Why do we call it the National Health Service? We don't refer to the National Education Service, yet primary and secondary education is free and people can opt to go private. Parents can choose a local school within their catchment area. The budget for schools is protected since it is passported direct to the individual school so it cannot be siphoned off or redirected elsewhere by local authorities. Schools come under local government, so locally elected politicians are accountable for their performance. Contrast this with the NHS. Primary care trusts (PCTs) now hold the budget for health services locally. They are responsible for commissioning local health services for acute hospitals and for primary care services, such as GPs, community nurses, occupational therapists, physiotherapists, dentists and allied professionals. PCTs are not democratically accountable to local people. Each PCT has a management board made up of senior managers from the PCT and non executives; people selected by the Government from industry, finance and commerce to bring to the board their expertise. They are not representative of local people and are not on the board to represent local people. The chair of the board and the chief executive are ultimately accountable to the Government's minister for health. How can PCTs be more democratically accountable at a local level? Local authority-elected councillors could be given seats on the board to represent local people. Some board members could be directly elected or PCTs could come under local government like schools. Does it matter that PCTs are not democratically accountable? Well it does if you don't agree with the closure of your local community hospital. It does if you are concerned about the lack of NHS dentists or the opening times of GPs surgeries or even waiting lists at your local hospital. It does matter if you are a carer and think there is not enough support for people who care for children, adults or older people with severe or multiple disabilities. What would be the advantages and disadvantages of PCTs becoming the responsibility of local governments? The main advantage would be local, democratic accountability for a range of health services. But it would also bring the health and social care responsibilities together under one, locally responsive structure, which would reduce duplication and improve co-ordination of services for children with disabilities, mental health and learning disability services, and services to frail or older people suffering from dementia. Local authorities have a good track record of managing cash-limited budgets, and are familiar, if not entirely comfortable, with the concept of rationing scarce services through eligibility criteria. The whole health-equality agenda would be easier to co-ordinate. At present, directors of public health have the lead responsibility for this, but most of the services that impact on health fall outside the NHS, and fit more comfortably within the remit for local government, for example housing, leisure, education, employment, regeneration and community safety. The disadvantage would be another major reorganisation of PCTs, when what is needed is astability and the opportunity to make arrangements work. This could be said about much of the Government's agenda for transforming the NHS. Blair McPherson is director of community services at Lancashire CC
