UNISON Scotland's response to the Scottish Government consultation on the Local Healthcare Bill

March 2008

Executive Summary

Introduction

UNISON Scotland is Scotland's largest trade union representing over 160,000 members working in the public sector. We are the largest trade union in the NHS, with over 55,000 members. UNISON Scotland welcomes the opportunity to comment on Local Healthcare Bill as it covers issues of great concern to our members not only in their professional lives but as citizens too.

Response

The responses to the earlier consultation on direct election to Health Boards indicated widespread support for this route to more accountable decision making within NHS Scotland. It also offers routes for a better understanding of healthcare provision amongst the public. The community anger and campaigns around changes to health service provision show clearly that the current process is not working.

The public have concerns about decision making and accountability. There is a general perception that consultations are a cover for decisions that have already been made and that the needs of local communities are not taken into account. Professor Kerr states in a recent article that 250,000 people in Scotland have participated in campaigns around healthcare decisions. This demonstrates clearly the strength of feeling about health services and that people are willing to give their time and energy to improving NHS Scotland. There is an obvious need for change if NHS Scotland is to win public support in order to transform to meet future health needs.

Section 1

Making things better

UNISON Scotland supports democratic structures that enable participation and improvement in public services. Democracy requires government at all levels to ensure adequate opportunities for the general public to participate in and influence the policy making process. This should be more than being asked to comment on plans that have been made in private. It should mean involvement in developing desired outcomes and the methods to achieve them. To facilitate this, organisational structures need to be decentralised to the appropriate level for each function.

All public bodies should have a statutory duty to meaningfully involve users as partners not customers in the decision making process. This involves a high degree of transparency and the provision of capacity for users to fully participate. Genuine involvement is more than just consultation. It means involving users and staff in defining the problems as well as the future direction of their public services.

UNISON Scotland broadly welcomed the Crerar Report as a means for improving scrutiny in public services; it supported our calls to cut the burden of scrutiny while increasing the involvement of users, the public and public sector staff. UNISON Scotland's submission to the review highlighted the heavy administrative burden of excessive and overlapping scrutiny and review processes which currently divert too much staff time away from actually delivering the service. UNISON Scotland believes that the development of appropriate performance measures is crucial to a process of improvement. These must be sophisticated enough to take into account all relevant factors in service provision. Any targets or key indicators should be designed to improve overall services.

UNISON Scotland will continue to argue for the voice of staff as both providers and users of services to be heard in the process. UNISON Scotland believes that direct elections to Health Boards and the inclusion of staff on Boards provide the best route forward.

Section 2

Direct Elections to National Health Service Boards

UNISON Scotland believes 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. We would therefore support direct elections to Health Boards.

Democratic structures create public bodies which are open and transparent in their dealing with the public. The NHS Scotland budget will be £8.6 billion in 2011 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; allowing a debate to take place about healthcare in local communities via the election process and by making Boards directly accountable to the people they serve.

UNISON Scotland believes that Health Boards should consist of directly elected members of the public, local authorities represented by councillors and specific NHS Scotland expertise by appointment, for example patients groups and staff from local partnership forums. Each of these groups would make up one third of the total board.

It has been argued that the presence of local councillors on Health Boards is sufficient local democracy and/or this could be supplemented by some form of scrutiny over Health Boards by local authorities. We believe that this approach fails to understand the role of councillors on Health Boards. They are appointed to improve joint working and view their primary function as representing their council on the health board. That is a legitimate role but it is not a substitute for direct elections of members whose primary responsibility is to local healthcare. UNISON Scotland strongly supports a strengthened role for local government but we do not believe it has to have a monopoly on local democracy.

UNISON Scotland also believes that this process has the benefit of greater democratic accountability while still retaining NHS expertise. It offers the prospect of developing genuine local healthcare partnerships with a real local understanding of the complex issues facing NHS Scotland. It will be part of a process that can improve the engagement culture of the NHS in Scotland.

9. What eligibility criteria should candidates meet (e.g., should they be resident in the Board area? Should there be any other qualifications?)

UNISON Scotland supports any move that enhances the individual's opportunity to participate in and influence the democratic process. We believe that as few people as possible should be restricted from serving.

UNISON Scotland believes that as a starting point current Local Government practice on restrictions for elections should be used for this Bill with some exceptions as set out below.

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. This can be clearly seen in some young people's disengagement from the electoral and political system.

UNISON Scotland supports any move which encourages participation from young people in the electoral process and believes that the age limit should be reduced further to 16 years.

