Where does democracy fit in the story – yet to be written – of a sustainable and integrated national health and care service?

I’m unhappy with the refuse collection, the state of the roads, planning permission; the car parking scheme or schools in my area. I know who’s responsible. I dislike my Dad’s GPs lack of awareness of the range of help at home or social support available to him.  Or the repeated requests for hospital outpatient appointments and the District nurses’ role in post discharge care. Who is responsible?

Well there’s a number of answers.  Ultimately of course the Secretary of State for Health is responsible for overall strategic direction of health and social care but that strategic role then siphons into two main tributaries – one via NHS England and Clinical Commissioning Groups (CCGs) and the other via the Department for Communities and Local Government and local authorities. And then bridging the two are a number of bodies drawing up integrated strategies and priorities – be they Health and Wellbeing boards (HWBs), CCGs or Sustainability and Transformation Partnerships (STPs) with Healthwatch providing input and the patient voice. Oh and there’s the Care Quality Commission as the regulator providing registration, assessing quality and performance. (Though what some of these bodies are called or how they interplay locally is likely to vary from area to area).

If, like me, you work in an organisation that helps people to navigate the health and social care system, you might have some clues as to where to go to find who’s responsible.  So I have the luxury of scrolling through the NHS Constitution, Joint Strategic Needs Assessments and other strategies and plans for my locality. But the ordinary citizen? How many of them have any clue about the role of these bodies or how delivery is planned, delivered, monitored and paid for? How many ordinary people have you heard discussing their STP’s local plans and priorities? How do they challenge or make a complaint about the services they receive? And who is accountable when things go wrong? And how does the citizen exert that accountability in real terms that are felt by the HWB, CCG or STP?  Has an opportunity been missed in engaging more energetically with the local population about the real choices and often tough decisions involved in STP’s plans?

I might be going too far by applying the American colonists’ sentiment ‘taxation without representation is tyranny’ to our current set up but I think we are very far from having real clarity about direct responsibility to the taxpayer in the local delivery of health and social care. As we all know, for many people the first time they come to understand how social care is funded is when they are facing a cliff edge crisis looking to find the care a frail older relative needs.

So if the Government is going to proceed with its promised consultation on the future of social care and consider all the options they also need to explain how any new ways to provide or pay for health and care deliver democracy and accountability to the citizen. Because any resulting bill issued to us as taxpayers needs to be clear who we are paying to do what, and how they will be held to account for delivering value for our hard earned taxes.  Even if many people will have to continue to pay for their own care and make their own provision with little input from the state.

Further, if we can achieve a political consensus on a new settlement for health and social care this will need to be carried out in dialogue with the British people, making clear the respective expectations of the state and the individual in a new social contract. As we know, since the foundation of the NHS in 1948 the sands have been shifting about our expectations of what it will deliver. These expectations have been exponentially expanding over the years (with notable exceptions for prescription charges, and oral and optical health). But more recently - like King Canute - we have seen ‘the powers that be’ trying to turn back the tide on our expectations at least with regard to our reliance on GPs and A & E departments. For many healthy adults their first port of call will be the Boots pharmacy counter, Counsellor or drop-in-clinic, as we increasingly avoid trying to make a GP appointment or rush to the Accident and Emergency department at our local hospital. And it is worth pondering whether this might form the basis of some common ground when it comes to clarifying our future expectations of both health and social care?

But that precludes the result of the (very green) Green Paper review, which I hope will consider all the funding options and models for paying for care available. The Government is unlikely to put forward a free at the point of use health and social care system funded from general taxation as their preferred option if their manifesto is anything to go by. But for those that do, the case for enhanced democracy and accountability will only be greater as we seek to square the principle of intergenerational fairness and increasing the tax burden on a shrinking working population.  Whatever options find favour, the public buy-in to a new social contract will be an essential requirement of British democracy. And where responsibility lies in the central to local continuum will need to be crystal clear.  Not least, because real change can only happen when those responsible have the authority and freedom to deliver. That is what clarity of accountability gives – a stronger mandate for change.

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