Wednesday, 6 February 2013

How would a Parliament for Health work?

The Francis Report shows the tragic consequences when patients and carers do not have a voice and are not heard. Improving systems, management and inspection is part of the answer. But this does not address the lack of democratic accountability and scrutiny in health matters.
A Parliament for Health could strengthen democratic scrutiny and accountability of all provision and legislation that affects health by creating a representative forum on health matters within our system of Parliament rather than Whitehall or the NHS. It would consist of representatives of stakeholders concerned with all aspects of health, including patient groups, staff, researchers, civil society organisations and elected representatives from other tiers of government, including parish and local councillors and MEPs. It could be co-chaired by back bench members of parliament. In time it could have directly elected ‘Health Representatives’ and be part of to a new kind of second chamber, to draw a wider range of experience and expertise into the political process. But MPs could set up a “Health Parliament” or Forum as an extension of the Select Committee to strengthen their oversight of health matters. A Parliament for Health could have statutory rights to discuss all legislation that impacts on their health, conduct investigations into the implementation of policy and report directly to the House of Commons through their Member of Parliament (the Co-Chairs).  
It would have the following tasks:
  1. Propose national priorities in health, for the NHS as well as public health;
  2. Hold the NHS Commissioning Board, Monitor and other strategic health bodies to account on behalf of Parliament (which should have the final say);
  3. Oversee and hear reports from our representatives on the World Health Organisation, EU Council of Health Ministers, the Food and Agricultural Organisation (FAO) and other international bodies influencing health policy;
  4. Promote dialogue round important issues, such as the Francis Report, the Bristol Royal Infirmary inquiry etc;
  5. Recommend priorities for research and development in health policy and provision;
  6. Organise public consultation on proposals by the Government, taking consultation on major health matters from the NHS and Whitehall;
  7. Pre-legislative scrutiny of proposed bills before they are presented to the Commons, to draw attention to health implications
  8. Scrutinise and revise legislation through a “public reading stage” before the second reading in Parliament;
  9. Contribute to consensus building, where appropriate;
  10. Advise and assist on policy implementation;
  11. Monitor implementation of all policies that affect health;
  12. Review and evaluate the impact of legislation.
This is a big and important agenda. Failures in the NHS are symptoms that this has not been done by Parliament and the lack of proper democratic oversight and accountability. Simply putting “patients in control” through market mechanisms will not solve these strategic problems. If greater choice, commissioning and markets have a role, then the rules and political oversight are even more important. The House of Commons simply does not have the capacity to address these issues, even if MPs had the knowledge and experience to do so.

A Parliament for Health (or National Health Forum) would dramatically increase the knowledge and experience to inform health policy-making. It could work through a mixture of open public meetings, online forums and a standing body of stakeholder representatives. Members could be elected through democratic associations of civil society, neighbourhood forums the professions and patients, thus strengthening the democratic processes across society. It could be supported by an all-party Parliamentary Commission and run by a new department of the House of Commons Service, not Whitehall or the NHS.
The following diagram shows the relationship between a National HealthForum, Parliament and the NHS: it is telling that the original, offical diagram had the public and patients at the bottom - the kind of perspective which led to the outcomes at Mid-Staffs and Cardiff University Hospital. 

Developing Democracy through Citizens’ Policy Forums
A Parliament for Health could develop a model for “Citizens’ Policy Forums” to improve democratic government by strengthening public participation and connecting civil society with the political process in new ways, using interactive meetings, the internet and imaginative forms of active participation, round the issues people care about. They would be a form of practical political education, through which people learn how to contribute their experience and expertise about health to the policy-making process.
Regular, statutory Citizens’ Policy Forums could replace ad hoc consultative bodies, strategic partnerships and advisory groups in Whitehall with a more open, accountable and interactive means of involving civil society in politics between elections. They would draw a much wider range of people into the Parliamentary process, contributing to the scrutiny of legislation and Government from the perspective of broad policy areas, rather than a party political perspective. Members of Policy Forums would be obvious candidates for an elected Senate. As a new kind of parliamentary chamber, Forums would also create new routes into Parliament and widen the pool of potential members of Government while strengthening the primacy of the Commons.
Instead of being the last western country to have an elected second chamber, Britain could be the first to create a new kind of parliamentary process which enables citizens to take a more active part in politics between elections through the internet, participatory community meetings and the democratic associations of civil society.
Civil society organisations should take the initiative and create a Health Policy Forums to scrutinise and challenge Government, because the cost of not taking into account the breadth of experience and interests in health is too high.

