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