Local authority scrutiny of health: making the views of the community count?

Abstract

Objective  To look at the preparations being made for the introduction of scrutiny of local health services by social service local authorities.

Design  A baseline postal survey carried out in late 2002 of all social service local authorities in England.

Setting  Against a backdrop of changing structures and policy, both within local government and the National Health Service (NHS) in England and before the official introduction of health scrutiny in January 2003. Survey from the local authority perspective.

Results  Progress is being made in the implementation of this new policy, and many local authorities have already carried out pilot scrutiny exercises of local health provision. The survey highlights the different approaches authorities are taking to initiate implementation of health scrutiny and the importance of support, in terms of resources, guidance and training, for overview and scrutiny to be successful.

Discussion and Conclusions  Further evaluation of the implementation of health scrutiny is required to examine the impact on local governance of the NHS and partnership working.

Democracy and the NHS

Concerns about the levels of influence that patients and citizens have over decision‐making in the English National Health Service (NHS) are not new. In the 1940s, before it was established, it was envisaged that governance of the new health service would be through joint boards of existing local government authorities. ¹ However, for its first 30 years, the NHS was fragmented into three distinct organizational clusters: hospitals, general practitioner (GP) services and local authority health services. Only the latter were subject to local democratic influences, while hospital and community health services were characterized by direct lines of hierarchical accountability to, and control by, central government. ¹ , ² Meanwhile, until the late 1990s, all of the GPs’ contracts were also negotiated with central government and managed by local committees that were also directly accountable to central government. ³

The transfer of community health services from local authorities to area health authorities in 1974 further weakened local democratic involvement in healthcare. Subsequently, the 1990 NHS and Community Care Act created new health authorities and all residual local authority representation on local NHS bodies was abolished. According to Hudson ⁴ a prominent and respected role for locally elected bodies in the governance of local health‐care was completely eradicated. Much has subsequently been written about the ‘democratic deficit’ in the NHS ⁵ , ⁶ but, despite initiatives such as the introduction of community health councils (CHCs) in 1974 and the ‘Local Voices’ initiative in 1992, ⁷ the views of the public have remained largely secondary to those of health professionals and, more recently, NHS managers.

Since 1974, CHCs have been the main official channels for public concerns about their local health service. However, CHC responsibilities were multiple and potentially conflicting – for example, they were expected to represent patients’ interests whilst at the same time advising on spending priorities. Moreover, CHCs were expected to be independent monitors and critics of local health services, despite being funded by regional offices of the NHS. There were also alleged variations in the ways CHCs operated and in their effectiveness, with some having huge workloads and most complaining of being marginalized in NHS decision‐making. CHCs were also criticized as being dominated by white middle class, middle‐aged people who were out of touch with, and unknown by, the local community. ⁸ The ‘Local Voices’ initiative was also unsuccessful in enabling active public participation in decision‐making and was mainly used for consultation on one‐off occasions. ⁹

Since 1997, the policy emphasis on patient and public involvement in the English NHS has increased. For example, primary care groups (PCGs) and trusts (PCTs) are required to develop mechanisms for early, systematic and continuous user and public involvement. ¹⁰ Since April 2002, PCTs have been expected to take the lead strategic role in local health economies, responsible for purchasing specialist health services; providing and managing primary health services; and improving the health of the local population. ¹¹ The new arrangements for local authority scrutiny of primary care ¹² that are the focus of this paper are intended in part to create a new means of making PCTs publicly accountable and user‐responsive.

Scrutiny is one of a number of recently introduced mechanisms to increase patient involvement in the NHS and to provide advocacy and advice services to replace CHCs following their abolition in 2003. ¹³ Four new measures have been introduced (Fig. 1). First, the new Commission for Public and Patient Involvement in Health (CPPIH) will have outreach workers in each PCT area, who will also liase with the local authority. The CPPIH will aggregate and disseminate information on the system of patient and public involvement and highlight trends and concerns from the patient's perspective. CPPIH is also responsible for setting up the 571 patient and public involvement forums (PPI forums), one in every NHS trust and PCT, as independent advisory bodies. These will monitor and review services; inform management decision‐making in the trust; and link to wider local planning forums such as Local Strategic Partnerships (LSPs) and Health Improvement Modernization Plans. The agenda for PPI forums will be set locally and they will also monitor the quality and effectiveness of the third development – the Patients’ Advice and Liaison Services (PALS) that have recently been established in every NHS trust and PCT. PALS are intended to guide people through the health system, resolve problems at the earliest possible stage and act as an early warning system in monitoring problems and gaps in services and staff training. Finally, overview and scrutiny committees (OSCs) within local authorities, consisting of democratically elected councillors, now have a remit to scrutinize local health services, as well as those services that are the responsibility of the local authority.

