Issue 7: Nov 2013

WE SHOULD HAVE FEWER COUNCILS - BUT THEY SHOULD RUN HEALTH

By Alison Payne

Devolution was never supposed to stop at Holyrood, but it did.  Indeed, not only did it stop at Holyrood, but since devolution Scotland has also undergone centralisation with functions such as council tax, through the centrally-organised freeze, and the police taken away from local authorities and placed with Holyrood.

Throughout Reform Scotland’s work, we have argued that more power needs to be devolved down to our local authorities and beyond to make public services more responsive to local needs and priorities as well as making service delivery more accountable and transparent.  Scotland is a diverse nation and as a result more powers should be devolved further to better reflect the different circumstances faced by different communities.

And this also applies to the way we manage health care in Scotland.

more power needs to be devolved down to our local authorities and beyond to make public services more responsive to local needs and priorities as well as making service delivery more accountable and transparent.

Health care in Scotland is currently dominated by 14 territorial NHS Boards, which are responsible for the planning and provision of health services for their local populations based on local need. Six of the NHS Boards are coterminous with one local authority – NHS Borders, Dumfries & Galloway, Western Isles, Orkney, Shetland and Fife. The other 8 – NHS Lothian, Greater Glasgow, Forth Valley, Highland, Ayrshire & Arran, Grampian, Tayside and Lanarkshire – cover more than one council area. Money flows directly from the Scottish Government to the health boards on the basis of need using the NRAC formula (NHSScotland Resource Allocation Committee). Central government is also responsible for setting national objectives and holding the NHS to account for these objectives.

Most non-executive lay members of the boards are appointed by Scottish Ministers; though a councillor from each of the local authorities covered also sits as a non-executive lay member. Pilot elections took place on 10 June 2010 in the NHS Dumfries & Galloway and NHS Fife Health Board areas to allow direct elections to the health boards, however turnout was very low – 22.6 per cent in Dumfries and Galloway and 13.9 per cent in Fife.

Reform Scotland does not believe that we should be creating parallel tiers of government, rather making better use of the ones we have.

This argument against devolving power to our councils because 32 authorities is too many is looking at the issue the wrong way round.

One of the issues constantly thrown back at us when we argue for more power to be devolved to local authorities is that this can’t be done as we have too many local authorities. This argument against devolving power to our councils because 32 authorities is too many is looking at the issue the wrong way round. We should first decide what we want out local authorities to do, and we think that it makes sense to link up health boards and councils.

Reform Scotland envisages that instead of having a parallel tier of government, whether it is directly-elected or appointed health boards, a smaller number of local authorities, with far greater powers, including fiscal powers, should take on board the responsibilities and expenditure of the health boards.

We believe that the activities carried out by non-executive health board members should be carried out by accountable, elected individuals.  The delivery of health care would be on the same basis as the other local authority responsibilities, but would create a simpler more transparent hierarchy.

It would be up to local authorities to decide how to meet the healthcare needs of their local population.

Local authorities having greater responsibility for the delivery of healthcare is not unusual and many European countries have a far more localised health system. For example in Denmark, which has a population roughly the same size as Scotland and operates a similar health care system to ours based on the principle of free and equal access for all at the point of use, responsibility for healthcare services lies with the lowest possible administrative level so that services can be provided as close to the users as possible. Although Denmark has undergone local government reform, there are still 98 municipalities, considerably more than in Scotland, which are responsible for home nursing, public health care, the school health service, child dental treatment, prevention and rehabilitation as well as a majority of social services.

Equally in Sweden, they operate a tax-payer funded system which is largely decentralized with responsibilities passed down to both the 290 municipalities and 18 county councils.  Again in Norway, which operates a tax-payer funded system, it is the country’s 429 municipalities which are responsible for a large element of health care and social services while the state is responsible for ensuring equal conditions through legislation and the financial framework.

This proposal would also bring the benefit of bringing together health and social care under one roof. At present the NHS, run by health boards and council-administered social services remain two different areas between which patients can fall.

Some may feel that such a structural issue should not be the focus of debate, but this debate is long-overdue.  There is no one solution for our health service – the needs of people living in remote areas of the Highlands and those living in deprived areas of Glasgow are totally different, and as a result it is vital that we have a health service that not only allows for different solutions, but actively encourages innovative ideas. Vitally, there would be a strong element of democratic accountability with local people being able to hold their councillors to account for the decisions made, just as they do on other local issues.

This proposal would also bring the benefit of bringing together health and social care under one roof.  At present the NHS, run by health boards, and council-administered social services remain two different areas between which patients can fall. Whilst the Scottish government is looking at this issue in current legislation, there is a danger that once again the solution will be a centralising one, with power being taken away from local authorities, rather than power devolved to them.  It is also likely that strengthening local government and giving it more power would also reinvigorate interest in local democracy.

Currently, there are six health boards in Scotland which are coterminous with a single local authority area, so it would be relatively easy to pilot this kind of localist solution. 

Scotland is a diverse country and, as a result, we need to have a health service that can address our differences, rather than a one-size-fits-all approach set out by Holyrood. In addressing the health and wellbeing needs of Scotland for the long-term, greater flexibility for local decision-making will yield major improvements and much needed local discretion to address distinct local need.

Alison Payne is Research Director of the independent, non-party think tank, Reform Scotland

 

By Alison Payne

Issue 7: Nov 2013

Issue 7: Nov 2013

HEALTH, WELL BEING AND AGEING: SCOTLAND 2020

Re-energising the move towards integrated care

Scotland's move to integrated care can learn from elsewhere by focussing on two key differentiators between successful partnerships and those paying lip service to integrated working: Shared outcomes and common language is one, the other is demonstrating mutual investments and mutual benefits.

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