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Rapid Responses: Rapid Responses published:
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Ideas for NHS democracy.
- Michelle E Tempest (14 January 2007)
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Patients are not the public
- Peter G Davies (16 January 2007)
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Does the NHS really need people power?
- Madeleine A Purchas (16 January 2007)
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Sherlock Holmes
- Robert J Reynolds (17 January 2007)
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democracy and choice
- stephen black (23 January 2007)
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Re: democracy and choice
- Robert J Reynolds (24 January 2007)
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Michelle E Tempest, Psychiatrist CB2 2QQ
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Will Hutton’s (BMJ, 13/1/07) interesting article is well-intentioned suggesting the need for more local involvement in the NHS. However, the mechanisms for introducing democracy may not be sufficient. For example, he suggests an institutionalising process such as surveys, citizen juries and focus groups. However, once these become more than merely small guides to the direction of public opinion and start to take on the significance of affecting policy, they would have to satisfy certain basic democratic requirements such as fairness, transparency and above all, being open to all. If they were to satisfy all of these, they would stop being focus groups or surveys and instead would be, in effect, the same as local elections. If we are to have local elections, it may be sensible to consider using existing structures. For example, if the whole structure of the NHS is simplified down to as few layers as possible, perhaps making health authority boundaries coincide with those of local authorities, then many elements of the decision-making process could be handed over to local politicians. For example, with the democratic safeguard national government could hand over powers to set targets and potentially even budgets. Primary Care Trusts (PCTs) could hand over the power of commissioning to make local authorities in effect into ‘local commissioning bodies’. The local authorities would then be responsible for implementing the will of the people through the mechanism of local politicians. This would not only invigorate local democracy but it would make the NHS far more responsive to local needs. Competing interests: I am the editor of a book entitled 'The Future of the NHS' |
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Peter G Davies, GP Principal Keighley Road Surgery, Illingworth, Halifax. HX2 9LL
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Will Hutton comes up with an interesting idea. He is right that there is a democratic deficit at the level of local primary care trusts which are not in any real sense locally representative bodies. They are largely agents of central government and any pretence about them being "representative" and "reflecting local priorities" is largely window dressing. There are however problems with involving the public in running local health services. We experience services as patients, but we vote about them as citizens. On the whole as citizens we cannot actually know what we will want and need as services when we become a patient. And most citizens are healthy and use health services only sporadically. So there is a key question as to who should be represented in running local health services, whether it should be patients or citizens. I suspect we actually need local councillors to direct our PCTs. At least they have a democratic mandate behind them. No one else does. Patient representatives, doctor representatives and management representatives are rarely fully representative of their apparent constituency. It is highly doubtful to me that central government would trust local government, or any other local representation system with running the local NHS autonomously. Competing interests: None declared |
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Madeleine A Purchas, Specialist Registrar in Care of the Elderly Royal Cornwall Hospital, Truro, Cornwall
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I was very interested to read Will Hutton's article on the accountability of the NHS to public demand and public priorities, but at the same time was filled with horror. The public are usually swayed by emotion rather than logic - hence the availibilty of herceptin despite its value for money, for example. As a specialist in medicine for the Elderly, I believe that increasing public choice and involvement in how to use scarce resources will result in the downgrading of services where users are less able to speak for themselves. Expensive oncology drugs or children's services will always be provided for, however the likes of elderly medicine or psychiatry will take a back step. We all recognize that we are already fighting against ageism in our workplace. Knowing the usual lay response I get to my professional title, I fear that ageism will worsen with increasing public involvement. Competing interests: None declared |
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Robert J Reynolds, Doctor North Devon District Hospital EX31 4JB
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Thank you first for Iona Heath’s sympathy towards the socially stressed – towards all “within a persistently unequal society”. Only last year, in a BMJ editorial you allowed yourself a wistful perplexity: “something important is quietly dying…the spirit of medical professionalism”. When, I wonder, will we see explicit recognition in the BMJ, of the single obvious solution to which so many social ambitions point? Thank you also for Will Hutton, given BMJ space to advocate (seriously or not I cannot tell) “deliberative democracy” for the determination and pursuit of “public value”. Sandy Anthony, in the Medical Protection Society’s Casebook went further, following Onora O’Neill on “intelligent accountability”, through splendid analysis to the verge of satisfactory conclusion: the need for “better attention to securing the institutional conditions for independent judgement”. Amongst respondents to Iona Heath, on bmj.com, Richard J Lyus gives “the fundamental problem” as “the profit motive”. Nagpal Hoysal, like Hutton, gets as far as the need for “balance”. Christopher Buttery hopes to be heard – and not ever to need rescue care or long-term support. Dominic C Horne has in mind “complete physical, mental and social wellbeing”: he despairs of “our elected representatives”, but goes no further. For Kevin Pearce, looked at in the right way, we don’t seem to be doing so badly. It is good to be reminded, David C Taylor-Robinson and Mark Jackson, that even as the great ship slides beneath the raised sea levels, there are worthwhile things we can be doing. In his heartfelt and elegant analysis, Alexander SD Spiers moves too quickly on from the convergence of aims - “not always the case in ordinary business relationships”. Anne Savage and Peter G Davies bring us focus on need – and back to politics. We have tried Autocracy: benevolence decays. We have tried the dictatorship of the majority: still no luck. Billions of people will this century will be born and will die in poverty and war. We run in a rat-race, greedily and unhappily to profit from the wasting of our children’s future. Is Mammon the mirror of true “human nature”? Or might we choose to live otherwise, with individual security, freedom of conscience, the real potential of representativeness, within us all, of us all?: Let games continue to be played, by all means, in the playroom and on the playing field, but let us speak seriously of human unity, and allow ourselves “the institutional conditions” for “intelligent accountability” - and collective self-determination for human survival. Which, after all, is the only income distribution that could ever be settled upon in a community of intelligence? Sherlock Holmes tells us, “when you have eliminated the possible, whatever remains, however improbable, must be the truth" : income equality? Heath I. In defence of a National Sickness Service. BMJ. 2007 Jan 6; 334(7583):19. Godlee F. While Rome Burns. BMJ. 2006; 333(2006) Hutton W. Why the NHS needs People Power. BMJ. 2007 Jan 13; 334(7584): 69. Anthony S. Moving forward: making regulation work. UK Casebook. 2007; 15(1):10. O’Neill O. Accountability, Trust and Informed Consent. P.272. Sir Arthur Conan Doyle. The Sign Of Four. Competing interests: None declared |
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stephen black, management consultant london sw1w 9sr
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This debate seems to me to be guilty of a modern error: the assumption that democracy is a moral good by itself. More sophisticated political theorists who remember the 20th century in Europe seem to have a better view: democracy is merely a mechanism for avoiding certain types of evil such as despotic, injust or corrupt government. Democracy is probably better reserved for the (infrequent) times when leaders need to be booted out and we shouldn't expect it to be either a cheap or effective way of fine tuning policy to the desires of the people. Anyway, we already have more effective mechanisms for working out what people want. We don't need a sophisticated programme of democractic engagement to work out whether the public want organic food in their shops. Supermarkets just have to put the (higher priced) organic food on their shelves next to the (cheaper) industrially farmed stuff and then observe whether their customers choose it. In a competitive market any good idea tends to spread rapidly (in supermarkets, Sainsbury loses market share to Tesco quickly if they fail to provide what customers want); we don't have to wait for the next election of consultation round. Because choice forces people to make tradeoffs in detail it is often better than democracy at revealing what people really want (democracy tends to encourage the public to demand all the benefits and none of the costs: everyone wants a hospital in their own back yard). Choice of hospital for elective care is likely to herald a rapid shake up of hospital provision. Excessive democracy seems likely to lead to perpetual stasis with any change being almost impossible to implement however strong the clinical rationale. Competing interests: None declared |
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Robert J Reynolds, Hospital Doctor North Devon District Hospital EX31 4JB
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Before 'we' can determine the 'moral good' of 'democracy', we surely need to agree understanding of what might be meant by 'moral', 'good' and 'democracy. If 'good' is a term of estimation of 'at least apparent benefit, to physical survival and/or spiritual comfort'; if moral is also a term of estimation, as at least 'likely to be favoured in the common view'; and if democracy can be accepted as 'social rule with maximum coherence between individual and moral good', then, as I think implied by Stephen Black, if we wish 'moral good' we need to determine the social conditions that would maximize individual freedom for all, and individual representativeness of all. Black reminds us of the power of 'choice in the market', to deliver 'what people will buy' on the supermarket shelf. "Choice' will of course also deliver 'what people will choose' - whether from problematic guidance on 'more than 200 hospitals and treatment centres', or from problematic manifestos evolved by parties committed to 'democracy' only in terms of 'our democratic system'. Whether what people choose is 'what people really want' is another matter: there are things not to be found on the shelves, in the star-ratings, and in the editorials, Would we not like to know, without constant and largely in- vain 'checking', that food quality was ensured, that hospitals were resourced, and that opinion-formers, law-makers, captains, corporals and apprentices of industry, were all guided, by real freedom of individual conscience? The democracy 'we' need, if we choose rationally sharable concepts of good, moral good, and democracy, is that in which the market is supplied by free people with feedback from free people - themselves. For 'the market' truly to 'work', for democracy, the suppliers must be free from 'corruption' (conflict between 'good' and 'moral good'); and buyers or voters must over time be equally powerful (in terms of finance direction towards purchases, campaigns, parties). Perhaps if extension of compulsory 'education' is confirmed to 18 years, room will be found for discussion of genuine democratic possibilities. People are more than capable of hope, and we are freshly acquainted with disappointment. We have almost cruelly allowed fine 'leaders' to be overtaken - with inevitability - by their own 'cleverness'. The planet and our children cannot afford the effective rule of 'Mammon', over education, opinion, investment and government. It is not only within Medicine that the voice of Onora O'Neill deserves to be remembered. Competing interests: None declared |
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