Democratic accountability in the Health White Paper

The Department of Health has published a number of accompanying documents to the Health White Paper that was itself published last week. Having written a detailed analysis of patient voice in the Health White Paper, I was thus particularly interested in the “Local democratic legitimacy in health” follow-up paper.

Though the paper addresses nowhere near all of the questions I outlined in my previous post, there is some good stuff in this accompanying paper on the role of local HealthWatch (HW) organisations (paragraphs 14-19).

In particular, it should be noted that additional funding will follow additional functions being added to local HW responsibilities (para 16), which themselves build on the Local Involvement Networks (LINks) that already exist.

These additional functions will be as follows: 1) an NHS complaints advocacy service, and 2) supporting individuals to exercise choice (essentially advocacy in its traditional sense). These are laudable functions which should make choice more available to everyone. I still have concerns over the ugly bunfight that will take place as existing and substantial advocacy organisations bid (through tender processes run by the local authority) for the right to become local HWs, but that’s something that the voluntary sector has become more used to over the few years.

A further welcome clarification is that one local HW representative will sit on the proposed statutory Health & Wellbeing Boards, representing patient voice and both influencing and contributing to the local decision-making process (para 40). This is supported by local authorities being responsible for supporting “local voice and the exercise of patient choice” (para 10) and should be welcomed.

The paper is strangely silent on what HealthWatch England will be, how it’s arranged, what it will do etc. I suspect this is because the government thinks this will be straightforward; I don’t think it will be, for reasons outlined in my previous post.

As ever, some confusion remains. This confusion is contained within two topic areas: 1) why the NHS and health encroaches so much on social care, and 2) the non-top down, top down approach.

Let’s take (1) first. For a document that has “Liberating the NHS” and “legitimacy in health” in its title, this accompanying paper sure does make considerable claims on social care. The key to understanding this better is to understand the differences between health, public health and (social) care and how they relate to and overlap with each other. I hope the planned White Papers on public health and social care will be clear on this.

The non-top down, top down approach is far more interesting.

In paragraph 28, the White Paper is keen to say that requirements for Health & Wellbeing boards will be “minimal” and that Local Authorities will enjoy “freedom and flexibility” as to how such a board would work.

But in paragraph 25 the government specifies that its preferred approach for proposed joint working on health and wellbeing is to establish a statutory board for such work. Indeed:

  • Paragraphs 29 to 33 specify the four functions of such boards
  • Paragraphs 34 to 37 specify how the boards will operate
  • Paragraphs 38 to 41 specify who will be members of the boards, including a statutory obligation for commissioners and local authority staff to attend
  • Paragraphs 42 to 50 note that the government wants the statutory functions of existing Overview and Scrutiny Committees will transfer to the proposed boards.

In truth, I don’t have any particular issue with specifying in statute the role and requirements of Health and Wellbeing Boards, especially if they are to receive presumably extra funding, transferred from the to-be-defunct PCTs, in the form of ringfenced health improvement budgets.

But it’s whimsical to pretend that this doesn’t represent a top-down approach from the centre.

It’s also whimsical to suggest this approach will remove “ongoing political interference from the health service” (paragraph 6). If there’s one thing involving elected Councillors at a local level will do, it’s introduce political interference into the health service.

This additional paper is useful and gives some encouraging detail on local HealthWatch arrangements, which were missing in the White Paper itself. But there remain significant questions around HealthWatch at a national level and the tensions of the White Paper between patient-led and GP-led reforms do not feel to be sufficiently addressed by the introduction of statutory health and wellbeing boards under the control of Local Authorities. And the ongoing confusion as to how health, public health and social care relate to each other quickly needs to be addressed by the imminent White Papers so as to appropriately reflect and recognise the distinct difference in what each of those policy areas requires as policy solutions.


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Man of letters & numbers; also occasionally of action. Husband to NTW. Dad of three. Friendly geek.

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