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Health Boards (Membership and Elections) (Scotland) Bill
The UNISON Scotland response to the Health Committee regarding
the Health Boards (Membership and Elections) (Scotland) Bill
November 2008
Evidence to Scottish Parliament Health Committee
Introduction
UNISON Scotland welcomes the opportunity to submit
a response to the Health Committee regarding the Health Boards
(Membership and Elections) (Scotland) Bill. We are Scotland’s
largest public sector trade union representing over 160,000 members,
more than 50,000 of whom work in health related services. UNISON
supports moves to make all public service organisations more open,
transparent and democratically accountable. UNISON Scotland believes
that this Bill is an important contribution towards achieving
this objective for health boards in Scotland.
Background
The main purposes of the Bill are to:
- alter the composition of health boards to include directly
elected members and provide a statutory basis for the presence
of local councillors as health board members;
- make provision for the holding of elections to health boards;
and
- provide that these provisions are to come into force on
a pilot basis.
This Bill follows a similar Members Bill proposed
by Bill Butler MSP in 2006/7 that UNISON Scotland also supported.
Principles
UNISON Scotland supports the general principles
of the Bill. We believe that all public service organisations
should be open, transparent and democratically accountable and
should encourage active participation from users, the community,
staff and their trade unions. The increasing use of unelected
bodies to run public services hinders this process.
Democratic structures create public bodies which
are open and transparent in their dealing with the public. Scottish
health board expenditure is over £8 billion and local democratic
accountability is essential for expenditure of this level. Government
at all levels must explain and accept responsibility for its actions.
Democracy requires that there is adequate opportunity
for the public to participate in and influence the policy making
process. This is more than being asked to comment on plans drawn
up in private. It is also about defining the desired outcomes
and the methods to achieve them. This proposal improves accountability
by: allowing individuals to become board members; promoting debate
about health care in local communities via the election process
and makes boards directly accountable to the people they serve.
The Bill will support changes like the Freedom of
Information (Scotland) Act 2002 and the requirement of the NHS
Reform (Scotland) Act 2004 to involve service users. UNISON believes
that the Bill will assist in changing the culture of health boards
in Scotland from one of ‘we know best’ to one of openness and
consultation.
High profile campaigns in recent years about hospital
closures and availability of treatments on the NHS in Scotland
demonstrate clearly that members of the public not only want to
be part of the process of planning health care in their areas,
but that they are willing to give up their time to do so.
UNISON Scotland also believes that this Bill has
the benefit of greater democratic accountability while still retaining
NHS expertise. It offers the prospect of developing genuine local
partnerships with greater understanding of the complex issues
facing the NHS in Scotland among the public. This is about decentralising
power to local areas and also about allowing democratic control
through the ballot box at all appropriate levels. We would therefore
support the principle of direct elections to health boards.
Specific issues raised by the Health Committee
on the principles of the Bill.
What the practical benefits of having elected
members on health boards would be.
The practical benefits of having elected members
accountable to the public would primarily be to change the culture
of public engagement within health boards. Direct accountability
gives a real and meaningful accountability that appointed board
members can never have. The mix of both types of appointment also
ensures that we get the best of both worlds, retaining staff and
specialist expertise.
Whether those benefits would outweigh the costs
arising from running such elections and supporting elected members
Democracy costs. If we followed this argument to
its logical conclusion we would have no parliament and appointed
governors to run local administrative areas. Given the scale of
health board expenditure (£7bn) the cost of democracy is modest.
What the risks are of having elected members
on health boards
It has been argued that it will lead to parochialism,
paralysis in decision making and that health issues are too complex
for lay persons to understand. Whole board elections address the
first of these arguments and there is no evidence from other democratically
elected bodies that they are unable to reach decisions. Democratically
elected bodies may engage better with the public and put more
effort into explaining the reasons for change, but they are still
capable of making difficult decisions. The last argument reflects
the ‘we know best’ culture that is still prevalent amongst the
health establishment. Elected members can and do reach decisions
on complex matters at all levels of government after proper consultation
and professional advice.
