Loving a geek fight as much as the next man (well the next geek), I can’t but help wade in on the ‘feud’ that has broken out between Rich and Phil as to whether Andrew Lansley is the root of all evil or a pretty straightforward guy (or words to those effect).
Rich has posited that NHS London should be in the driving seat in terms of reorganising the NHS, whilst Phil pointed out that making the NHS more accountable to local people is a laudable aim. Of course, they are both wrong… and right.
Localism is again set to be gabbled out with depressing regularity by this government but whether any localism will actually be delivered is another thing. Save for devolution to the nations, Labour should be ashamed of its record on devolving power to the lowest appropriate level (the subsidiarity principle). They did carry on building on the quangocracy started by the Tories and they suffocated local government in targets and buraucracy. It’s far too early to say whether a coalition which includes the original localists, the Lib Dems, will be able to resist the temptation to keep most of the power to themselves.
But being a good localist does not necessarily mean giving all responsibility to local authorities. Direct and indirect accountability can reside at the regional and central level, where there there also can be more appropriate expertise. Subsidiarity is about devolving power to most appropriate lowest level. In many cases local authorities do not have the skills (or interest) to take on functions currently delivered at the national or regional quango level. More fundamentally local authorities will only have the interest of their own constituents at heart (or more cynically, those constituents who are likely to vote for them) which can mean you get a destructive race to the bottom or the inefficient use of resources.
Two examples of the quandaries of localism. The proposed abolition of Regional Development Agencies and their replacement by Local Enterprise Partnerships may mean that initiatives that promote economic growth and innovation across local authority boundaries, which is where most economic activity takes place, will not happen. Individual local authorities and their elected (and sometimes egotistical) leaders have a hard time collaborating under the best of circumstances. We are now in an environment where there will be massive incentives for them to keep get as much funding for local bread and butter issues and not think about the efficiencies and gains that can be made by working together.
I believe the rationale behind the NHS London reorganisation was to, as much as possible, remove the parochialism that always occurs when any medical facilities are proposed to be closed down. However, I agree with Phil that local people should know who is politically accountable for any hospital closures that occur but they should not necessarily have the final say.
Interestingly the solution to this particular dilemma is at hand but is not being reached for. The Mayor of London is democratically elected, already represents all of London on planning, housing and economic development issues and is likely to be given further powers over the Royal Parks, Port of London Authority and Olympic Legacy (the last of which potentially involving taking powers away from local authorities). Yet no control or significant oversight of NHS London is proposed. The original and latest Greater London Authority Acts have never given the Mayor any significant powers over health (other than duties to reduce health inequalities etc) but there is an argument that the Mayor would be well placed to represent all of London, in what will necessarily still be a national decision about how the reorganisation of a national entity will be implemented at the regional level.
Whilst a passionate supporter of localism what is appropriately local will vary from circumstance to circumstance. In most cases very strong incentives will be needed to foster the collaboration between localities and at the moment there are neither the ideas nor the funds to support this. Yet there are situations that exist where a local democratic mandate is a contrary to the interests of good, effective and efficient public service delivery. Just as many of the quangos that are likely to be dissolved were put together (in some cases by the last Tory government) for good and sensible reasons, so it is that certain powers are not at the most local level for a reason.