account: the implications of Hazel Blear’s new White Paper Communities in control: real people, real power

Last Wednesday, on the 9th of July – Hazel Blears published a White Paper Communities in control: real people, real power. It didn’t make huge headlines and a very important implication for health seems not to have been noticed.

The Government’s stated aim is ‘to pass power into the hands of local communities, giving real control over local decisions to a wider pool of active citizens.’  What implications does this have for healthcare?

Here is the key extract – the words were emboldened in the original text.
‘To make it easier to influence the agenda at a local level we will introduce a new duty for councils to respond to petitions, ensuring that those with significant local support are properly debated. Local authorities should respond clearly to petitions, for example those dealing with empty properties, transferring the ownership of a building to the community, or participatory budgeting. If people are not satisfied with a response to a petition, they could ask for it to be debated in full council. Councils will also act as community advocates for petitions related to the Primary Care Trust.’

In the Foreword, Gordon Brown writes, ‘this is not about making people sit in meetings on wet Tuesday nights, it is about helping citizens to get involved when they want to on their own terms – paving the way for a new style of active politics that not only gives people a greater say but ensures that their voices are heard and that their views will make a difference.’

The move looks like a demonstration for localism and something that will demonstrate meaningful support for the central ideas of the Darzi review.  Is the government completing the logic of its reform by setting in place a parallel aim of strengthening local accountability?

Hazel Blear’s introduction is very interesting.  It places a really strong onus on local government and devolution. "My 30 years in politics, as a community activist, councillor, Member of Parliament and Minister have convinced me that there are few issues so complex, few problems so knotty, that they cannot be tackled and solved by the innate common sense and genius of local people. With the right support, guidance and advice, community groups and organisations have a huge, largely latent, capacity for self-government and self-organisation. This should be the hallmark of the modern state: devolved, decentralised, with power diffused throughout our society".

The problem with the paper is that Hazel Blear’s bubbly optimism shines through, and as a consequence, there is a naive tone.  

There is an assumption that an army of civic citizens exists that is waiting to work in productive and voluntary ways.  ‘We will support local communities in developing local events such as litter picks, painting community centres, street parties or fairs in local parks.’

These words are not to do with health, of course, and in the document there is some cross reference to DH plans. ‘Through consultation on the NHS Constitution Primary Care Trusts are being asked to consider how they can strengthen their direct engagement with the public.’

This will absolutely be needed. Commissioners need strong relationships with patients to ensure services work in patient interests. But this process will also help assure and legitimate the choices they make in buying specialist services. There is particular potential for patients to work with groups of GPs in practice-based commissioning (PBC) consortia (or whatever they will be called).  Practices could group together to share their quality and outcomes framework (QOF) points that are available for patient involvement.

Perhaps a more local focus will lead to local communities getting more involved in commissioning decisions and how money is spent. The document makes it clear this is the direction of travel, without spelling out how. ‘Citizens should have a greater say in how local budgets are spent. Participatory budgeting – where citizens help to set local priorities for spending – is already operating in 22 local authorities. We want to encourage every local authority to use such schemes in some form by 2012’.

At this stage in the reform of the NHS, the crucial thing for the Government to get right (if it is serious) is to encourage localism, through strengthening planning of local health economies (through commissioning or otherwise), by creating the conditions for clinicians to innovate in services and by strengthening local accountability.

The White Paper says the move will build on their policy of introducing elections to NHS foundation trusts are an extension of participatory democracy.

The problem is that people often want contradictory things.  Imagine a consultation containing three options for service development.  Which view will hold most weight if the governors of a foundation trust hold one view, the local LiNKs another, and the local council has gathered a petition in favour of the third option?

What the paper lacks are the mechanisms to resolve these political problems.  It will be for local authorities to try and construct this and it will not be easy.

A likely implication of the new duty is that it will make for more adversarial relationships between health and local authorities.  The former will claim expertise, and the latter democratic legitimacy.  This will only be avoided if the mechanisms are set in place now, under joint commissioning and the like, to make joint decisions.