We believe staff should be allowed to stand for election and be able to retain their employment with the same health board if elected, with appropriate safeguards to prevent conflicts of interest arising.

10. How could equality and diversity of candidates be promoted?

UNISON Scotland believes that all electoral systems should be fair, open and democratic and encourage participation from groups which are currently under-represented - women, people with disabilities, people from ethnic minorities, lesbians and gay men and younger people. We believe that while direct elections to Health Boards will be a step towards making Health Boards more representative it will not do so without taking explicit steps to achieve this aim.

The Audit of Political Engagement (2006) published by the Electoral Commission and Hansard indicates that new forms of direct participation are most likely to be used by those who are already active rather than brining in the disengaged. This is particularly true of those from lower socio-economic groups: the people most likely to be in poor health. They therefore have the most to gain from having a say in how the health service is run.

UNISON Scotland believes that the recommendations made by COSLA's Widening Access Group in regard to local government are a good starting point for widening access to Health Boards. UNISON Scotland believes that:

11. Should candidates have to submit profile statements and declare any interests and/or relevant qualifications / skills /experience, for example membership of a political party or a pressure group?

UNISON Scotland believes that current Local Government practice on declarations for elections should be used for these elections. In order to campaign candidates would of course be declaring their interests and/or relevant qualifications / skills /experience.

12. Is there a case for excluding candidates standing as a representative of a political party?

UNISON Scotland believes that candidates should stand as individuals and not as representatives of parties. However we do not believe there is a case for excluding individuals who are members of parties or any other group.

13. In what circumstances might someone be disqualified from seeking election?

UNISON Scotland believes that current Local Government practice on restrictions for elections should be used for these elections except in relation to health board staff. We believe staff should be allowed to stand for election and be able to retain their employment with the same health board if elected, with appropriate safeguards to prevent conflicts of interest arising.

14. Who should be allowed to vote in the election? Should the same rules as apply to local authority elections be followed?

UNISON Scotland believes that the same rules as apply to local elections should be followed except that we believe that the age limit should be reduced to 16 years for both elections.

15. How often should elections be held, and when? Local authority elections are held every 4 years. Should elections to NHSIS Boards follow the same pattern?

UNISON Scotland believes that the term of office for those elected to the Boards should be in line with Local Authority practice and those elections should take place every four years. However, the elections do not have to take place at the same time as local elections.

16. Should directly elected members form a majority of the members on a Board?

UNISON Scotland believes that the profile of the Boards should be one third directly elected members of the public, one third with specific NHS Scotland expertise primarily from patient organisations and staff from local partnership forums and the remainder made up of councillors from each of the local authorities represented in the Board areas. The precise numbers will depend on the number and size of Councils in the Board area.

This link is essential to promote a wider public health approach to health improvement and better joint working between NHS Scotland and Local Government. This means that the precise numbers may vary between Board areas. However the proportions as set out above should be maintained.

In this model officials would revert to their original advisory and management roles and would not have voting rights.

17. Should the existing categories of appointed Board members (lay members, stakeholder members and executive members) remain in place?

See above

18. Among the appointed "stakeholder" members on NHS Boards are local authority Councillors. What should their role be if directly elected members sit on Boards?

See above

19 Should NHS Board areas be divided up into electoral wards?

UNISON Scotland is not opposed, in principle, to dividing health board areas into electoral wards. We are though concerned that members of NHS Boards take into account the needs of all communities within the health board area when they are making decisions regarding the provision of services.

NHS Boards must consider the wider needs and impact of decisions made regarding localised services. Decisions made by the Board should reflect the needs of the board area as whole rather than smaller parts in isolation. UNISON believes this may be more achievable if members are elected to represent the whole of the health board area although there may be a need for wards in rural boards or others where there is substantial community interest. There may also be a case for linking electoral areas to CHP boundaries where that is practical.

20. Would the emergence of groups or individuals with particular views be a difficulty or a potential threat to good governance and direction of the NHS in Scotland?

Any election runs some risk that someone who is a threat to the organisation is elected. Democratic elections are still the best way to ensure that the public, who pay for services, have a real say in how they are run. There is no reason to believe that groups or individual with particular views would be any more of a problem on Health Boards than any other directly elected body. Independents elected to the Scottish Parliament are no threat to the good governance of Scotland. UNISON Scotland believes having directly elected members as one third of a Board would provide an appropriate level of checks and balances to safeguard against disproportionate representation by special interests or political groups.

