Introduction

As components of democracy, the health authorities currently responsible for the local governance of the NHS are a nonsense. As Regan and Stewart pointed out 25 years ago,1 their quasi-independent statutory existence precludes clear accountability on the part of the political centre yet without (as in the old nationalised industries) providing a clearly delegated management role, and without providing local democratic accountability. Health authorities, especially given recent suspicions surrounding the closed nature of the appointments process, are truly examples of Stewart's “new magistracy”2: unelected, unaccountable, and tacitly assumed to refrain from challenging the status quo.

The rationing of health care is inevitable in any system of third party payment for health care,3 4 and where the system is publicly or quasipublicly financed rationing decisions are political decisions in the sense both of requiring accountability for public funds and of involving the allocation of resources which may significantly affect people's life chances. This remains so whether or not they are taken on party political lines and whether or not they involve substantial technical input (about, for instance, the efficacy of specific health care interventions).

It follows that health authorities are not appropriate bodies to be making such decisions. As Regan and Stewart noted more generally, the consequences of the present arrangements are threefold.1 Firstly, the centralisation of electoral accountability means that in practice there is none. The centre does not have “the time or resources to provide more than partial, selective and spasmodic accountability.” Secondly, the attempt even to provide that much leads to administrative and political congestion. Thirdly, these arrangements leave a highly unsatisfactory role for the people who are appointed as authority members. If all this is so, reform in relation to healthcare rationing might logically take one of two directions.

A stronger role for the centre?

One is to …