Will Hutton wrote an interesting article (British Medical Journal13/1/07) suggesting the need for more local involvement in the NHS. However, the institutionalising mechanisms he suggested such as, surveys, citizen juries and focus groups for introducing democracy, may not be sufficient. 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.
This has been added as a response to the BMJ article on eBMJ.