For more details about how Citizen’s Policy Forums could strengthen parliamentary democracy, see:

We need a Parliament for Health

We need to look at how our democracy deals with health issues in response to the Francis Report into the terrible failures of care at Mid-Staffordshire  Hospital. This blog looks are why we need a 'Parliament for Health'; the next blog looks at what it would do and how it would work
The Francis Report, Ann Clwyd’s shocking description of her husband’s death “like a battery hen” in Cardiff’s University Hospital and the “hundreds and hundreds” who have writtento her are just the latest horror stories about failures in our health services. While every day thousands of patients get wonderful care and 90% are satisfied with their experience, too many people have a bad or even terminal experience through mal-treatment, neglect or hospital acquired infections. 
But our problems in health are much wider than issues of leadership, management and organisational culture of the NHS. How services are run is just the most visible part of health care, which includes the way we look after our own health, how we care for each other and the health effects of work as well as the food, drink and tobacco industries. Each of these present problems which cost many more lives and misery than mis-management at Mid-Staffordshire. The direct cost of health services are also a critical issue. Direct cost through taxes is about £1,700 per person per year, £106bn, and indirect cost of ill-health are about £100bn a year or another £1,600 each. Add to that the soaring cost of personal care, the lack of support for carers and the value provided by six million unpaid carers (variously valued at £23bn to £119bn, and we have a very complex picture for the state of health.
Many urgent issues need to be dealt with in our health services, some of which are strategic and many of which are local, in an area or institution. But it is decisions on strategic issues which create the framework for the whole system and set the conditions which allow tragedies like Staffordshire and Cardiff’s University Hospital to occur. These strategic decisions are political, about the priorities, structure and funding for every aspect of health, including the balance between prevention and cure, between personal and collective responsibility, or between environmental and medical factors.
Health is one of many areas where our political system has failed for decades and Governments have kept people powerless to do much about it, as the experience of whistle blowers in the health service shows. Our centrally run health service gives Ministers the illusion of control, so we have had decades of ‘start-stop and start again’ health reforms which make it very difficult for people themselves to take part in creating better provision for health.
Since 1974 successive Governments have grappled with the complexity of preventative health, primary care, hospitals, nursing, social care, mental health, medical effectiveness, an aging population, rising costs and a myriad issues that affect our well-being. The NHS has been almost continuously reorganised in pursuit of better patient care, greater clinical leadership, devolved responsibility and less bureaucracy. The objectives have been largely consistent, but successive Governments have taken us on an expensive rollercoaster, plunging and twisting through GP Fundholding, Care in the Community, Family Practitioner Committees, Primary Care Groups, Primary Care Trusts (PCTs) and now Clinical Commissioning Groups (CCGs). While some interest groups (GPs, consultants, dentists) have done well out of this mystery tour, many others have not, the public is losing out, and the cost is enormous.
The Francis Report will be added to the shelf of recommendations and another transitory Government will give the NHS another shake. Some improvements may occur, if we're lucky, but wider problems will persist and some will get worse because political attention and resource is elsewhere: when you turn the spotlight on one problem, the rest are left in the dark. Some things may get better due to lack of interference, while others get worse through neglect.
Most battles over health reform are among politicians and the professionals. The public is rarely involved in difficult debates about how to balance priorities between prevention, primary care, social care, hospitals or our £9 billion annual drugs bill £8.81bn in 2011, except when mobilised to fight over a particular hospital, treatment or reorganisation.  
