The public has a second chance to have a more direct say in healthcare provision, reports Katie Mackintosh
“Greater public and patient involvement in the planning and delivery of local NHS services in Scotland.” On the face of it, this is a goal that few would argue against. Nor would most dispute that attempting to extend the arms of democracy and increase public confidence in statutory bodies is sound in principle. However, in the case of the Local Healthcare Bill consultation, it is not the principles that are in dispute.
The Scottish Government’s aim of building public confidence in public services and ensuring NHS Health Boards take the views of local people sufficiently into account in decisions about how local health services are designed and delivered is something that has long been acknowledged as in need of attention. Instead, it is its proposals for achieving this and the practical implications of their preferred method where the dispute lies.
The consultation, which will run until April 1, sets out a range of options for meeting this aim, but chief among them lies the Government’s stated intention to, subject to the consultation, introduce legislation in a Local Healthcare Bill that would provide for direct elections to health boards. Given that a pledge to introduce direct elections was a key plank of the SNP’s election manifesto, its inclusion in the consultation document does not come as any particular surprise.
It is also not a particularly new idea, having been much debated in the last parliamentary session as a result of Bill Butler MSP’s Private Member’s Bill, ‘The Health Board Elections (Scotland) Bill,’ which he introduced in March 2006. However, while Butler’s Bill was eventually voted down at the second stage by 63 to 55 MSPs - with all but two of his Labour colleagues voting against it - the SNP Government feels the issue deserves a second airing.
So, second time around, does the consultation document offer much to placate those who previously opposed direct elections and satisfy those who supported them?
“It asks all questions that we asked,” says Butler. “And the consultation seems to me to be a reasonable first step.”
Given his history with the topic it is unsurprising that Butler has been keeping a keen eye on the consultation. What would he like to see coming out of it?
“I will be interested to know what the response from the Government is if, for example, the public say they want a majority of elected individuals to the health boards.
“I think anything less than 50 per cent plus one, or as my Bill had it, a simple majority, wouldn’t give that degree of accountability and sense of ownership that I feel people want in respect of their own health board and health boards generally.”
So does he still believe the idea has merit?
“No one is pretending that simply by introducing direct elections it is a panacea,” he continues, “That’s ludicrous. However, I do think that a growing number of the electorate out there want their views to be properly heeded and one way of doing that is by allowing a democratic element within health boards. In other words, allowing people to speak, and as a democrat, I think that [is] quite a good idea.”
While the proposals are by no means finalised, theoretically, is this an issue he could see himself backing the Government on? Yes, he says tentatively, but only if they get the balance right.
“If they come back with less than 50 per cent plus one, I couldn’t support that,” he says. “Anything less than a simple majority to me would be unacceptable.
“But likewise, I think to go for 70, 80, 90, even 100 per cent is also the wrong approach, so I couldn’t support that either.”
Why? “Any less than a simple majority and I don’t think the public would be reassured that it would be transparent and accountable enough,” he explains.
“Conversely if you went for more than a simple majority, you would exclude those who have served well, including local councillors and NHS staff, in recent years.”
Given Labour’s opposition to the Bill in the previous session and the increasingly fraught relations of late between them and the SNP, is it an issue he thinks his party could support second time around?
“The Labour Party doesn’t have a problem with the principle of directly elected health boards,” he says, “In fact on page 100 of our manifesto it says that the party would pilot direct elections.”
Furthermore, he says, an interest in direct elections was also expressed in their 2003 manifesto, but was dropped following coalition talks with the Liberal Democrats.
Why? “There was a view to explore directly elected health boards and for whatever reason in the coalition talks of 2003, that was one of two things that dropped off the radar.
“That was unfortunate,” he adds, “and that’s one of the reasons that I took it forward as a Private Member’s Bill.”
Was he disappointed that his Bill didn’t go through? “I think it was a pity that people didn’t go for it in the last Parliament. Labour doesn’t have an ‘in principle’ opposition to it,” he repeats, “but some members wondered whether it was practicable or not. I think it is.”
Does he think this time it could stand more of a chance? “I hope so,” he says. “Last time round the Lib Dems couldn’t bring themselves to vote for it and the majority of my Labour colleagues were persuaded that it wouldn’t be practicable, [former Health Minister Andy Kerr argued at the time that the proposals would risk “fragmenting” the NHS by making it harder to implement national policies] and I regret that.”
