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Tuesday, May 27, 2008

Taking politics out of politics

As a slogan, taking the NHS out of politics is alluringly attractive. After all, who trusts politicians to run anything these days? However, the reality is much more complex than that. I do not think that Dr Layla Jader does herself or her profession any credit by raising it in the way that she has.

Of course as a politician I may be expected to say that but Dr. Jader's own solution speaks for my argument. She wants to set up an NHS Board for Wales, which would be independent of direct government control, but it would be accountable to the National Assembly through a health scrutiny committee. Elected representatives from the four main political parties in Wales would sit on the board, alongside expert representatives from NHS professional groups, including doctors, nurses, professionals allied to medicine and health service managers.

So already, we have the national equivalent of a Local Health Board with politicians as its members, being scrutinised by politicians and which would implement government policy. Hardly a politics-free environment.

Dr. Jader's problem is that the health service secures the biggest slice of public sector funding. Its performance affects the lives of all of us without exception and we need to know that it is accountable for the way that it performs and that promises of reform given at elections are deliverable. That is the reason why the NHS can never be politics-free.

What we can do is to set doctors and clinicians free to make choices about the allocation of local resources on the basis of medical priorities, providing that they are acting within an overall national framework, are working efficiently and effectively and are conscious of and accountable to local priorities. We do not need an elaborate and unworkable structure to deliver that but we do need a greater level of sensitivity on the part of health professionals and administrators to the genuine concerns of their patients and the populace at large.

Maybe that is what Dr. Jader is aiming for. If so then she needs to drop the catchy slogans and sit down with all the stakeholders to discuss how we achieve her policy aims without disrupting the service too much and without setting up yet another unworkable reorganisation.
The National Health Service Board
Moving the extra mile to stabilise the NHS for the next 60 years

The Proposal
To recommend that the WAG’s consultation model of an NHS Board for Wales be amended to make it independent of government control but directly accountable to the Welsh Assembly through a Health Scrutiny Committee . Although this Board will not be under the direct control of the government of the day it will not be removed from politics. This can be achieved through a balanced and democratically elected representatives from the four main political parties in Wales- Labour, Plaid Cymru, Liberal Democrats and the Conservative party . The NHS Board will for the first time also have expert representatives from NHS professional groups of doctors, nurses, professionals allied to medicine and health service managers from trusts and the new health authorities. It will also have representatives from community health council and the Academy of Royal Colleges in Wales. This Board will be advised by an independent and accountable NHS Advisory Body.
Such an independent board would oversee policy, planning and performance management. It would bring a balanced political and electoral representation to the NHS as well as the expertise of highly experienced health professionals elected to represent the NHS staff from within their clinical, professional, and health service management organisations. It would be better placed to deal with the difficult issues of prioritisation and future funding of the NHS . The board would not have to change to follow the outcome of the general election. It is independent of macro-politics, above and beyond the needs of the government of the day.

Why this model?

Precious NHS resources have been wasted in constant structural changes. The NHS needs a system that replaces political dogma with clinically driven decisions, confrontation with agreement, unaccountability with democracy, and short term decision making with long term stability.

Is there a precedent for such a move? Yes: the successful delegation of the Treasury's role in controlling inflation to the Monetary Policy Committee of the independent Bank of England, a move that greatly contributed to the country's economic stability. Since its inception in 1997 people have respected the decisions of the Monetary Policy Committee, and the interest rate has ceased to be the political football it used to be.
At the BMA’s 2006 annual representative meeting doctors expressed their alarm at the incoherence of NHS reform programme in England. The council was urged to examine the reforms and produce a policy report. A rational way forward for the NHS in England was published in 2007 . It stated: ‘In order to separate national politics from day-to-day running of the NHS, an independent board of governors for the NHS should be established, appointed and accountable to Parliament. The governors will take responsibility for ensuring compliance with the NHS constitution. An executive board, appointed by the governors, will be responsible for guiding the performance and national operations of the NHS’.
The Nuffield Trust commissioned a project to help move the debate about the independence of the NHS and explore governance models from different angles and to review the special position of the NHS . Professor Brian Edwards, an Emeritus Professor of Healthcare Development at the University of Sheffield and author of the report argued that it is time for the NHS to stop being a political football because of the negative impact that it has on staff morale, decision-making, recruitment and doctor-patient relationships. While accepting that anything that takes up almost 9% of GDP is never going to be free of political influence, he believed that in some parts of the UK, the NHS is “in danger of being encased in political ice”. The report argued that the operational control of hospitals and primary care should be passed to an independent corporation, similar to the BBC, operating under a charter that guaranteed a free service to patients.

What are the strengths of this model?
1. For the first time, representatives of front line NHS staff will share control of the NHS with politicians. The pursuit of new dogma, fad or imported unworkable ideas for the NHS will be aired, challenged, checked and voted on. Only two thirds majority decisions will be passed by such a Board.
2. Legitimate interest and accountability for tax payers money through elected Assembly Members is kept in this model with a difference. The monopoly of decision making by the governing party with an eye on the next election is removed.
3. Difficult decisions on prioritisation, rationing, and funding of the NHS would be faced head on, free of government interference. Decisions made by a trusted body that is seen to be independent will be better accepted by the people.
4. Policy decisions made cooperatively and in a participatory manner by managers, professionals, and politicians will be more intelligent and appropriate decisions. Politicians, managers and health professionals should accept with humility that each one alone does not have the monopoly of knowledge, experience, skills and mandate to run such a complex organisation and only by working cooperatively will they ever succeed.
5. The pressure of constant media attention and the threat of political retributions—which drive many politicians to short term solutions—will be eased.
6. The current unaccountable, dogmatic, and archaic style of NHS management, which is at odds with the highly sophisticated medical innovations we continually face, will be modernised.
7. Removing politics from the equation will facilitate rational assessment of constant technological advances, which will otherwise destabilise the NHS. Advances in genomics, proteomics, nano technologies, lab-on-a-chip, silicon quantum dots, new terahertz imaging, smart drug delivery systems, new drugs, gene therapy and many others are increasing in an exponential manner and only cool and rational heads will be able to make decisions on introducing them and modernising the NHS.
8. In this model, an Advisory Board that is accountable to its advice will be formalised, beefed up with the best brains in the country and linked up to the statutory national professional advisory groups that are properly organised and run.
9. This model will give the NHS the stability it craves and will secure it for the next 60 years.