Whether elected members' scope for action will
be affected by health boards' continuing accountability to Ministers
Almost all other democratically elected bodies have
accountability elsewhere in one form or another. Legislation lays
down standards for local authorities and Scottish Ministers have
the power of direction under legislation. They also have indirect
methods of direction through administrative action, budget and
guidance.
However, local democracy may on occasion raise issues
of conflict between national and local priorities or policy direction.
That tension can be a positive driver for change. One persons
‘postcode lottery’ can be another’s ‘local priority’. Scotland
is not a homogenous nation and it is unrealistic for NHS Scotland
to operate as a national monolith where the centre always knows
best.
Whether alternatives to direct election exist
as a means to increasing public involvement in the NHS
UNISON Scotland does not view direct elections as
a panacea to improving engagement with users of health services.
As stated above we see local democracy as compatible with other
changes to improve health board performance in this field introduced
by successive Scottish Governments. Direct electoral accountability
is one very important element of democracy, but it is not enough
on its own. Participative engagement at all levels is also essential
if we are to develop public services that are more accountable
to the people they exist to serve.
Specific issues raised by the Health Committee
on the mechanisms to introduce direct elections.
The composition of heath boards as set out in
the Bill
UNISON welcomes the provision that puts local authority
members on a statutory basis. However, we do not believe that
they should count towards the simple majority of elected members
on a health board in s1(2) of the Bill.
The appointment of councillors to health boards
was primarily done to recognise the key role local authorities
have in promoting better health and the importance of joined up
services through initiatives like Joint Future. Most councillors
on health boards therefore see their primary role as representing
their council, not as some form of directly elected member. We
do not believe that councillors should have a monopoly on local
democracy and the NHS is large enough to warrant its own dedicated
democratic structures.
It is also unclear from the Bill what the role of
senior officials is under the new board constitution. UNISON has
always taken the view that officials should be advisors, not voting
members, of the health boards they are employed by.
UNISON supports the retention of some appointed
members and the current arrangements for staff representation
through the Partnership Forum.
The arrangements for elections as set out in
the Bill including the franchise, voting system and designation
of each health board area as a single ward
The Bill essentially provides for the detailed management
of elections to be developed through secondary legislation. We
agree that this is a practical approach. UNISON has no strong
views on the method of election we broadly support:
- Whole board election with the possible exception of large
rural health boards.
- We agree that it is sensible to use an existing voting system
rather than further confuse the electorate with a new system.
We have no strong preference although we have previously supported
STV for local authorities.
- UNISON strongly supports extending the vote to those aged
16 and over. Young people in Scotland can marry at the age
of 16, be called up to the armed forces, and pay tax and National
Insurance. We believe that age discrimination is not only
patronising, but also serves to alienate young people from
society and the electoral process.
- UNISON Scotland believes that as few people as possible
should be restricted from serving on the health boards and
that proper consideration is given to other ways to prevent
conflicts of interest
The arrangements for piloting direct election
as set out in the Bill
UNISON does not believe that pilots are necessary.
However, we recognise that this approach holds the best prospect
of achieving parliamentary support and dealing with the concerns
of some organisations over the principle of direct elections.
We note that the Bill requires an evaluation no
later than five years after the first election. We would favour
an earlier evaluation before the end of the first term elections
in the pilot boards. We believe the pilot board areas should include
an urban board, a rural board and one that has elements of both.
The practical implications and cost of bringing
the Bill's provisions into force
We see no practical difficulties in running elections
that have not been addressed by local authorities or the National
Parks. The National Parks offer a good model for extending democracy
to the quango state. We have commented on the cost above.
Conclusion
UNISON supports moves to make all public service
organisations more open, transparent and democratically accountable.
We also support all moves which enhance individuals’ opportunities
to participate in and influence decision making in their communities.
UNISON believes that this Bill is an important step towards meeting
both these aims in relation in health boards.
For further information please contact:
Matt Smith, Scottish Secretary
UNISON Scotland
UNISON House
14, West Campbell Street,
Glasgow G2 6RX
Tel 0845 355 0845 Fax 0141-331 1203
E-mail: matt.smith@unison.co.uk
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