The Commission Pages

The NHS was founded to dleiver free and equal access to comprehensive health care - one of the great leaps forward of the century, both in promoting the nation's health and entrenching social citizenship. The NHS retains its national mandate: to provide the same care to every Brithish citizen irrespective of location or income, financed by general taxation and publicly owned and accountable. Ever since its foundation it has commanded extraordinary popular affection and loyalty. Its medical and non-medical staff alike have been strongly committed to its success and values. Indeed they have been one of the NHS's strongest and most enduring assets.

However, there is now a gap opening up between what the NHS is able to deliver and the expectations and needs of its users. The stress signals vary. Complaints, for example, are growing across the system; the bill for clinical negligence suits is £2.8 billion and climbing; and there are widespread and popular campaigns against hospital closures. The groundswell of criticism and unease is backed by recent opinion poll evidence indicating that the NHS is widely thought to be deteriorating.

There are three main reasons for these disturbing trends. First, funding for the NHS has never kept pace with need. Governments have sought to manage this problem by redefining what the NHS provides, so eroding the principles of comprehensive care and services free at the point of delivery. A growing number of services - NHS dentistry, optical services, some routine elective care and the majority of long term care services - that used to be provided by the NHS have in effect been privatised and left to individuals to fund. Within the NHS rationing has increased, but the criteria vary between health authorities. At the same time there is a consistent inability to raise standards of provision in line with the public's rise in living standards and its accompanying expectations.

The second reason is closely related to the first. Important inequalities have followed the introduction of the internal market. Aiming to devolve decision-making and responsibility to promote efficient resource allocation, the consequence of the new structure was the introduction of major inequalities between local NHS providers and fund and non-fund holding GPs. The new Labour government recognises these deficiencies but its 1999 Health Bill only partially addresses the problem. The financing of new hospital construction through the Private Finance Initiative (PFI) will lead to the progressive privatisation of the NHS's infrastructure. The new Primary Care Groups (PCGs) and Primary Care Trusts (PCTs), who are to run integrated, unified budgets for the total health care in their areas, will be placed under intense financial pressure to continue contracting out and privatising further services. Inequity will thus be built into the NHS's core structure.

But the third reason for the gap, and which directly concerns this Commission, is the erosion of the democratic structures and mechanisms within the NHS which protect the public interest. This has coincided with the increasing insistence, in all walks of British life, on more accountability, more information and higher standards in decision-making and subsequent execution. The NHS as a major British national institution is inevitably exposed to the full force of these developing trends. The government seeks to address the issue through regulation and regulatory structures. But in the absence of adequate, strong democratic structures the public is increasingly using the NHS's inadequate complaint mechanisms or even the courts to seek redress of grievances; a development that is bound to increase further when the Human Rights Act (1998) becomes operational. It is a trend that could ultimately undermine the capacity for rational, collective decision-making that is properly at the heart of the NHS.

The principal route in a democracy to close this kind of trust gap between the public and the institution is to promote its accountability and thereby secure its legitimacy. The more accountable the NHS, the more the public's sense of its ownership and the more it is legitimate. However, although the NHS's accountability has been debated ever since the service's launch the issue has never been satisfactorily resolved. In general the approach has been that the Secretary of State or minister responsible for health is accountable to the public via the House of Commons, with all the strengths and weaknesses of the British system of parliamentary accountability (in Scotland and Wales accountability has been devolved to their respective health ministers and assemblies). Over the NHS's history there have been a variety of regimes in which decision-making has been delegated to regional and local level with a varying readiness to incorporate external voices and assert some degree of accountability, but no settled system has been established. In addition there are ad hoc independent inquiries and review panels in response to individual problems and public concerns, and there is a complaints procedure for individual cases. But allnone are unbacked by any framework of patient rights. In sum the system of accountability is the weakest since the NHsS's launch in 1948. It is the least accountable of Britain's major public institutions even though access to health is the prime concern of British citizens. This democratic deficit in the NHS has been widened by recent changes to its structure and is likely to widen still further as the next round of change takes effect.

There is only one formal mechanism for giving voice to the concerns of patients and families - the Community Health Councils (CHCs). But recent structural changes have removed the regional health authorities and downgraded the district health authorities with which they have had formal links. They have no such links with the new Primary Care Groups, which are being set up to drive the re-shaped NHS onwards at the local levels at which CHCs work. CHCs have also in practice acted as local agencies for the redress of grievances, alongside the Parliamentary Commissioner for Health at national level, and they have continued to do so even after the advent of the Patients’ Charter. But this has always been an informal, if invaluable, role, and their ability to fulfil it is now evenmore constrained than previouslyever.

The system of accountability in the NHS now needs to be reviewed, overhauled and improved. However, this is not just a question of trying to re-legitimise the NHS and offer patients a more streamlined and effective system for the redress of grievances. It goes to the heart of the rationality of NHS decision-making, and thereby to its efficiency and effectiveness as the nation's provider of health care. It could not be more fundamental.

This Commission was established in March 1999 by the NationalAssociation of Community Health Councils for England and Wales (ACHCEW) in order to examine the issue of the public interest and accountability in the NHS. Although launched by ACHCEW it is fully independent, and its mandate has offered it a wide remit. Our terms of reference are: " In recognising that the ultimate purpose of the NHS is to serve the public interest, to identify the ways in which that public interest can best be served by the achievement of a full and effective system of accountability". (See Annex 1 for membership of the Commission)

What follows is our interim report, representing our thinking after three months of analysis, discussion, research and written and oral evidence and which signals the direction and shape of our final report. It is work in progress, and we have deliberately come to no firm conclusions. However readers will see that we are beginning to establish a relationship between better accountability, more equity and increased economic efficiency,. This will mean not merely a reduction in complaints and lawsuits but also better decision-making and resource use. We are anxious that our work in the next six months should reflect the real concerns and preoccupations of those who work in and use the NHS, and also, of course, the anxieties of the wider civil society. We welcome the views of those any person or associations who can help us advance the discussion and improve our analysis and eventual recommendations. We thank the nearly 200 organisations and individuals who have already submitted evidence (See Annex 2); we very much appreciate the effort and work that has been made to help us so far.