Figure 1.

New Initiatives to enhance public involvement in the NHS (adapted from Ref. 13).

Local government modernization

Since 1999, the role of local government has also been transformed, with local authorities being assigned a clear role of ‘community leadership’ and a new responsibility to promote the well‐being of the local population. The 1998 White Paper ¹⁴ stated that:

Community leadership is at the heart of the role of modern local government. Councils are the organisations best placed to take a comprehensive overview of the needs and priorities of their local areas and communities and lead the work to meet those needs and priorities.

The reform of local government has a number of dimensions. One of these, which has been given particular prominence by central government, is democratic renewal. Democratic renewal has three broad themes: developing electoral arrangements; modernizing the way in which councils work; and involving local communities. ¹⁵

Modernizing the way in which councils work includes both the internal restructuring of local authority political leadership through the establishment of separate executive and overview and scrutiny (OSC) committees; and enhancing local authorities’ involvement in wider activities such as health improvement, reducing health inequalities and promoting the well‐being of communities. The Centre for Public Scrutiny ¹⁶ suggests that overview and scrutiny is the most challenging part of the modernization agenda and a key element for delivering effective services within the public sector as a whole. Scrutiny involves overseeing the development and review of key local policies and strategies, both internal and external to the council, and their effectiveness. For the elected councillors who are members of the new scrutiny committees, this is a significant new role. There is however, still some confusion over what scrutiny actually is: it can include holding the Executive to account; reviewing policies and their implementation; link into Best Value reviews and scrutinize of external activities and agencies that impact on the well‐being of the local population. ¹⁷ Individual local authorities apparently place different emphasis on each of these roles, so that progress across the functions varies from one authority to the next. ¹⁸ Most progress has so far tended to be in policy development and review, while the most problematic role is that of holding the local authority executive to account.

According to Bradshaw and Walshe, ¹⁹ reviews carried out to date by local authority OSCs on their own services have varied widely in effectiveness and approach. These variations reflect differences in the resources allocated to OSCs and in the levels of councillor involvement. The government appears keen for OSCs to develop a strong outward focus, examining and investigating the work and impact of outside bodies on the communities that the council serves and encouraging input from local partner organizations and the public. ²⁰ Although the scrutiny process will differ according to the topic under scrutiny, the Centre for Public Scrutiny ¹⁶ argues that effective scrutiny, internal or external, will depend on three factors: independence, access to information, and appropriate support and training.

Health scrutiny

From 1 January 2003, local authorities have been required to scrutinize the provision of local health services, thus giving added power to their responsibilities for promoting local community well‐being (Local Government Act 2000). Health scrutiny has been introduced in a context of policy, structural and organizational change in both the NHS and local government and as a result the legislation pertaining to it is widely dispersed. Key elements include the restructuring of local authorities and their new responsibilities for promoting the well‐being of local communities (Local Government Act 2000); powers for local authorities to exercise scrutiny over health services provided by NHS bodies in the area (Health and Social Care Act 2001); and the creation of patient and public involvement forums and CPPIH (NHS Reform and Health Care Professionals Act 2002). This latter legislation also abolishes CHCs from September 2003.

The introduction of health scrutiny introduces a major new role for elected local councillors within the English health‐care system. The legislation describes health scrutiny as:

Reviewing and scrutinizing health service matters and making reports and recommendations to NHS bodies on such matters (Health and Social Care Act 2001).

Detailed guidance from the Department of Health ¹² describes the purpose of health scrutiny as:

Acting as a lever to improve the health of local people…and securing the continuous improvement of health services and service that impact on health.

