While the NHS in England has embraced patient choice and provider competition, the other three health systems of the UK have taken alternative routes in the quest for improved health services. Since 2004 Scotland’s approach has been to remove the purchaser-provider split and unify management into territorial Health Boards responsible for all health services in a geographical area.
Last month’s much-publicised Nuffield Trust and Health Foundation report comparing the performance of the four systems concluded that (with the exception of Wales, which is falling behind on some key indicators) the remarkable structural differences which are now evident within the ‘UK NHS’ are not translating into significantly distinct performances. But this report concentrated on costs and patient outcomes, and made no mention of other aspects of health systems we might value as a society. Accountability to the public is one such value. While in the English NHS the key mechanism of accountability has been recast (at least rhetorically) as patient choice between competing providers , in Scottish policy circles there is a perceived distaste for competition in public services. This has led to some interesting, if not always coherent, experiments in alternative means of ensuring ‘voice’ in the NHS.
Back in 2004, Scott Greer identified the primary levers driving the four health systems of the UK in the years since devolution. He saw Scotland’s system as ‘professionalistic’, arguing that by and large Scotland had “placed a distinct bet on professionalism to run its health service”. The role of the public is a rather glaring omission from this formula.
In the early years of devolved health policy in Scotland public involvement, an ever-present component of New Labour NHS policy (albeit alongside more consumerist formulations), was a fairly unimaginative affair, broadly replicating the model of the Community Health Councils, and then the Patient and Public Involvement Forums, which existed south of the border. A series of contentious decisions about the closure of hospitals and accident & emergency departments escalated rapidly to the national political arena, even drawing the fire of prominent Scottish MPs at Westminster. The absence of any public voice in Scotland’s bet started to look a little unwise. But the unexpected SNP victory in 2007 (bringing to power a party with a long history of shouting from the sidelines but minimal experience of governing the NHS) brought with it a period of experimentation and new ideas. The headline idea was ‘mutuality‘, and a determined reassertion of the public ownership and unity of the Scottish NHS.
So what does public accountability look like within a ‘mutual’ NHS? The ‘John Lewis model’ of running an organisation through partnership has many advantages, but one major disadvantage is that it offers little space for dissent and conflict. If, as the SNP’s flagship health white paper proclaimed, we are all (NHS staff, patients and tax-payers) ‘co-owners’ of a public service, then we need some mechanisms to navigate moments when the (real or perceived) interests of these groups clash.
The key answer to this dilemma was a proposal for direct elections of members of the boards which govern Scotland’s regional Health Boards. This idea, while innovative in the UK – where England’s elected Foundation Trust governors run ‘oversight’ bodies rather than engage in actual decision-making – has been a feature of the New Zealand NHS for decades, and has also been attempted (and abandoned) in various Canadian provinces. The idea of inserting structures of local representative democracy into the NHS, in the same way that education is overseen by elected councillors in local authorities, has intuitive appeal, not least to elected national politicians, and the proposal to pilot direct elections in two health Boards won cross-party support at Holyrood.
However, in operation, the pilots failed to live up to their radical potential or, indeed, to the fears of ‘politicisation’ which numerous stakeholders had expressed. First, turnout in the postal elections was low, mirroring the Canadian experience of health board elections and disappointing those who had argued that there was a great public appetite for influencing the NHS. Second, the public who did vote were particularly drawn towards electing health professionals, both practising and retired. While marking a shift from the retired business people or senior managers who tend to populate public sector boards in the UK, the pilots did not inject many new public perspectives into the world of NHS management.
Third, having been duly elected, new Board members were thoroughly and effectively socialised into behaving much as their predecessors had: understanding their primary accountability as being to the Minster; respecting the ‘corporate responsibility’ according to which disagreement among board members was to be quietly negotiated in private, not publicised; and minimising their engagement with members of the public. Some of these limitations were resisted more than others, and not all elected members fell into line, but those most committed to an alternative model of their role were more likely to resign their positions than stay and change the way Boards did business. Following the report of an independent evaluation, the Government decided to discontinue the pilots in favour of encouraging Boards to broaden their non-executive recruitment processes.
By concentrating on who sits round the table, this leaves unresolved the question of what these non-executive Board members are there for, and particularly their role in public accountability. The basic NHS model of accountability, through the Minister to parliament, has always been questionable, and the Public Partnership Forums which still exist at local level have no formal clout at the Board table, and are better understood as consultative devices. The under-explored role of local authority councillors on Health Boards undoubtedly has some potential, but we know little about how this role is fulfilled in practice, and councillors are in any case heavily out-numbered on Boards.
Recent speeches by the Scottish Health Secretary have stressed measures to strengthen ‘patient voice’, and entirely ignored whether and how the public’s stake in local services is to be made meaningful. Scottish advocates of a genuinely public NHS look south, at a system so fractured that public accountability has in some cases been outsourced to privately run ‘consumer watchdogs’, and feel thankful for what has been protected in Scotland. However in doing so we must avoid complacency and acknowledge the continued challenges of our ‘mutual’ NHS.