Whatever the rhetoric, the public only has a token voice in how we look after health as a society and how services are provided. Formal participation has been channelled through a succession of weak bodies, from Community Health Councils (1974-2003), Patient Forums (2004-8), LINks (Local Health Involvement Networks, 2008-2012) and from October 2012 HealthWatch. There is a tiny amount public participation through representation on health trusts, and more active involvement through fundraising, self-help groups, volunteering and charitable provision such as hospices, but these are largely excluded from decision-making. In many areas the voluntary sector, PCTs or local councils have set up forums for health and social care, which can comment on decisions but are powerless.
The 1974 NHS reorganisation also created joint consultative committees (JCCs) to promote joint planning between health and local authorities, but they did not have the power to be effective. Now the Government is setting up local Health and Well-Being Boards which will face similar challenges with even greater financial pressures than those which undermined the JCCs in 1974 (see Health and wellbeing boards: system leaders or talking shops?).
When the Coalition Government ran into political difficulty over its health service reforms, it set up the NHS Future Forum, a group of health experts led by GP Professor Steve Field, but barely two or three of its 55 members represented patients or the public.  It listened to more than 11,000 people face to face at over 300 events as well as engaging with people online, but then public involvement stopped. Then it is set up the Nursing and Care Quality Forum for another burst of consultation. 
But neither Government nor Parliament have the time or capacity to give health matters the sustained scrutiny they need, or to develop the political framework which balances all the different issues and interests involved in health and well-being. What we need, therefore, is a “Parliament for Health” to grapple with the political issues in public. A Parliament for Health could have directly elected representatives (MHPs) or indirectly elected from local Health and Well-Being Boards and other stakeholder groups, with a majority of from civil society, to ensure that the people are in charge of the professionals, as it should be in a democracy.
If the NHS were a country, its £106bn budget  would make it the 55th largestcountry in the world, about the size of New Zealand, Hungary or Vietnam in terms of GDP. It would have a seat at the UN – and it has one in the World Health Organisation, WHO, and its civil service, the NHS Commissioning Board, Monitor and other bodies, would be answerable to citizens through Parliament.  
If all health-related policy and legislation had been systematically scrutinised by “Health Parliament”, with a majority of representatives from patients and the public, feeding into the democratic processes of Parliament, Governments would not have been able to lurch from one reorganisation to another. Sustained public dialogue between interest groups involved in health, including the public, is more likely to have created better patient care, greater clinical leadership, devolved responsibility, less bureaucracy and greater emphasis on public health, health promotion and well-being. Problems like those at Staffordshire, Cardiff’s University Hospital, Alder Hey, the Bristol Royal Infirmary, Great Ormond Street and elsewhwereare much more likely to have been raised by “Health MPs”, listened to and dealt with than the regulators who have clearly failed.
We do not need more inspectors – the most likely response to the Francis Report. David Cameron's proposal for a chief health inspector may be a useful lightning conductor for failings in future, but what will make most difference are the hundreds of thousands of inspectors who go into the NHS every day -  patients, their families and frontline staff. They are also the people who will make most difference to the health of the nation, in homes, workplaces, shops and streets as much as in doctors surgeries and hospital wards. We are the people who determine what happens to our health, and we need more democratic accountability from bottom to top to make sure that health services and support meet people's needs with care.