The lead responsibility for carrying out health scrutiny lies with local councils that are responsible for social services (county councils, metropolitan and London boroughs and unitary authorities). In line with local authorities’ new responsibilities for promoting well‐being of their communities, the activity of health scrutiny is likely to be vast and include local inequalities in health, health promotion and the prevention of illness, as well as the roles and activities of statutory bodies in planning, commissioning and providing services, and supporting activities of community and voluntary sector organizations. Many of the core functions of local authorities (e.g. housing, transport, leisure, regeneration and environment) can influence the physical and or mental health of local communities. According to the Department of Health guidance, ²¹

Any scrutiny exercise is likely to include reviewing the local authority's contribution to the health of local people and the provision of health services.

Scrutiny also offers a unique opportunity to take a thematic, cross‐cutting inter‐sectoral perspective on health and health‐related services, such as mental health, older people or children's services. Chief Executives of local NHS organizations are required to attend OSCs to answer questions at least twice a year, if requested. Local NHS organizations include strategic health authorities, primary care trusts, NHS trusts, teaching PCTs and, in the future, foundation hospitals, all of which are organizations that provide, arrange or manage the provision of services to people living in the local authority area. ²¹ Chief Executives may also be required to attend OSCs when the latter take over the responsibility from CHCs for examining major reconfigurations of local health services.

Many factors could affect the local implementation and the impact of health scrutiny. These include local political factors; conflicts between national policies and local priorities; the strength of strategic and operational partnership arrangements between local authority and local NHS services; and the existing respective accountability arrangements of each sector to local people and central government.

Research into preparations for health scrutiny

An exploratory, qualitative study commissioned by Office of the Deputy Prime Minister (ODPM, the central government department responsible for local government) ¹⁸ into the development of overview and scrutiny functions suggests that, although many local authorities are still concentrating primarily on the review of their own functions and responsibilities, their experience in undertaking scrutiny of external organizations and functions is nevertheless developing rapidly. Moreover, elected local councillors are beginning to identify the benefits of linkages between their overview and scrutiny activities and their wider partnership and community leadership responsibilities, although the study also warns of the risk that external scrutiny might worsen the local authority's relationships with its relevant external partner(s).

Also in 2002, The Democratic Health Network produced a ‘Toolkit’ for local authorities carrying out health scrutiny. ²² This recommends that health scrutiny committees should be flexible enough to address cross‐cutting issues that impact on other policy areas. Local councils are not required to establish stand‐alone health scrutiny committees; indeed, the Toolkit suggests that the defining characteristic of arrangements so far is diversity. For example, although unitary and higher‐tier local authorities (in areas with two‐tier local government) have statutory responsibility for health scrutiny, in the latter areas district councils responsible for housing, environment and leisure activities will also need to be involved. Flexibility will also be required to scrutinize health services that cover more than one local authority, such as ambulance services and regional specialist hospitals. However, the Toolkit warned that problems could arise because no additional resources have been allocated by central government to support the implementation of scrutiny activities.

Although health scrutiny only became a responsibility of local authority OSCs on 1 January 2003, following the implementation of the health scrutiny power in the Health and Social Care Act 2001, many local authorities had already begun to set up new structures and carry out pilot health scrutiny exercises. A survey was conducted by the Democratic Health Network in late 2000 of all the 409 local authorities in England and Wales. ²³ The survey asked whether and how local authorities were incorporating health issues into their preparations for setting up their new OSCs. Only 36% of local authorities responded, so the results may over‐represent those that had started the implementation process early. Although scrutiny was not at that time a statutory requirement, some authorities had already begun to set up scrutiny committees. Even at that early stage, 60% of respondents included health issues in their existing scrutiny/policy review arrangements.

Another survey examined preparations for health scrutiny from an NHS perspective. In early 2002, as part of a national longitudinal survey of 15% of English Primary Care Groups and Trusts, ²⁴ PCT Board chairs were asked about their involvement in preparations for local authority scrutiny. The results of this survey also showed that discussions between PCTs and their corresponding local authorities were already under way for almost all of the PCTs. PCT Board chairs anticipated that the local authority scrutiny function would be important in developing closer working between NHS organizations and their respective local authorities and in increasing local authority understanding of the NHS. Most thought that local authority scrutiny would be a positive complement to the work of the PCT itself, so long as it was conducted in a non‐confrontational manner.

