Should clinicians or politicians control the local health budgets? Who is more accountable and more able to represent the population?
Should clinicians or politicians control the local health budgets? Who is more accountable and more able to represent the population?
Clinical commissioning and clinical commissioning groups (CCGs) were created just two years ago. At last after endless prevarication and false starts, GPs were handed the keys to designing local services. For years, they and their patients had more or less got “what they were given” with virtually no say over hospital and community services and how NHS money was best spent. Now, clinical commissioners and leaders of CCGs are beginning to have a real impact on the system and, in spite of the tightest funding in the NHS ever, services have been maintained and cost efficiency has been improved.
Despite this great start, some politicians are suggesting that there should be greater ‘accountability’ in the system and that budgets held by clinical leaders, and CCGs should be handed to health and wellbeing boards with the implication that local councillors offer greater accountability than frontline clinicians.
The longstanding Ipsos Mori poll of Trust in Professions continually puts GPs at the top while politicians generally languished at the bottom. So, where is the proof that people and patients really want local politicians to call the shots or indeed that they are more accountable than clinicians?
Who knows best?
Local politicians may claim that they have credibility and accountability because local people voted for them. Does this stand up to examination? Local GPs have to prove that they are up to the job for local patients to sign up to them and their practices.
In my experience, when people are looking for local input in health leadership they come to us as GPs and not to the local councillors.
Then there is another big issue when it comes to health, namely who knows most about it? GPs with a registered list know well their local estates, schools and retail businesses – for instance. It is a level of connection that the politician representing a far larger area can never have.
Money may be important. It is in everyone’s lives. For GPs it is not more important than patients. So when it comes to patients and the general public, who do we think has the greatest vested interest – our clinicians or our politicians?
There is a further argument that concerns fitness for the job. Clinicians sign the Hippocratic Oath; we have a yearly appraisal that covers issues such as probity and mental health; we have a five yearly revalidation that ensures we are up to scratch. Visits by the Care Quality Commission (CQC), contract reviews by NHS England and standards set by the Department of Health and Government all help to ensure that we have high quality GPs, who are acting in good faith for their patients. Are there any such safeguards when it comes to the quality of local councillors?
Evidence matters
I don’t say any of this lightly. Twenty-five years ago as a young GP, I sat on the local health authority alongside local councillors – they were pleasant, colourful and well-meaning men and women.
Yet in spite of all these considerations, there are politicians that are suggesting the commissioning role and budget of frontline clinicians and CCGs should be handed over to health and wellbeing boards and, effectively, locally elected councillors. There is absolutely no evidence that this would improve things, no evidence so far that health and wellbeing boards have delivered and absolutely no evidence that public health has been safer in the hands of local authorities. Some say that the only good thing to come out of the Health & Social Care Act was the creation of clinical leadership and clinical commissioning and yet there are some that now want to reverse even that. Clinical leadership in commissioning was the triumphant success of the Health and Social Care act 2012, which had many flaws. Any politician that wants to remove the one success of that act must be responding to emotion and dogma not reason.
Generally though local councillors and politicians have no greater claim to local accountability than their local clinicians.
When it comes to health, I believe that patients would rather rule with their frontline clinicians than with their locally elected politicians.
Mike Dixon, chairman of the NHS Alliance and a GP at College Surgery in Cullompton, Devon and a Royal College of General Practitioners presidential candidate.
