Policy responses and statements
- Name of organisation:
- The Scottish Government
- Name of policy document:
- Local Healthcare Bill - Consultation Document
- Deadline for response:
- 26 March 2008
Background: The Scottish Government wants to encourage greater public and patient involvement in the planning and delivery of local NHS services in Scotland. The Government believes that direct elections to NHS Boards in Scotland can help to secure this and, subject to consultation on the issue, intends to introduce legislation in a Local Healthcare Bill to provide for direct elections. The aim of this consultation paper was to gather views and comments on whether a Local Healthcare Bill should include provision for direct elections to NHS Boards, and if so what form these might take.
COMMENTS ON
THE SCOTTISH GOVERNMENT
LOCAL HEALTHCARE BILL - CONSULTATION DOCUMENT
The Royal College of Physicians of Edinburgh is pleased to respond to the Scottish Government on its consultation on the Local Healthcare Bill.
This consultation document contains proposals that will influence the good governance and public acceptability of NHS Boards for the future.
The consultation has many questions. They vary from extremely complex matters of underlying principle, to the very specifics. It is unsatisfactory that some of the most demanding questions are left right to the end - for instance, the degree of autonomy of NHS Boards and the status of national guidance when planning health service delivery at a local level. These questions do not belong comfortably beside the preceding section on specific matters such as the scope and frequency of pilot election schemes.
While the Royal College gives a general welcome to these discussions and questions, the paper does not offer a compelling argument for change, or assessment of the sufficiency of current arrangements. This weakness undermines both the authority of current proposals and the merit of reviewing critically international experience and effectiveness of existing arrangements that have been in place for a comparatively short time.
We turn now to answer questions contained in the consultation:
1. Do you think the current proposals for independent scrutiny of service change proposals help achieve the aim of better engaging and involving local communities?
There is no compelling case for better engagement and involvement of local communities within these proposals. In principle, there is still room for improving the transparency and public understanding of contentious health proposals but we have arrived at current arrangements by a very long route. These seek to achieve a balance between local and national priorities and arrangements, single and all-issue considerations, challenging issues such as clinical risk and patient safety that commissioners and public representatives see differently, and overall notions of corporate governance with NHS Boards that are already complex. Within these proposals, there are no compelling arguments that justify such a major revision of arrangements over those that already exist, in our assessment.
2. How could additional guidance to NHS Boards on making public consultation as effective as possible help achieve this aim?
Guidance could develop methods of audit of equity of interests represented to the consultation, such as hard to reach and disadvantaged groups. However, the responses of NHS Boards to ensure such principles in their current arrangements are already articulated in guidance and legislation.
3. Would the appointment of more lay members to NHS Boards - perhaps to directly represent patients or other groups - help achieve the aim? How might this be achieved?
Once again, there is no compelling argument that the following proposals offer a demonstratively better method of lay groups representing themselves to NHS Boards than current arrangements. Any lay representation must offer a broad view of patient interests and public interests, and there is a substantial risk of single-issue lay members who could potentially both de-stabilise current arrangements and undermine overall governance and public accountability.
4. In particular, would adding more local authority councillors (one councillor from each local authority whose area a Board serves is currently appointed to that Board) help achieve the aim? Could local authorities have a role in scrutinising public and community engagement?
It may be possible to enhance the number of local authority councillors. The role of councillors already is one that has not been extensively studied or evaluated, and opinions are mixed. The performance of councillors on NHS Boards depends on their individual attributes as well as their notion of representativeness. Recent local experience and more long lasting international experience, does not lead us to favour stronger local authority representation over the current input, particularly when it comes to making difficult and potentially unpopular decisions.
5. Should we develop further the role of the Scottish Health Council to bring about more effective engagement and involvement? If so, what additional responsibilities could the Council take on and what would the benefits be?
We are in favour of giving the Council time to grow and deepen its influence, particularly in its role to engage hard-to-reach groups and auditing effectiveness of the use of engagement locally. The Scottish Health Council is in a stronger position (than with other arrangements) to offer an all-issues view of merits of proposals and sufficiency of consultation in reaching difficult decisions, in our view.
6. How could the Public Partnership Forums associated with Community Health Partnerships encourage greater public engagement?
On balance, the College is in favour of these existing mechanisms, suitably strengthened over time and with clear guidance and purpose, in fulfilling roles that ensure public engagement and user involvement.
7. How could local Community Planning Partnerships best ensure improved public engagement with NHS planning?
The College is in favour of these partnerships using their duties and powers to increase the levels of engagement with local interests, in clear and transparent ways across health and other functions.
8. What other measures could be introduced to increase effective engagement and involvement of the public with the NHS in Scotland?
We suggest that the quality of consultation questions is kept high, that key controversies form the focus of consultations, that language is accessible to all and that greater effort should be given to stimulating debate amongst users, carers and the general public (particularly using the Scottish Health Council and Community Planning Partnerships) on clinical risks of all health service delivery options and health issues.
9. What eligibility criteria should candidates meet (e.g. should they be resident in the Board area? Should there be any other qualifications?)
The usual criteria should apply, such as bankruptcy and criminality. The candidate should be committed to the use of the NHS as their main health service, both personally and as family custom and practice.
10. How could equality and diversity of candidates be promoted?
The best candidate for the post should always be the main principle. The breadth and depth of knowledge of the issues, understanding of the perspective of others, and the ability to listen to and assimilate views should count heavily within the promotion of candidates generally.