National survey of local authority preparations for health scrutiny

A postal survey of all social service authorities in England (i.e. those with lead responsibility for health scrutiny) was conducted in late 2002. The survey aimed to:

• • Provide an overview of the progress made by lead local authorities in implementing their new scrutiny role and their plans for extending this to scrutiny of health;
• • Identify emerging problems and issues that required more detailed subsequent investigation.

Local authority scrutiny of NHS activity is of course likely to include both primary and secondary health‐care services. However, the survey focused on the scrutiny of PCTs, because of their major roles in commissioning and providing local health services, improving local health and, increasingly, their strategic and operational links with local authorities.

The postal questionnaire was sent to local authority chief executives, with a request to forward it to the senior officer responsible for establishing and servicing the appropriate scrutiny committee. This proved problematic, as a large proportion of the mailed questionnaires did not appear to reach their intended destinations. Non‐respondents were therefore contacted by telephone after 3 weeks and an 86% (n = 128) response rate was eventually achieved. It is possible that respondents may have been biased towards those having made most progress in health scrutiny implementation as, when contacted following the closing date, non‐respondents typically stated that they either did not have time to participate in the survey or had very little information to contribute.

Preparations for health scrutiny

In 90% of local authorities responding to the survey, health was included within the brief of one of their overview and scrutiny committees (OSCs). This was most commonly (33%) the OSC that also had responsibility for scrutiny of social services. Despite not being required to establish special or stand‐alone health OSCs, a quarter (25%) of the respondents, who had considered how they would carry out health scrutiny, had taken the option of developing a separate OSC for this purpose. A further 18% included health within the remit of an OSC with responsibilities for another service such as housing or education (Fig. 2).

Figure 2.

Within which overview and scrutiny committee is health included? (n = 114). *Other most commonly referred to the overarching scrutiny board, overall policy/overall commission or a combination of more than one of the stated category choices.

By the time of the survey, 84% of local authorities said that they had had discussions with all the PCTs that covered their area about the new scrutiny function and a further 7% had had discussions with at least some of the PCTs in the area.

Health scrutiny undertaken

Almost half (45%) the local authorities stated that they had already carried out some scrutiny of their local health services or health organizations. Among those that had already conducted some health scrutiny, the most frequently mentioned topics were local NHS trusts, acute trusts or hospitals (29%); a local PCT or former health authority (24%); delayed discharge from hospitals (18%); and reconfiguration of services, including the closure of facilities or location of new premises (18%). In addition, many local authorities had carried out health‐related thematic reviews. These included topics such as winter pressures, intermediate care, health inequalities, mental health services, children's services and older people's services. These thematic reviews were reported by 60% of respondents who had already carried out some health scrutiny.

Plans for health scrutiny in the next year

Over four‐fifths (84%) of the authorities planned during the next 12 months to carry out scrutiny of health services or organizations in their area, although 56% of these were still unable to specify what the topics would be. One in seven (16%) were intending to look at local PCTs and one in eight (12%) at other local NHS trusts. Twenty‐three per cent planned to carry out thematic reviews (e.g. reviews of mental health, children's services, winter pressures or older people's services) in the next 12 months.

Resources for health scrutiny

Effective scrutiny needs resources; these include officer support and material resources for training, consultations, meetings, research and publicity. Over a third (34%) of responding authorities stressed the importance of adequately resourcing health scrutiny. Respondents were asked about the adequacy of support for health scrutiny currently within their authority (e.g. in relation to finance, officer support and clear guidance). Over two‐fifths (44%) rated the overall support currently available as inadequate or very inadequate (Fig. 3).

Figure 3.

Levels of support for scrutiny (% of respondents).

Training in preparation for health scrutiny, for both councillors and officers, was reported to have been undertaken in 53% of local authorities. However, in 30% of local authorities, neither group had received training and in 46% training for officers – the very people who will support both the process and the elected councillors – had not taken place (Fig. 4).

Figure 4.