He continues: “The Conservatives last time around were minded to support at stage one. It never got to stage two but they would then, I think, have moved amendments that would have reduced the directly elected element. They had worries that there was, perhaps, too high a percentage of directly elected members proposed. I would have hoped if we had got to stage two to persuade them otherwise.”
However, he hopes that despite these initial objections the policy still stands a reasonable chance. Ticking them off as he goes he says, “It is SNP policy. Labour doesn’t have, in principle, opposition. Not sure about what the Conservatives will do this time but I would hope they would still be open to persuasion. And similarly, I hope the Lib Dems would this time be a little more adventurous.”
But can the SNP count on his vote? “I’ll support it,” he says pausing, “but only if it’s radical enough.”
So who else is with him?
Dave Watson, Scottish organiser, policy and information, UNISON, says that they are broadly supportive of the principle of extending democracy to health boards. While he says the consultation document contains a range of options for achieving this, following the parliamentary defeat of Butler’s Bill, he is more concerned with establishing a parliamentary majority for the principle first than getting hung up on the details.
For the record, however, UNISON favours a 1/3:1/3:1/3 split between elected members, local councillors and appointed members and would also like to see the voting age and eligibility of candidates extended to those aged 16 years and up.
But as Watson says: principal first, then practice. To this end, he says, they will continue to remind the various parties of their manifesto commitments.
Like Butler, he too has been doing the maths. “The Government has made a clear commitment to the principle. Labour are in favour of piloting it.”
Here he interjects to say he is not convinced pilots are entirely necessary but adds that they are “comfortable” with it if they prove to be the best way to build a parliamentary majority.
“The Tories supported it last time,” he continues, “but their policy is now less clear. While the Liberal Democrats were upset about it and largely scuppered it last time, but their main opponent was Euan Robson and democracy did for him at the last election,” he chuckles. “So now Labour aren’t constrained by the Liberals, we will see what way they go.”
But while Butler’s confidence that Labour could well prove more amenable to the proposals second time round is no doubt music to Watson’s ears, what do the other political parties make of direct elections?
While not as ferociously opposed to the idea as his former colleague Robson, Scottish Liberal Democrat health spokesperson Ross Finnie says he remains to be convinced by it. He says that while the party recognises that, given the levels of expenditure involved, there has to be some form of democratic involvement at a local level, he adds that he is not sure the solution is to elevate health boards to being that vehicle. Instead he argues there needs to be better integration with local government and also expresses concerns about the system being “held to ransom” by single issue candidates.
A spokesperson for the Scottish Greens says the party also has reservations about the consequences of party candidates standing for these elections, and the “politicisation of the health service that could flow from that.” However, he adds that the party backed Bill Butler’s proposals for elections to health boards during the last session, and has a commitment to involve communities in the decision-making process about their health services, from the earliest stages, and not just ‘consult’ after decisions have been taken in their manifesto.
Meanwhile, Scottish Conservative health spokesperson Mary Scanlon says the Conservative Party line is that they would be supportive of direct elections to health boards, but with no greater than 50 per cent elected members. Alongside this, she says it is also critical to retain “at least one” elected councillor on the NHS boards, alongside representatives from the ambulance service and general practice.
However, while Watson will undoubtedly be encouraged to learn that the residents of Holyrood are willing to be cajoled, what do the health service staff make of the proposals? Is UNISON, as their representative, reflecting the general view among staff on this issue?
“There are mixed views among health service staff,” Watson admits. “But our broader policy is to extend democracy, so we support it.”
But why does he think some staff oppose it? “There is a culture in the health service of doctor knows best,” he says. “In the last Parliament, I gave evidence on the Bill to the health committee at the same time as the BMA and RCN and their view was very much that health is very complicated and really isn’t appropriate for democracy. They gave a very poor impression of the health service.
“That culture is changing,” he argues, “and we are at last moving away from that old establishment view that the doctor knows best.”
But Peter Terry, chair, BMA Scotland, said: “We don’t think it is necessary. The aim is to increase public confidence in the way decisions are made and there are other ways of doing it.” Instead, he would like to see more effort put into strengthening Community Health Partnerships and further developing patient forums.
He also expressed a concern that in the resulting melee, Scotland’s “reasonably coherent national policy for health” could be “corrupted” by local issues, adding, “It is quite possible under these circumstances where if turn out is low in a particular area, pressure groups and practical interest groups could mobilise resources and get people elected to pursue their own agendas, which might not be what’s best for the population as a whole.
“So when you put all these reasons forward, I don’t think it is a particularly good idea,” he concludes.