11. Should candidates have to submit profile statements and declare any interests and/or relevant qualifications/skills/experience, for example membership of a political party or pressure group?
Yes, we agree that this is very important.
12. Is there a case for excluding candidates standing as a representative or a political party?
We have no view.
13. In what circumstances might someone be disqualified from seeking election?
We have no view.
14. Who should be allowed to vote in the election? Should the same rules as apply to local authority elections be followed?
We have no firm view.
15. How often should elections be held, and when? Local authority elections are held every 4 years. Should elections to NHS Boards follow the same pattern?
We have no view.
16. Should directly elected members form a majority of the members on a Board?
On balance, given the existing scale of NHS Boards and the number of legitimate interests already represented, we are not in favour of directly elected members forming a majority on a Board.
17. Should the existing categories of appointed Board members (lay members, stakeholder members and executive members) remain in place?
Broadly, we believe that the existing categories should remain in place and be given time to settle and show their merits.
18. Among the appointed "stakeholder" members on NHS Boards are local authority Councillors. What should theirrole be if directly elected members sit on Boards?
Current experience shows their ability in this respect. Their role should be clear and transparent and less variable. They should have a stated link to their host local authority, commitment to represent the views of the authority generally and not necessarily their own party loyalties. They should have a clear link to local political matters, Community Planning Partnerships, and public democracy at local level. They should be able to demonstrate assimilation of all views, as well as offering balanced advice on single issue topics of the moment.
19. Should NHS Board areas be divided up into electoral wards?
Yes, there should be division of the NHS Boards where there is compelling case for an election.
20. Would the emergence of groups or individuals with particular views be a difficulty or a potential threat to good governance and direction of the NHS in Scotland?
There are definitely threats to good governance, and that governance includes clinical freedom within the NHS accountability structure. Narrow views such as those offered by some religions, single issue candidates and those with alternative views about the practice of medicine or health care, could undermine good governance in the NHS in Scotland.
21. Should safeguards be introduced to prevent unrepresentative/disproportionate representation of a political party or special interest group on a Board, and if so what form might such safeguards take?
There should be safeguards to prevent such representation, but setting such safeguards would be very challenging. Within a liberal democracy that espouses human rights, there are checks and balances in place to respect, protect and refrain from infringing the rights of others. Quite how these are defined within a specific Health Board context would be for much further thought than this 33 question consultation can offer.
22. Would you favour a simple "first past the post" voting system, a proportional representation approach or another type of system?
We have no strong view. It depends on the number of places on offer for election.
23. How should voters be allowed to cast their votes? By postal ballot or at a polling station? Or either, depending on the voter's choice?
We have no strong view.
24. Should directly elected Board members be remunerated? If so, at what rate - the same as appointed members currently receive?
We have no view, but compensation should be sufficient to avoid any tendency to corruption or endorsement or undue influence from other interests, both financial and resource-providing, that are available towards members.
25. Are pilots a good idea? 26. How many pilots should there be? 27. How should pilot areas be selected? 28. How long should pilots run for? And, 29. What criteria should be used to assess and evaluate the pilots?
Pilot schemes are a good idea. They should have subsequent rigorous evaluation in order to determine added value and they should last at least one complete electoral cycle, plus the time taken to complete evaluation and consider the results.
30. Should NHS Boards continue to provide generally consistent levels of performance across Scotland and follow national policies and priorities? Or should elected NHS Boards have the freedom to exercise local discretion and flexibility?
These questions (30-32) lie at the heart of issues underlying this entire consultation, and should have been placed first and not last. They address the very purpose and balance of NHS Boards within a National Health Service-Scotland structure. The issues are complex. In broad principle, NHS Boards should have the freedom to exercise local discretion and flexibility within a national framework. There is no point in NHS Boards existing unless there is an element of discretion and that has to include local accountability, as well as national accountability. Fairness and transparency in discharging these dual-facing roles is a matter for on-going debate, which is not possible within this current format.
31. Should current guidance, e.g. on governance, priorities and performance standards be set out in future in legally-binding form, and to ensure that elected Boards comply with them? What would be the advantages and disadvantages of this?
Once again, these matters are complex. It has been said that "guidance" has the status of "quasi-law" and this term needs further elucidation. A heavy-handed remit to ensure enforcement of such guidance would threaten the autonomy and purpose of NHS Boards and would need further debate. A further valid point is the interplay between geographically-orientated NHS Boards and those that offer national functions that have very important influences on local work - for instance, NHS24, waiting times and Jubilee Hospital organisation, the Scottish Ambulance Service and so on. There has been no discussion of their role and relative importance, and there should be no definitive view on such a matter unless there has been consideration of these issues.
32. Ministers currently have powers to remove members. Should they be able to remove elected members? What sort of reasons might justify such a power being used?
We have no view.
33. Should NHS resources be used to support direct elections? What do you think would be a reasonable amount to spend on elections?
As is emerging from the responses that the College is providing for such a consultation, we judge that there is no compelling case for the deployment of appreciable resources towards elections. We therefore find it difficult to justify the use of local resources to support direct elections over and above the competing calls on resources that the NHS Boards currently face. Without a compelling case for direct election to NHS Boards, there should be no compelling case for allocating resources to discharge their function.
Copies of this response are available from:
Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.
Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939
[27 March 2008] |