Training undertaken for health scrutiny (n = 128).

For two‐thirds of the authorities that reported having conducted some form of health scrutiny training for councillors and/or officers, this consisted of internal presentations or seminars. A quarter had sent representatives to seminars run by national organizations such as the Local Government Association and 19% had organized workshops locally. One in seven (14%) stated that training for health scrutiny was included in the more general OSC training within their authority. Presentations and workshops were often of a general nature, presenting information about health scrutiny and/or the local health economy and included presentations from local health organizations such as PCTs, CHCs and NHS trusts.

Two‐tier/unitary authorities

Three‐quarters (76%) of the authorities responding to the questionnaire were unitary, with the remaining quarter (24%) being two‐tier. Two‐tier authorities were asked what steps were being taken to involve district councils, where appropriate, in the health scrutiny process. Of these, 53% said that they had had already held initial discussions or invited district councils to be involved in their health scrutiny activities; 37% said that their health scrutiny committee included district council representatives; and 20% said they intended to co‐opt district council members onto committees carrying out health scrutiny when appropriate. Only two authorities were considering actually delegating some powers from the upper to the lower, more local level of district councils.

Discussion and conclusions

Developing effective overview and scrutiny arrangements is one of the most challenging tasks facing modern local authorities – nowhere more so than in respect of their scrutiny of local health and NHS provision. This is perhaps not surprising, as the new scrutiny arrangements replace a committee system that has structured decision‐making in local government for over 100 years. New systems involve unfamiliar ways of working and, according to Snape and Taylor, ²⁰ there is an inevitable tendency to revert to traditional, well‐known practices until any new system is proven. However, the scrutiny process potentially involves a wide range of investigative, consultative and deliberative processes. It therefore has the potential to make major contributions both to the democratic accountability of local NHS organizations and to the integration of NHS activities with wider, inter‐sectoral strategies to reduce health inequalities and promote well‐being.

Our survey showed that many local authorities were beginning to implement health scrutiny, even before it had become a statutory requirement; and were taking a generally positive attitude to the process. With the historical background of the gradual withdrawal of local authority influence and involvement in the planning and provision of health services, and with considerable subsequent organizational change, extensive education and training will be required in order that local authority councillors and officers can make the most of these opportunities. Similarly, officers and members of PCT boards and other NHS trusts are likely to be unfamiliar with the new structures and roles of local government, so appropriate information and education will be required for them as well. In particular, professionals, managers and non‐executive members of NHS organizations are likely to require reassurance that overview and scrutiny committees are not intended to manage the performance of NHS services, but instead can add new community and local perspectives through the active participation of elected councillors. According to our survey, these training and education needs have been widely recognized, although actions to meet them are still far from extensive and substantial concerns were expressed about the resources likely to be available for these essential preparatory functions. Indeed, no additional funds have been provided for local authorities to carry out their new health scrutiny roles. Limited resources will seriously impair the effectiveness of health scrutiny. ²⁵

Necessary resources include support from well‐informed officers, time, training and research capacity. Publicity and communication will also be important in following up the results and recommendations of health scrutiny, and communicating these to the wider community – indeed, the latter is essential if health scrutiny is indeed going to increase local democratic accountability and involvement. All these resources will be essential, too, for local authorities to meet their new statutory duty to promote the well‐being of their communities through the scrutiny process.

NHS organizations, particularly PCTs, with their extensive budgetary and local planning responsibilities, could make a major contribution to the implementation of health scrutiny. Offers of information, expert advice and staff support could complement the resources available from local authorities. Collaboration in developing a joint scrutiny programme could also encourage more effective partnership working; develop trust between sectors, organizations and key individuals; and ensure that NHS organizations are not overburdened by requests from OSCs. At the same time, however, OSCs will need to retain their independence, otherwise the aims and outcomes of health scrutiny risk being undermined.

