A spreading sickness of secrecy: The NHS is losing something valuable as it grows less accountable, argues Nicholas Timmins

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The Independent Online
TODAY the permanent revolution that grips the National Health Service will take another turn, when Virginia Bottomley takes the axe to regional health authorities.

Once upon a time - and not such a long time ago - these health authorities, and hospitals, were run by people called administrators. On the authorities sat doctors, nurses, trade unionists and local councillors. These people, the administrators aside, were unpaid volunteers, and at times represented deeply sectional interests. None the less, all of them, the administrators included, saw it as part of their job to be public advocates for their local populations: joining in the cacophonous mixture of shroud-waving and special pleading by which the NHS then distributed its cash.

The health authorities met monthly in public and sometimes stormy sessions, with the media present. They had a tendency to resist, or at least complain about and question, the policy - usually the financial policy - of the government of the day. This applied just as much to Labour as to Conservative governments.

It was all rather messy. Angry exchanges resulted. But while to ministers in the Department of Health's headquarters the process appeared to be deeply and despairingly unaccountable, these health authorities were plainly accountable to their local communities. Equally their decisions, when made, had some legitimacy. They were made by local people who at least lived in the area and worked in the service, within the framework set by government.

Now, a mere 10 years on, all that has changed. NHS administrators became first general managers, and then chief executives. Each one was subject to performance-related pay and an accountability review, with a place in an increasingly line-managed system.

So worried did managers become about stepping out of line, rocking the boat, or failing to meet their targets, that last year there was talk of 'a climate of fear' in the health service, while the chief executive of the NHS himself had to call for an end to 'macho management'.

Over the same period, health authorities - and the new NHS Trusts that go with them - have been transformed from loosely representative bodies into entirely appointed ones. They no longer have local councillors on them by right, and many board members are not even local people.

Despite all the talk of community care and co-operation with local authorities, not even the local chair of social services now sits by right on any local health authority or NHS trust. All trust and health authority members are in effect the appointees of ministers, even if the lower- level appointments are made at arm's length. They are also all paid - pounds 5,000 a year for ordinary members and anything from pounds 13,000 to pounds 20,000-plus for the chairman.

The agendas for public meetings are decided by the authority or trust. But trusts now only have to meet in public once a year. And one effect of all members being paid is that they no longer have among them the disgusted doctor, angry nurse, bitter trade unionist or even opposition councillor who has nothing at all to lose in ensuring that awkward items are put on the agenda - or at least raised under 'any other business' with the press and public present.

At the same time, ministers in Parliament, in keeping with the Government's general drive towards agency status for everything, are increasingly referring MPs' questions on to trusts and districts for answer, rather than answering them themselves. This has the neat effect that answers, when they do come, are no longer publicly recorded and available in Hansard for intrusive journalists and awkward customers or employees to read and make a fuss about.

In addition, while NHS managers are notably more reluctant to rock the boat in public, they and their trust members are increasingly attempting to impose a culture of corporate silence on doctors, nurses and others who wish to complain about the NHS.

The paradox is that over the past 10 years, the NHS has become much more accountable internally than it ever was - but much less accountable externally.

In place of this lost accountability we have public opinion surveys run by health authorities and a mix of national and local patient charters. In themselves, these are fine. We probably should have had them years ago. But they should be an addition to more traditional forms of public accountability, not a substitute for them. For it is appointed board members who decide which questions are asked - and just as importantly, which questions are not. It is ministers and the management executive, the trusts and the authorities, not the public, who decide what goes into local or national patient charters.

And the next stage in this transformation of public accountability comes with the expected announcement today of the abolition of regional health authorities.

This will take legislation, and therefore time. So the first stage will be to merge the existing 14 regions down to eight or so, before abolishing them, probably in 1996, and turning them into regional arms of the National Health Service management executive.

This will have two effects. The first is a massive extension of Whitehall control into the regions - a huge act of centralisation. The second, as a consequence, is a further loss of public accountability at regional level. The already limited public visibility of the existing regions will disappear.

Below ministerial level will be the NHS Policy Board - a body that already exists but meets in private, with unpublished agendas and no record made public of its conclusions. Beneath that will be the NHS management executive, which also meets in private. Below that will be the regional arms, again inaccessible to public scrutiny.

Information that is now available, allowing public and press at least to glimpse what is happening across and between regions, will disappear from view.

On their own, none of these changes to the NHS may greatly matter. Cumulatively, they do. For one profound effect of the NHS market is to make decisions about what health care is purchased - and therefore what health care is not - much plainer and starker. Health authority members therefore have to take tougher decisions. And second, the revolution in medical technology and day-care surgery is likely to mean widespread hospital closures and changes in hospital use over the next decade.

None of these decisions is going to be popular or easy. And since the NHS is a tax-funded service, those who make them need some public legitimacy. If they do not have that, their decisions are likely to be greeted with greater hostility, and public support for the NHS itself may diminish. For all the Government's protestations that public consultation still takes place, decisions will in fact be made by an appointed magistracy, not by people who have a locus and standing in the community and the service itself.

No one would advocate a straight return to old-style health authorities. And the introduction of more internal accountability in the NHS has been far from all bad. But something valuable to the NHS is being lost in the growing suppression of information, representation and external accountability. Today's announcement is the latest example.