A brief scan on a new initiative to engage the public in scrutinising decision-making in the NHS.
Tim Kelsey, one of the senior directors in the NHS hierarchy is leading on this programme (see here). He’s brought in a number of friendly faces familiar to Puffles to help scope and deliver this idea. (See here – Puffles has bounced off from each of the three organisations, having probably been treated to wine, coffee and pistachio nuts at various points in the past).
To be honest, I don’t really know enough about the idea or its history to make a judgement call on whether it’s good or not. That said, if the idea was that bad, the people working on it wouldn’t have touched it with a Cambridge punting pole. While they have a financial incentive to take part in this, my take is they also have good judgement and sound principles too. They also wouldn’t want to tie their own small businesses to something that has little chance of succeeding.
An entirely new system – but where does it fit within the big picture?
This is something Catherine, Tilly, Anthony (a different one to me) and Simon have all touched on in a series of opening blogposts. (See here). The structure of the NHS looks something like this -> see here. What’s not clear to me is how different this new assembly is to the current arrangements for ‘Healthwatch‘ – the latest incarnation of the organisations supposedly representing the interests of patients. During my time in the civil service I dealt with their predecessor – Local Involvement Networks (LINks), which at the time were supposedly succeeding the Patient Advisory Liaison Service – or PALS. Hence feeling a little confused by this. Bear in mind you’ve also got a pre-existing consultation hub (see here). Will this be integrated into the new system?
Interface with local government
Local government has taken on public health functions – not without criticism as a recent Communities and Local Government Select Committee report explains here. This matters because there will inevitably be some overlap between NHS functions and local government functions. If not handled well, inevitable turf wars will flare up. I saw this during my time in the now defunct Government Office for the East of England where the public health function were not integrated into the regional office structure as other departments were, thus there was continued uncertainty in the office as to whether they wanted to work with the rest of the office or not. Sometimes it would suit them, sometimes it would not.
Who’ll be accountable to who?
Where you have functions/activities that cut across public health and NHS areas, where does accountability at a local level lie? Is it with the NHS assembly member? Is it with the local authority? Does this risk undermining the role of the local MP? How will the people on the NHS Assembly be selected? Elections? Appointments? If the latter, how will appointees be held accountable? What will be expected of those who serve? How will their performance be assessed?
Who’s paying for all of this?
Is this going to be an additional spend, with demands for a big meeting hall and administrative support to go with it, or will this replace some existing structures? What sort of training will NHS Assembly members have to undertake? Will minimum standards say of education be required given the nature of the role, or can anyone stand? How much will members be paid? Will elected councillors be able to stand for an assembly post?
What happens if there is a persistent health issue being caused by something that is outside the scope of the NHS to deal with?
I’m thinking in particular about housing and pollution. The NHS Assembly might pick up on the health impacts of poor housing in one part of the country. When I lived in Brighton over a decade ago the state of housing stock in that part of the world was shocking – especially in the private rented sector. Students, the low-paid, and regularly-moving migrant workers all over the country – those with the weakest roots (and thus more vulnerable) are at particular risk. But whose responsibility is it to deal with the issue? The NHS can help alleviate the symptoms but can’t touch the cause because of the silos of public administration. I could go onto talk about pollution from transport and industry too in the same manner.
Aren’t these issues beyond the scope of what being asked of the organisations running these initial stages?
They are – and my main criticisms are at policy rather than delivery level. I’d like to see evidence of engagement with local government – in particular managing the overlap issues. I’d also like to see how plans for an NHS Assembly are joined up with existing policies and programmes related to civic society – ‘Big Society’ if you like. Community empowerment, citizenship, call it what you want. But it means policy advisers in the Department of Health having their colleagues from the Department for Communities and Local Government and from officials working in Cabinet Office for the Minister for Civil Society.
There is a big party political context here – one that is a looming cloud of uncertainty. It is this: Labour has gone on record time and again saying it’ll repeal the Health and Social Care Act. It’s less than 2 years to the next general election. Do the proposals for an NHS Citizens’ Assembly have cross-party support or will the whole thing go should Labour end up in government post 2015? Which brings me onto another issue. What is the risk of the Assembly becoming a party-political forum? This matters because health is (understandably) one of the most important political issues in society. When I look around my community, it’s the primary healthcare services as well as the primary schools that help form and hold the foundations of local communities.
Lots of food for thought.