The new scrutiny arrangements also face a number of threats. Scrutiny committees will need to be prepared to monitor and, if necessary, to challenge the decisions made by external bodies such as PCTs and other NHS organizations. Party political loyalties may exert a strong influence over scrutiny activities. This is a particular risk when NHS policies are also heavily shaped by national political agendas, so that scrutiny may become either wholly uncritical or wholly oppositional, depending on the alignment of local and national political parties. Some of these threats can be avoided, or at least reduced, if the process of health scrutiny focuses on local health strategies and monitors the progress made towards these strategic objectives, rather than on specific organizational configurations. The location of health scrutiny within the remit of OSCs that have closely related responsibilities for issues such as social services, and the thematic reviews of local health issues reported by the respondents to our survey both exemplify this approach.

In two‐tier authorities, district councils are likely to have a particularly close involvement with the concerns of local communities and are also responsible for a number of services that have a crucial impact on local well‐being. However, statutory responsibility for health scrutiny lies with the county authorities. It was clear from our survey that the need for close liaison between the two tiers had been recognized and a range of mechanisms, such as co‐option and delegation, to facilitate collaboration between the two were reported. Similar collaborative arrangements will be required for the effective scrutiny of regional NHS activities that extend beyond single local authority boundaries. Clarity will also be required in relating health scrutiny to wider local partnership activities (particularly the new, overarching local strategic partnerships) and to the other mechanisms that have been introduced to enhance user and patient involvement in the NHS. Clear protocols may need to be developed to guide the respective roles and activities of district councils, regional bodies and wider inter‐sectoral partnerships; these could also include agreements to pool the scarce resources needed to support effective health scrutiny.

According to Ashworth, ²⁶ legislation for the role of OSCs is far from prescriptive and leaves the details to individual authorities. As a result she states that ‘there is likely to be considerable variation in systems and roles of scrutiny committees adopted by local councils’. This will have an impact on the development of OSCs with responsibility for scrutinizing health. In addition health scrutiny, along with the other mechanisms to enhance public and patient involvement in the NHS outlined earlier in this paper, has been justified as an improvement on the variable quality of the former CHCs. However, the survey showed considerable variation in the pace of implementing health scrutiny and in the structures being established to carry out this new local authority function. These variations may reflect local circumstances, but there is nevertheless a risk that they may also come to reflect differences in performance and effectiveness similar to those alleged to characterize the old CHCs. Moreover, CHCs were to be abolished on 1 September 2003, ²⁷ before the new patient and public involvement forums become fully active. However, in a ministerial statement (June 2003), ²⁸ this date has been put back to 1 December 2003 giving a few months extra time for overlap, but if health scrutiny is still not fully effective at this point, a gap in arrangements for representing the interests of patients may still occur. ²⁹

As CHCs are abolished, local authorities and the new public and patient involvement bodies will need to sustain local lay knowledge and expertise in health issues and services. Recruiting CHC members onto the new PPI forums, co‐opting them as expert witnesses/advisors to ‘health’ OSCs and involving them in training the new ‘health’ OSC members will also help to sustain local expertise. However, in using these local resources, the ‘highly variable’ performance of the former CHCs will need to be kept in mind. Moreover, co‐opting and drawing on ‘expert witnesses’ may risk compromising the aim of increasing local democratic accountability through the new OSCs.

Above all, challenges will arise in ensuring that health scrutiny actually provides new opportunities for community involvement and democratic accountability. Local authority councillors may have been elected by a majority of local voters, but these voters will not necessarily include ‘hard to reach’ groups such as ethnic minorities, the homeless, young people and refugees, who may have a diverse range of health problems and require specific, targeted service interventions. Additional consultation mechanisms, such as local authority citizen panels, ³⁰ could be employed to enhance community participation in health scrutiny. Joint panels that operate across local authorities, health providers and the police make much sense as costs and results of consultation can be shared, thus avoiding duplication of effort, encouraging a more representative view (larger panels) and encouraging joined‐up policy. The local media can be utilized to advertize forthcoming scrutiny investigations and publicize their outcomes to the whole community.

Finally, it will be important for local authorities and their associated NHS organizations to learn from each other so that the successes can be repeated and failures avoided, as overview and scrutiny (of both internal local authority functions and external organizations like the NHS) develops. Further research will be needed to define and identify good practice that can deliver positive outcomes for local democratic accountability, minimize damage to other local collaborations and partnerships; and add value to other initiatives intended to increase the public accountability and responsiveness of the NHS.