Despite the rise of patient and public involvement, evidence from the junior doctor’s strike suggests that little has changed in terms of the power of Westminster and the lack of public accountability for decisions that lie at the heart of how the NHS is organised. Here, Jonathan Tritter and Mio Fredriksson discuss the tensions between representative and participatory democracy in NHS decision-making, and argue that Jeremy Hunt is pursuing a centralised vision of the NHS rather than responding to consumer-driven demand.
What does the junior doctors’ strike tell us about public accountability and the NHS? The rhetoric behind the ‘new’ contract is the ‘need’ for a 24 hours a day, 7 day a week health service; ensuring the more efficient use of resources or ‘sweating the capital’. These aims appear to have little to do with the views of members of the public or patients and instead reinforce neo-liberal inspired managerial reforms of the NHS. In the absence of public demands for these changes the justification for the Secretary of State for Health pursuing this course of action is that he is acting in the interests of the public he represents by addressing an issue of patient safety on weekends; an action legitimated by representative democracy. The rise of public and patient involvement and increased choice suggests the growing relevance of participatory democracy. The tensions between these two approaches raise questions around how decisions about the NHS are made and what parties are involved, challenging public accountability assumptions and the ways in which these have changed over time.
The NHS was founded on 5 July 1948 to provide health care free at the point of delivery to all independent of their ability to pay. It brought together disparate providers in to one, relatively integrated health system to provide care ‘cradle to grave’. Over the past 67 years reforms have changed the NHS making it less rather than more integrated and embedding mechanisms that create and recreate inequality and lessen solidarity. But to what extent have these changes created more accountability and to whom?
The Griffiths Review published 33 years ago critiqued the NHS for being too centralised and “being swamped with directives without being given direction.” (1983: 15). Roy Griffiths’ recommendations which have been seen as heralding managerialism called for greater delegation of everyday activities to NHS organisations and away from Whitehall and challenged Bevan’s vision of a democratically accountable NHS ensuring that “the sound of a bedpan falling in Tredegar Hospital would resound in the Palace of Westminster” (1948). Indeed health reform over the last 25 years has transformed the NHS through multiple mechanisms promoting the commodification and marketization of health services. The promotion of competition through Payment by Results, patient choice and creating a diversity of ‘qualified’ providers, among other mechanisms, has been justified on the grounds of cost control, quality improvement and latterly producing a locally responsive service through local commissioning. Alongside these changes a growing emphasis on patient and public involvement in the NHS first codified in Section 11 of the Health and Social Care Act 2001, has created an opportunity for a different form of accountability. Reforms led to mechanisms such as members and elected governors of Foundation Trusts and more recently the requirement that Clinical Commissioning Groups ensure public involvement and consultation in commissioning processes and decisions. Indeed many Mental Health Trusts now habitually include patients and members of the public on appointment panels. Despite the rise of patient and public involvement, evidence from the junior doctor’s strike suggests that little has changed in terms of the power of Westminster and the lack of public accountability for decisions that lie at the heart of how the NHS is organised. Would the outcome of the strike and the negotiation have been different if patients and the public had been involved? Would the outcome have been different if the public rather than patients were involved?
The issue of accountability for publicly provided services centrally concerns the relationship between citizens and the state. Such relationships are different from those between service providers and service users. In part this is a debate about the distinction between representative democracy and participatory democracy and who best represents the interests of citizens. Is it political representatives, voluntary organisations or citizens themselves? Many different actors claim to represent the public’s voices, opinions or interest in the policy making process such as from the British Medical Association to the Patients Association. Elected officials can represent the public differently; either as delegates or as trustees. Delegates mediate their constituents’ expressed preferences whereas trustees act according to their own understanding about the appropriate course of action, they then claim to represent interests rather than opinions. The latter may be problematic if the elected representatives pursue policies that the people do not support or even actively object to. The question is what approach is the Secretary of State pursuing and how does this fit within the evolution of the NHS?
An alternative approach is based on the ideal of participatory democracy where the people are more directly involved in making decisions rather than delegating the responsibility. The promotion of patient and public involvement pursues, to an extent a participatory approach to accountability within the NHS which is distinct from Bevan’s vision of central control. Such an approach should draw on those who have experience of the service; it should involve patients. But while patient and public involvement is usually presented as if these categories are synonymous they are not: patient interests that are individual and specific can often be at odds with collective needs. For example, they might be in conflict where funding for expensive drugs limits surgical interventions. If we are keen to promote participatory approaches we should be clearer who should participate and why. In the end we are left wondering how different the negotiations with the junior doctors would have been if patients had been seated at the table and how different the outcome if the public had been a direct party to the process.
The handling of the junior doctors’ strike reinforces a vision of the NHS which is centralised and where local voices of citizens and patients are neither sought nor listened to. It is ironic to think that the current Conservative Secretary of State may be acting more as Nye Bevan imagined in 1948 rather than by responding to consumer-driven demand.