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More democratic accountability in the NHS

03/05/2022

By Elin Jones AM.

Plaid Cymru considers that it is timely to propose a debate on the democratisation of the NHS, given two Welsh government initiatives that provide the vehicle for this issue to meaningfully take place. I do not want this opportunity for strengthening the democratic oversight and improving the integration of services to be missed by Welsh Government. I hope therefore that this Senedd debate can provide the impetus for these issues of democratic accountability and more effective delivery to be taken forward in two ways:

First, there is the First Minister’s Commission on Public Service Governance – and in my opinion it’s essential that one of the largest public service sectors is fully included in that discussion. It’s also useful that Paul Williams, as ex-Chief Exec of the NHS is also the Commission’s Chair.

Secondly, the passage of the Social Service and Well-being Bill also enables a debate on the future structure and joint working of NHS and Social Service departments. The Bill as drafted provides the powers for Welsh Ministers to make regulations to require the integration of services and budgets between more than one local authority social service department or between a local authority and a LHB. However, this is an example of powers without policy. The powers currently in the Bill could enable ad hoc joint working in some areas or between some partners – a patchy approach that characterises too much of Welsh public service. What the Bill should do is reflect in legislation a clear policy direction on the future structures of service delivery in Health and Social care and ensure effective integration of service in every part of Wales.

Why is there a need for joint working and pooling of budgets between LHBs and Social Service Departments?

Well you only have to look at the Minister’s Statement on Unscheduled Care last week. In that statement, the Minister clearly outlined the problems caused by the lack of integration and pooled budgets between NHS and Social Services and the impact on patients stuck in hospital beds whilst the two organisations discuss where to place and who should fund a patient’s post-hospital care.

All of us as AMs will know of countless cases where there are lengthy discussions between Local Health Boards and Local Authorities on who is responsible for an individual’s care – and the individual and his or her family is left in the middle of what can at times feel like an inter-organisational turf-war.

Whether a person needs home care, residential, nursing or NHS nursing care should be a matter that is decided on the basis of an individual’s assessment need, not on organisational convenience. The traditional boundaries between NHS care and social care need to swept away – they are no longer relevant to the kind of fluid, integrated care needed by our increasingly elderly population.

There are impressive results on the impact of cutting out this organisational turf war by merging health and social care budgets. We hear over and over again of the Torbay experience – it is often quoted in Wales, but is yet to be properly replicated here.

After 10 years of integration and pooling of budgets in Torbay there have been dramatically positive outcomes. The Kings Fund analysis reported that

The daily average number of occupied beds fell from 750 in 1998/99 to 502 in 2009/10.In Emergency bed day use for people aged 75 and over fell by 24 per cent between 2003 and 2008 and by 32 per cent for people aged 85 and over in the same period.

And all of this happened with a reported saving of £250,000 in the first year of operation.

The Social Service and Wellbeing Bill provides powers for Ministers to pool budgets – but it is my view that Welsh Government could be braver and use this legislation to finally fully integrate health and social services throughout Wales. In our recent Health Committee scrutiny on this legislation, Local Government was asking for clearer direction by Welsh Government on integration – but the Welsh Government to date is sitting on the fence – still wanting the powers, but without a policy.

It’s timely therefore to ask the Commission on Public Service governance to consider this issue and I was pleased that the FM confirmed yesterday a willingness to do so. In Scotland, they are looking at a standalone piece of legislation to integrate health and social care – and Welsh Government could also consider revisiting the current Social Services Bill and remove the ad hoc regulation making powers and introduce standalone legislation to fully integrate these 2 services.

Of course in considering the integration of NHS and adult social care the Commission will instantly face the question of democratic oversight of any newly-formed joint arrangement. If, for example, adult social care responsibilities are transferred to an LHB – where is the democratic overview of the new arrangements?

Currently Local Health Boards have one councillor per Board, appointed by the Welsh Minister alongside all other Board appointees. We should consider strengthening the democratic legitimacy of such Health Boards, especially if they become Local Health and Social Boards.

We could consider direct elections at the same time as Local Government elections, or a model more akin to the Fire Authority or a National Park Authority where already-elected councillors are elected by their Councils onto the Board.

In Scotland, they have already set up direct elections in two pilot areas. For NHS Dumfries and Galloway and NHS Fife Health Boards there were direct elections in June 2010. The Health Boards Act 2009 which set up these pilots also set out on a statutory basis that there must be at least one councillor member per local authority on each Health Board, and that elected members would form the majority of Board members. This contrasts starkly with the Welsh situation where it is only one councillor member on a Health Board

In addition to democratising the Health Boards, the question also arises of the democratic accountability of Community Health Councils. CHC members are also appointed by the Welsh Government. The weaknesses of this system was revealed recently in the west – the Community Health Council and the Health Board, both appointed by the Minister, both disagreed on Hywel Dda’s plans, with even the threat of legal action against members of the CHC by one of the Health Board’s contractors, ORS.

The Community Health Councils need independent opinions and the right to differ from the Health Board. A democratic mandate by election is a means of ensuring this – members of CHCs could be elected through a model of elections from among local Health Service users. The elections could take place in surgeries over a period of time – on a model similar to co-operative society or building society elections.

I would also like to refer to the financial accountability of Health Boards - over £5billion of the Government’s budget goes to the Health Boards, into one annual budget stream, and their inability to stay within budget is known to all.

We in Plaid Cymru are convinced that financial scrutiny of the Health Boards needs to be strengthened and opened up – and the National Assembly’s Finance Committee is the means of doing this.

The Welsh Government now has the opportunity to integrate health and social care to create a service which gives the priority to patient care, rather than the requirements of competing organisations. There is also an opportunity to introduce direct democratic accountability to health and social services.

We hope that the Welsh Government will be willing to grasp these opportunities.