And what of the health boards themselves? Given that it is they who would feel the most immediate effects should the proposals come to fruition, where do they stand on the issue? In an interview with Holyrood magazine shortly before he stood down as chair of NHS Greater Glasgow and Clyde, Sir John Arbuthnott expressed his doubts about the practicability of direct elections. “I think that it could work, he said diplomatically, “but I think you have to think about it very carefully because we have to work towards a situation where we have a plan, a long-term vision, and along that pathway you have to deliver.
“So you have to think about the governance and the composition of the bodies along that pathway that are actually going to take the decisions to deliver, and if you make it too complicated, you may actually slow down the delivery process.
“I’m not intrinsically opposed to greater democratisation,” he added, “but I think you just have to remember that there are a lot of people involved in delivering and you have to watch that you don’t impair that.”
Arbuthnott also gave extensive evidence on this matter to the Health Committee during their scrutiny of Butler’s Bill, however, the current NHS health board chairs have so far proved more reticent in their comments.
While all 14 Scottish health board chairs were contacted and given the opportunity to contribute to this article, most merely chose to state that they were still “considering their response” to the consultation.
Others, however, have clearly enjoyed a swirl of gumption in their morning porridge and are more willing to put their heads above the parapet.
John Ross Scott, NHS Orkney chair and former leader of Scottish Borders Council, says he is “unconvinced” that elections to health boards are the correct route.
“Having fought eleven elections at local and national level in the past, I would be happy to do so again to retain my NHS position. But, while I applaud the SNP Government for giving the topic an airing, I remain to be convinced that it is the right way forward.
“On the plus side,” he says, “it would allow NHS Orkney and Orkney Islands Council to take the national lead in true partnership working and move closer towards a merger, grasping power away from the centre and placing innovation at the heart of all we do.”
On the negative side, however, he says that nationally, a “wealth of real academic talent” would be lost to the NHS.
“The NHS is a different animal from local government and needs these strategists and academics to carry on the work it is doing. The last thing it needs is one-issue candidates that will take the focus away from the corporate picture of what actually needs to be done.”
He also queried whether the public really want the cost and confusion it would no doubt involve, arguing, “Patients, and therefore the public, should be at the heart of all the NHS does, anyway. If they are not then more thorough checks should be done to ensure that in future they are”.
Overall, however, he says that if there have to be direct elections in the future, it should be with the proviso that they are undertaken on a county-wide basis and not based purely on a ward system.
“This,” he says, “will maintain a corporate approach and reduce parochial stances by board members.”
Furthermore, he says, he also believes it would be wrong – if elections are to be held – for them only to relate to territorial, or area boards, and not Special Health Boards that cover the whole of Scotland as currently proposed.
And on that, what does Scotland as a whole make of it? While this is clearly a hot topic for politicians and those within the health sector, does the issue of direct elections even make it onto the radar of Joe Public? As each side draws their battle lines in preparation for round two of the debate - both claiming to be marching under the banner of ‘in the public interest’ - is it something the public really care about and want?
Jean Turner, executive director, Scotland Patients Association (SPA) and a former MSP who was a member of the Health and Community Care Committee when Butler’s Bill was being scrutinised, says the previous Executive failed to grasp the true extent of the public’s loss of faith in health boards and so she thinks it is an issue that deserves to be debated.
“Patients hold their health as the most precious thing they possess and need transparency from health boards, which are spending our money
Patients hold their health as the most precious thing they possess and need transparency from health boards, which are spending our money 
,” she says.
“Over the past ten years there has been much evidence of public loss of faith in health boards providing what patients would like in services, appropriate and easily accessible to where they live.”
She says that communities never had general hospitals at the end of every street, nor did they expect to have - but they did expect that any change in the NHS should provide an equivalent or better service.
“When centralisation of services was the only plan on health boards’ tables, their argument was that campaigners wanted a hospital at every road end, which was not realistic. This was not true and it was believed to be repeated many times to discredit campaigners.”
As a result, she says that patients have little faith in the public involvement events organised by health boards, adding: “Health boards seem to use such events as propaganda exercises to get ‘their message across’ to the public, rather than to take on board what the public have to say.”
Consequently, she says many patients think it is “worth a try” to have elected members on health boards as, “they are likely to make more commonsense decisions than the present health boards have done till now.”
Given the consensus on the principle of greater public involvement, she too welcomes a second chance to debate the issue, adding that she fails to see how elected members could make the situation worse than exists at present. But most of all, she adds, “at very least, we should not be afraid of the debate.”
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