21. Should safeguards be introduced to prevent unrepresentative disproportionate representation of a political party or special interest group on a Board, and if so what form might such safeguards take?

UNISON believes that it is important to prevent unrepresentative or disproportionate influence by special interest groups or political parties. Setting a low limit on election expenses for candidates and third parties in the elections would operate as a safeguard against this. Wealthy organisations and individuals would not be able to use their greater resources to buy more influence in the elections. A previous Bill to introduce health board elections suggested a limit of £500 for candidates and £250 for third parties. UNISON believes this limit is reasonable.

UNISON Scotland believes having directly elected members as one third of a Board would provide an appropriate level of checks and balances to safeguard against disproportionate representation by special interests or political groups once boards are in place.

22. Would you favour a simple "first past the post" voting system, a proportional representation approach or another type of system?

UNISON Scotland has no strong preference for a particular electoral system. In local government we supported in the introduction of proportional representation but we recognise that this would be less relevant in a board wide election.

23. How should voters be allowed to cast their votes? By postal ballot or at a polling station? Or either, depending on the voter's choice?

UNISON Scotland believes that a postal vote would be most appropriate for direct election to Health Boards. It is simple and cost effective and will encourage participation. This is in line with the process used to elect board members for Scotland's national parks. Turn out, for these elections, was in the range of mid 30s to high 40s per cent.

24. Should directly elected Board members be remunerated? If so, at what rate - the same as appointed members currently receive?

A level of remuneration is important to ensure that no one is discouraged from standing from election because of their financial circumstances. UNISON Scotland would support the current arrangements whereby board members and chairs are remunerated at a daily rate for an agreed number of annual days of service.

25. Are pilots a good idea?

UNISON Scotland believes that direct elections are the best route to more accountable decision making within the NHS in Scotland. They also offer routes for a better understanding of healthcare provision amongst the public. We therefore believe that there is no need for a pilot but would support a pilot as a means towards winning wider acceptance of democratic accountability and testing election systems etc.

26. How many pilots should there be?

UNISON Scotland has no particular view on this although logically it should include at least one urban and one rural health board.

27. How should pilot areas be selected?

UNISON Scotland has no particular view on this.

28. How long should pilots run for?

Any pilot must be long enough to properly assess the workings of the process but should not be used as a delaying tactic to avoid local democratic accountability. Two years should be the maximum period.

29. What criteria should be used to assess and evaluate the pilots?

A range of criteria should be used to evaluate any pilot. UNISON Scotland believes that it is crucial that opinions of staff and the public are properly in assessed and given due weight in the evaluation.

30. Should NHS Boards continue to provide generally consistent levels of performance across Scotland and follow national policies and priorities? Or should elected NHS Boards have the freedom to exercise local discretion and flexibility?

NHS Scotland Boards should work to standards and relevant national frameworks with appropriate outcome measures set. This should be matched with appropriates resources to meet those outcomes. This will allow Boards the flexibility to meet local needs and priorities. There would of course need to be provision for national services.

31. Should current guidance e.g. on governance, priorities and performance standards be set out in future in legally-binding form, to ensure that elected Boards comply with them? What would be the advantages and disadvantages of this?

Guidance on governance, priorities and performance standards should be set out in future in a similar way to local government: a mixture of legally and non legally-binding guidance.

32. Ministers currently have powers to remove members. Should they be able to remove elected members? What sort of reasons might justify such a power being used?

UNISON Scotland believes that directly elected board members should be have the same rights and responsibilities as other elected members like MSPs and councillors.

33. Should NHS resources be used to support direct elections? What do you think would be a reasonable amount to spend on elections?

Direct elections will have a cost but that is a poor argument against democracy. National Parks have elected board members and an organisation as crucial as NHS Scotland should have a direct input from the public. There is also the cost to NHS Scotland of the current running, reviewing and rerunning and changing of controversial decision in response to public outcry. The use of postal voting rather than polling stations will keep costs manageable. UNISON Scotland does not believe it is practical at this point in the process to set a limit on costs.

Conclusion

UNISON Scotland believes 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. UNISON Scotland therefore supports the principle of direct elections to Health Service Boards.

For Further Information Please Contact:

Matt Smith, Scottish Secretary
UNISONScotland
UNISON House
14, West Campbell Street,
Glasgow G2 6RX

Tel 0845 355 0845 Fax 0141 342 2835

e-mail matt.smith@unison.co.uk