[For more details of how a ‘Parliament for Health’ might work and contibute to democracy, see discussion paper on Citizen’s Policy Forums, at

Tuesday, 15 January 2013

Why we need a national Forum for Britain in the World

A national “Forum for Britain in the World” could give everyone a say in the debate about the future of Europe, so that we the people can say what kind of Europe we want as the negotiations develop, not just in a referendum after everything has been decided.
David Cameron’s European dilemma is that we need to weave a tapestry but some people only want to use scissors. Weaving is difficult but it takes only a few cuts for the whole thing to unravel. The pattern of Europe will not come in one big picture treaty that can be put before the people like the American constitution, but in the warp and weft of rules for banking, fishing, agriculture, carbon emissions and countless details that make a large integrated market work. Ironically, Europe is creating a constitution in the British style, bit by bit, not a grand constitution that  can be voted on as a single text. Another irony is that English has become the lingua franca of Europe, the dominant language of discussion in its corridors of power. At the end of our squabbles over Europe, we could find ourself cut out of yet another contential power that uses English in ways we do not understand 240 years after our ancestors insisted that the British Parliament alone should decide its rules.
The fundamental question is not "in or out of the European Union", but whether Britain keeps a seat at the table where the rules are decided and how well our negotiators play their hand. Withdrawing simply means we no longer have a say on our terms of trade with the rest of Europe.
The next critical question is what those rules should be. New rules are being drawn up right now which will radically change the EU and Britain’s place in it (see this blog on 21 Sept 2012). So the really important questions are a) what rules do we need to flourish as a country, and b) how good are our people - ministers, officials, MEPs, lobbyists, pressure groups and media - at negotiating on our behalf. Many voices who speak for Britain are owned abroad or have more interests in global markets than the high street.
This makes it essential that European issues are debated thoroughly so that the British public can tell our politicians precisely what they want from our relationships with Europe in every area of our lives, not just trade and finance.  UKIP and other Eurosceptics have done a good job in provoking debate, but now we need a proper forum to have the debate in a way that everyone can take part.
I suggest a national “Forum for Britain in the World” to scrutinise all proposals relating to our place in the world - the World Trade Organisation, UN agencies, NATO and other agreements which bind us in internationally. It is worth remembering that just a 100 years ago, in 1914, our international obligations pulled Britain into a terrible war in Europe. A Forum for Britain in the World would put the EU debate in the wider context of trade, aid, security and the environment.
A national Forum would allow all interested parties (stakeholders) to have a say, so that campaigners for or against any position in Europe (or any other international agreement) would have to justify their views in the face of evidence and argument from others directly affected, not just Ministers or officials. It would give people a place to address specific policies, item by item, as they come up, and have some real influence on them.
Parliament already has several Select Committees dealing with international issues, nine on Europe alone, but hardly anyone outside Westminster knows what they are up to. They do important work on our behalf, alongside the much larger number of working groups and consultations run by Whitehall.  A Forum for Britain in the World could connect these internal discussions with the wider public debate about Europe in a direct, practical way, so that the public can improve official policy through crowd sourcing, drawing on wider experience of specific issues and deepening the debate.

The obvious question is how could such a Forum join up the debate and weave a worthwhile tapestry of Britain in the World, instead of tangled threads and loose ends? 

The Forum for Britain in the World could channel the debate in three ways:
First, an online forum which sets out what the Government does, current policies and proposals, including all directives and draft legislation from Brussels and other international agencies, as well as Government consultations, such as the current review of the balance of competences between the EU and the UK, or the Synoptic review of the EU Internal Market. A lot of the infrastructure for this already exists, through the Parliament Website and (e.g.
This could be made more interactive through a system for online comments, rating and even voting on proposals.

Second, a ‘Representatives Panel’ of stakeholders,  including all MEPs, representatives from local government, the devolved assemblies and umbrella bodies of groups affected by European and international issues, from aid agencies and farmers to the Women's Institute and exporters. Groups could register to join the panel, stating their mandate, area of competence and what issues they are interested in. They would get email updates on policy areas they are intersted in (much as info4local does in local government), and opportunities to comment through the online forum. Contributions from the Representatives Panel to the online forum could be flagged up and notified to other panel members.
In addition, members of the panel could nominate and vote for members of a citizens’ policy forum, on the basis of broad interests (civil society, employers,  workers, researchers, etc)

Third,  a Citizens’ Forum for Britain in the World could hold regular public debates on the top issues raised through the online forum. The participants would be drawn from the Panel to representative different interests and chaired by Members of Parliament (MPs and Peers), and report directly to Parliament.  Discussions could be held on a regional basis (e.g. London & SE, SW, North, Midlands, Northern Ireland, Scotland, Wales), and feed into a national forum once or twice a year.
This process would strengthen the role of Parliament, by giving back-bench MPs a role in chairing the Forum and its working groups, as an extension or addition to Select Committees. It would also strengthen Ministers’ negotiating position in the Council of Ministers and other international negotiations, because it would provide more detailed arguments and evidence as well as broader endorsement as a result of informed public debate.

