Lesley Riddoch: Unhealthy to think big is beautiful

Direct elections to health boards aren’t the cure for our medical service problems, says Lesley Riddoch, they are a symptom

Alex Neil, now health secretary, cheers Monklands Hospitals A&E reprieve with campaigners. Picture: Neil Hanna

Direct elections to health boards won’t be rolled out across Scotland because pilot polls in Fife and Dumfries attracted turnouts of only 10 and 20 per cent respectively. Instead health boards will be exhorted to recruit more widely.

The story was hardly reported last week even though Scotland retains the unenviable position of the Sick Man (and Woman) of Europe and spends £10.9 billion per annum through its 14 territorial and nine special health boards – a third of all public spending.

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So did the ultra-low turnout demonstrate we have “too much democracy” as panellists on a Radio Scotland weekend political programme suggested? Does the public really not care about health – despite its top position in most public surveys – or think health managers are doing a good job without well-meaning amateurs? Or does the enormous population size of each health board make efforts at democracy well nigh impossible?

Scotland has 14 territorial health boards with an average population of 380,000 apiece. How on earth could the best qualified, hardest-working health activist hope to be known in such a massive constituency? Take a look at Fife – the least responsive pilot area and my own stamping ground. This “local” health board serves a population of 363,585. That’s larger than the population of Iceland.

Within this “locality” there are three “Community” Health Partnerships (CHPs) – Dunfermline & West Fife (population 139,407); Kirkcaldy & Levenmouth (population 96,894) and Glenrothes & North-East Fife (population covered 127,284). These “community” units are enormous – closer to strategic planning authorities not the intimate, delivery-oriented, community-sized tier of governance that exists in most normal European democracies.

Scotland’s Health Board elections began in 2010 and ran for two years before an independent evaluation found candidates showed similar characteristics to those already appointed. It seems that disappointing homogeneity – combined with low turnout – was the tin lid. And that’s blatantly unfair.

If elections were scrapped each time only “usual suspects” came forward, there would be gey little voting in Scotland at all. If widening board membership was the objective, elections were never going to provide a solution. Not in a country with as weak a democratic performance as Scotland.

Every way you measure it, Scotland is doing badly. In Norway, with genuinely community-sized, tax-raising municipalities of around 14,000 people, election turnouts range from 70-82 per cent and one in 80 Norwegians stands for election. In Scotland, community councils have a tiny average annual budget of £400 and no statutory clout and services are provided instead by large council bureaucracies for an average 162,000 people. These “local” councils receive most of their cash from central government. Turnout in the 2012 elections was 38 per cent and one in 2,071 Scots stood for election.

It is a no-brainer.

The bigger, more remote and more centrally funded the “local” council, health board or quango, the less the public participate in its governance and the lower the election turnout.

Apathy? Not a bit of it. Wrong-sized governance is to blame.

So why were direct elections ever suggested? In 2008 the then health secretary Nicola Sturgeon said her proposal was “massively popular”. Perhaps the rammy over Monklands Hospital played a disproportionate and distorting part in that judgment. SNP won the seat from Labour – and the 2007 election – after a canny political decision to pledge the local accident and emergency facility would stay open.

Labour’s Lewis Macdonald had backed NHS Lanarkshire’s decision to close the unit a year earlier saying: “The health service needs to look after people on a continuing and preventative basis, rather than through isolated episodes of acute emergency inpatient care.” He was absolutely right.

But in a country with some of the worst health outcomes in the developed world, the proximity of top-notch, hospital-based emergency care is still regarded by the public as the very acme of health provision.

Suspecting they had tapped into a potent source of public disaffection, the SNP promised more input into health board planning – hence perhaps the direct-elections idea. But without threats to the very existence of their local hospital, public motivation to get involved in the day-to-day running of the cumbersome health service would always be very low.

It’s become a Catch 22 situation which cannot be untangled by direct elections alone.

Until health managers and politicians shift status and resources to the preventative (and non-health related) areas of spending that create genuine well-being, they can hardly be surprised if the passive, pill-popping public reflect back their own hospital-based spending priorities.

Professionals could already be heading off ill health at the pass with truly community-based services, early intervention and better food, housing and heating. The Christie Commission suggested it. Common sense demands it. But despite “local” Health and Social Care Partnerships to force joint planning between social work and health boards – it isn’t happening. So why bother to waste precious time telling professionals what they don’t want to hear?

I’d make only three pleas. First, NHS managers should catch up with the rest of humanity and allow the use of e-mails and even texts to make appointments, discuss medication and record symptoms.

Second, nurses and doctors should challenge patients on their diet at every available opportunity. In Norway, diet and exercise changes are offered by clinicians before any medication is handed out. In Scotland such “lifestyle” solutions are rarely discussed – even though diet contributes massively to the rise in diabetes, high blood pressure, obesity and joint problems – for fear of “upsetting the patient.”

Upset is desperately needed.

Third, senior health professionals agree more cash should go towards prevention and helping people live with arthritis, lung diseases, chronic back pain, asthma, diabetes, cancer, heart disease and mental health problems. But highly effective voluntary organisations working in all these sectors have had their budgets cut. Which politician has the courage to remove £800 million from hospital budgets to make low key, local health care investments which may not visibly yield dividends for a decade?

Hospitals are tangible. Services that help diabetics stay out of hospital are not.

If the Scottish Government thought thrawn, outspoken members of the public would come to the rescue and demand long-term, ultra-local spending from professionals – they were wrong.

In Scotland the only currency is the short-term fix and the large institutional spend. Live by the sword, die by the sword. And sadly, back to square one for Alex Neil.