NHS Reform Under the X-Ray

“The person I trust most for my health, number one, is my GP. And I’ve always seen him or her as a kind of a gateway to any other services. And it’s his judgment, ultimately, or her judgment, that I would back.”  That’s what Eric Pickles told The Telegraph last Saturday. There’s something bucolic about the government’s attempt to put commissioning power into the hands of local GPs, and take it away from “faceless bureaucrats”  in the Primary Care Trusts; it comes from the England of Cameron’s mother, the Berkshire Magistrate, from John Major’s England of “cricket grounds, warm beer, green suburbs, dog lovers, and old maids cycling to holy communion”.  But, the government are also, as Hague once put it, “Thatcher’s children”. Andrew Lansley wants to empower patients, and by empower them, he means increase their choices, and by increase their choices, he means create a market, and by create a market, he means promote efficiency and cut NHS costs, and by cut NHS costs he means offset the effect of the £20 billion of savings required by 2015.

The leaked account of the Strategic Risk Register, which lists the potential pitfalls of the reforms, suggests it challenges both horns of the government’s approach. GPs, it is alleged to say, may lack the experience and skills to manage funds efficiently. Equally, the introduction of a market may lead to private companies failing to do more with less, and simply siphoning away public funds in profit. Consequently, the NHS could eventually prove “unaffordable”.If this is an accurate report of the contents of the Strategic Risk Register – if it seriously moots the possibility of the reforms rendering the National Health Service prohibitively expensive – then it is not surprising that Andrew Lansley does not want to publish the report until after the Health and Social Care Bill is enacted.

The government is appealing an Information Commission order that they should release the full document. The Department of Health has pointed out that Risk Registers express the dangers of policies in “worst case” scenario terms and so can be open to misinterpretation if read out of context. It suggests that Risk Registers in their current form could not be produced if they were subject to FOI requests, for fear of giving the public the wrong impression.This is a version of the chilling effect argument, which Blair put like this:

“Governments, like any other organisations, need to be able to debate, discuss and decide issues with a reasonable level of confidentiality. This is not mildly important. It is of essence. Without the confidentiality, people are inhibited and the consideration of options is limited in a way that isn’t conducive to good decision-making. In every system that goes down this path [FOI] what happens is that people watch what they put in writing and talk without committing to paper…’

The Information Commissioner recognises the danger of FOI causing a chilling effect.  However, in this case it emphasised the fact that, whatever information is released vis-a-vis health reform, officials will still be required to be fully frank when they produce Risk Registers. The Commissioner felt that publishing information about NHS reform might make officials less forthright on that particular subject during the current process, but that there would not be a chilling effect on the record of risk across the policy spectrum.

The appeal will be heard by the Information Tribunal on 5 and 6 March, which may or may not be before the third reading of the Health Bill in the House of Lords – the last chance to substantially amend it. However, Labour propose to discuss the publication of the Risk Register  in an opposition day debate on 22 February. It is possible that this move will prove more effective than the Freedom of Information Act in getting the Strategic Risk Register into the public domain.

FOI and Accountability?

Does freedom of Information increase accountability? Officials think that it does not, according to a survey by the Ministry of Justice recently mentioned in the Guardian.  The key word here is think. They think it doesn’t because they don’t directly see its effects.

Officials don’t notice FOI because often it works with other accountability mechanisms, especially the  media or NGOs (see Voices for Libraries on going campaign).  FOI rarely hunts alone and its use is lost amid lots of other questions, communications and research. A long running parliamentary investigation into extraordinary rendition , for example, used FOI in the UK and the US alongside Parliamentary Questions to show that a little more was known about the mysterious flights than was admitted at the time.

Officials also don’t notice it because it is not always high profile or immediate. For every MPs’ expenses  scandal or list of visitors to Chequers there is the patient, often slow, digging up and fitting together of pieces of a jigsaw. Chris Ames has spent many years exposing bit-by-bit the inner workings of government as it prepared for the War in Iraq. His work has raised many questions about the defences made by the politicians involved.  At local level there are many groups using it to pursue all sorts of important issues that may escape officials’ radars, allotments being a good example.

FOI does make government more accountability but not everyone sees it.  Sometimes it is not the kind of accountability politicians or officials want. Often it is for unexpected things. But that doesn’t mean it isn’t happening.

Why won’t expenses go away?

The point of transparency, according to the theorists, is two-fold:  You’ll be judged for what’s exposed and – only when effective sanctions or accountability mechanisms exist for bad behaviour – you won’t want to continue to act badly. Sounds easy, right?

The problem, in the real world at least, is the definitions in the concept above. Who constitutes the ‘judge’ of what’s exposed? Who decides what sanctions are appropriate? What’s riskier for an actor – attempting to hide behaviour or taking the punishment a ’judge’ hands out?