This could be dismissed as a talking shop, but it would improve both efficiency and democracy in several ways:
a)      streamlining the current process for consultation and participation on European and internation issues would make it clearer, simpler and probably cheaper;
b)      improving policies through crowd-sourcing could save money as a result of better outcomes: many international decisions have a big impact, and bad decisions can be very costly;
c)       strengthening Ministers’ position in negotiations on issues where there is a strong consensus on specific points.

 There is a real danger that short-term electoral considerations and sincerely-held views on Europe could jeopardise Britain’s long-term interests by over-simplifying the issues.  A Forum for Britain in the World could deepen the debate about any EU treaty negotiations as well as the many smaller changes which often add up to something bigger in Europe's unwritten constituion. If we are to have a referendum on Europe, it should be informed and endorsed by a broad-based forum in which many different interests have a voice, following a thorough and informed discussion.  Democracy is more than a one-off vote in elections or a referendum, but a process through which people engage with the issues before coming to a decision. A Forum for Britain in the World would strengthen our ability to take part in all international decisions that affect our lives, which will become much more important as China, India, Brazil and other countries grow stronger.  Britian and Europe are just small parts in a global tapestry that is changing rapidly. How we take part in this unfolding scene matters for us and the world.

A national Forum for Britain in the World is a particular example of Citizen’s Policy Forums as a way of briding the gap between civil society and politicians and improving democratic governance.

Monday, 7 January 2013

Agenda for Democracy 2013

After 1913 the world changed dramatically. Europe’s rulers went to war, hundreds of millions were slaughtered, empires were broken up, new global powers rose, women won the vote in Britain. Bit by bit people created a new economy, news systems of social security and new forms of global governance that connect almost every country in a shared framework of rules today. Last century’s traumas of war, economic depression and oppression were the consequence of fatal political decisions, and the changing fortunes after 1945 were also the result of political decisions.
The dramatic contrast between North and South Korea, or between Gaza and Tel Aviv, or the City of London and inner city Lambeth, are the consequences of political decisions. Politics matters, and democracy means that everyone shares some responsibility for what happens.
Looking ahead from January 2013, the coming century may be much worse than the last. Climate chaos, population growth, water scarcity, food shortages and dramatic shifts in economic and political power could make our troubles look like squabbles over biscuits in the Parish Council. Ten or twenty years from now England could be a rump state, separated from Scotland, excluded from Europe and struggling alone in a world of high prices and tariff barriers; the USA fragmented under the burden of debt, its warring States and cities policed by private armies; and the assertive powers of China, India, Indonesia and Brazil run the new world order to meet their needs, not ours. Or it could be an era of global peace and sustainable prosperity, governed equitably under the rule of law and robust, democratic institutions resolving conflict and managing the earth’s resources wisely.
What happens depends on decisions people take now. Citizens, consumers and entrepreneurs can make as much difference now as the elites of nation states, corporations and international bureaucracies. The elites are still powerful, but they must also follow the markets, public opinion and popular pressure as never before. New technologies make it possible for people to take part and shape events, and democracy has disruptive power to reshape the world. What happens depends on the ability of our politics to solve multiple problems simultaneously, in our families and firms, towns and cities as much as between countries and in our relationships with nature.
Democracy is a great engine for decision-making. People highlight problems, identify needs, propose solutions and galvanise action. They challenge, organise and make a noise about what matters to them. When politics fails, people turn to violence – the gunshot it Sarajevo, civil war in Syria, riots in the streets. Democracy is a verb not a noun, and we need to renew democracy to make the decades from 2013 better than after 1913.

To be continued.