What are the weaknesses of such a model?
1. Some would argue that such a solution is too complex and unworkable—but how much more difficult it would be compared with the consultation’s proposed new NHS Board? With political will and determination obstacles will be overcome.
2. Another objection is that the sharing of power in the NHS Board between all the political parties would not be attractive to the government. Conversely, the removal of the burden of running such a nightmare organisation and of constantly being under the media spotlight may well be an attractive proposition.
3. Another complained: ‘What would politicians argue about at the Assembly if you remove the NHS from direct government control?’ Each party can still argue in the assembly their case and for their own policies and manifesto towards the NHS. The difference is that this time they first need to change public opinion and canvas representatives of front line NHS staff to get two thirds majority to pass important decisions at the NHS Board level. A truly democratic process.
4. Might it be a step down the slippery slope of reducing government's power to run the country? No, a similar depoliticisation of other ministries such education or law and order would simply not be possible. The size and the complexity of the NHS—not to mention the number of reorganisations it has faced—makes it unique.
5. Will it lead to inertia in decision making and a slowing down of the whole process? No, with a constitution and remit that is based on advice from constitutional experts laying down proper rules and regulations on how to conduct the work of the Board, taking into consideration lessons from the past, decision making will not be impeded and may well be streamlined.

Why now or never?
While our colleagues in England can only dream of having an Independent Board for the NHS as they watch while private companies are taking over the delivery and commissioning of various parts of the NHS, we can make it happen in Wales. Now is the time for the new Assembly powers to be used effectively and wisely to lead such an important change that will be remembered for generations to come.
We have a golden opportunity to achieve the change we aspire this time because of the right political climate for the following reasons:
1. For the first time in the history of the NHS we have an NHS reorganisation that will undo a previous re-organisation carried out by the same main political party under the same First Minister but by a different Health Minister who still serves in the government. If anyone has any doubts about the damages continued re-organisations have had on the NHS needs to look no further. The cost of 2003 reorganisation was put at around £80 million. This sum did not include the paralysis in decision making the year before its introduction and the following year while new organisation is being set-up and taking shape. What is the cost to the NHS in patients’ care terms of at least two if not more years of paralysis in decision making?
2. So far there has been total lack of accountability for wrong decision making at the political level whichever party was in power. From the internal market, purchaser provider split and competition by the Conservative Party in the eighties and nineties to the constant obsession with structural reorganisations, performance management and targets culture by the Labour Party. No party escapes criticisms.
3. The Labour Party governed Wales after the devolution in coalition with the Liberal Democratic Party and in the last election with Plaid Cymru. Sharing power to run the NHS with other political parties should not be abhorrent to the main ruling party.
4. The NHS has never seen such a whole sale re-organisation in its history. All trusts, LHBs, HCW, NPHS and dozen other smaller organisations even the health and social care division within WAG itself with the creation of the proposed NHS Board are being reorganised. Not one single NHS organisation will be left untouched! What we are asking is not far removed from what is planned and will not add to the complexity of this whole sale re-organisation.
Finally I would like to ask you all: are you prepared to wait and see what happens to the NHS in five to ten years' time? What is there to stop any future government from looking towards England or the USA importing their model and imposing it on the NHS in Wales? Do you feel the sense of urgency that we may lose, through our inaction, all that was once good about our NHS? How many more re-organisations we have to endure before we say enough is enough? What are we waiting for?
It is time for politicians, health professionals, managers, and patients, through their professional organisations, to work together to arrive at the best model for a new NHS in Wales fit for the 21st century.

Dr. Layla Jader MB ChB, DA, MD, FFPHM, Consultant in Public Health Medicine, Cardiff
Personal view, 29/05/2008
I am not convinced. Apart from the unreality of these proposals there appears to be a democratic deficit at the heart of them. It seems that you want the NHS to be accountable to those who work in it but not to those who use it.
I’m 100% with Peter on this one.

Also, I don't like global "only" statements, e.g., "and only cool rational (medical) heads ..." I also don't like the idea of a remote body overstaffed with medical professionals able to ignore or ride rough shod over public concerns which are best expressed through their elected politicians. Let's face it - medical professionals are not always free of private agendas, some like to build self-serving castles at tax payer expense. There has to be democratic accountability to the people. After all, huge sums of tax payers’ money are pumped into the NHS. We should not go back to the days of patients being cowered into being grateful for everything, including shoddy out-of hours-medical cover and medical appointment systems when they are not fit for purpose.
One could make the same argument more or less in favour of abolishing the Ministry of Defence and handing the job back to the Chief of the General Staffs.

Since the armed forces kill fewer people (or at least British people) than the NHS and cost taxpayers less then on Dr Jader's model this would make perfect sense - provided one shares her contempt for the principle of government accountability to parliament (or such regional assemblies as parliament chooses to establish).

I guess in fairness i should take this point to it's logical conclusion and confess that I am uneasy with the principle of central bank independence and with the existing governance structures of the BBC!
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