Looking at some news stories over the last few weeks, the FOI ‘expenses’ fad is more than a fad after all  – FOI requests for expenses continue to be made, and in tandem with proactive publication, hundreds of column inches  continue to be filled by stories about expenses.

And the reason this is still happening is that it continues to be unclear (and therefore newsworthy) about what any expenses system is ‘supposed’ to look like. The goal posts keep shifting – what was acceptable before the banking (or indeed the MPs’ expenses crises) isn’t necessarily ok now, though of course, it could one day be again. Where the real accountability lies is often not with the headlines in the media, but by the structures already in place in the system. Transparency’s two benefits are by no means a given.

In the context of increasing student fees and a decrease in the teaching budget, the expenses of university vice-chancellors this week, investigated by the Independent on Sunday, makes the perfect story. The expenses “cover worldwide travel and lavish entertaining” according to the paper, while the universities argue that “the expenses were largely run up on official business” and they insisted they had “robust mechanisms to weed out frivolous claims.”

Comments on the expenses by union and student leaders did not call for the resignation of any vice-chancellors. Usman Ali, vice president of the National Union of Students, argued “Universities must listen to students’ unions and make their expenses and pay structures transparent to stop abuses.” But without stronger sanctions, and keeping in mind the theory above, what can listening and more transparency do to actually instigate the kind of behaviour change students and unions want? In reality, the buck stops for many vice chancellors at their respective university councils.

Universities argue their expenses regimes are fit for purpose and by being exposed they are acting responsibly. A Housing Association has taken it upon itself to begin publishing details of their expenses. Being threatened with FOI-inclusion by Minister Grant Shapps, they have embraced the push towards transparency and opened themselves up to the scrutiny of others.

Is that a safe move, PR-wise? Even when efficiencies are made overall, exposure of expenses doesn’t always inspire trust: the total claims made by MPs’ are down by a fifth this year, but that hasn’t stopped the Daily Mail focussing on first class travel. Context is everything: “[MPs’ expenses claims] highlight the extent to which the system cossets MPs from the crippling rises in the cost of living that are squeezing the incomes of ordinary families.” Ouch.

The issue remains a touchstone across the public sector: this week examples come from the police, the British Council, the BBC, former MPs like Tony Blair (and less recently, Thatcher,) and even popping up in the Leveson Inquiry.

The most interesting piece of expenses news this week however, might be a small survey by YouGov, carried out for Concur, a firm which specialises in expenses software. 18 per cent of respondents said they would exaggerate expenses claims if they believed they were otherwise underpaid. Who’s fit to judge now?

Judicial Liability and Judicial Pensions: Italy and Britain

One of the difficulties associated with developing a theory of judicial independence and accountability is that national practices and expectations vary so widely.

Last Thursday, the Italian government approved a draft package of measures to reform the Italian judicial system. Some – such as the proposal for a strict separation between judges and prosecutors – are arguably quite sensible. Not so positive, however, is the proposal that it should be possible to sue judges for violations of rights in the context of judicial decisions. According to The Guardian’s report, the proposals make judges and prosecutors subject to personal civil liability for acts committed in violation of rights in the same way as other state officials and employees’. The example given in the bill is of ‘unfair detention or other irregular limitation of personal liberty’.

The proposals have a long way to go before they can become law (and as they involve constitutional change, approval of both houses of the Italian parliament or a popular referendum will be required to ratify them). However, the real risk that this kind of regime would create a chilling effect limiting judges freedom of action – particularly when it comes to wealthy litigants or defendants with the capacity to sue at little personal risk to themselves – makes it a worrying one (although as the measure will be prospective if enacted, Silvio Berlusconi’s upcoming encounter with the judiciary will not be affected).

Back in Britain, Frances Gibb reports in The Times today that former Lord Chief Justice Lord Woolf, and three former Lord Chancellors, are fighting the Pensions Bill (currently going through the Lords) because of a threat to the independence of the judiciary (amongst other reasons). Part 4 of the Bill provides that the appropriate Minister may require judges to make contributions to the cost of their pensions (judges already contribute to the cost of benefits for their spouses and dependents).

At a time of austerity this issue is likely to be controversial. Other public servants facing redundancy and pay cuts may look wistfully at the terms and conditions of the judiciary and wonder why judges should not share at least some of the pain. And certainly the proposed measure does not threaten the independence of the judiciary to the same extent that the Italian proposal would. On the other hand we pay judges well, and protect them against reductions in salary, in order to preserve their independence and ensure the quality of those who serve on the bench. An effective pay-cut of 6% (Gibb’s figure) is significant by anyone’s standards. If, as Lord Woolf argued in the Lords, these measures will have a serious effect on judicial recruitment then the objections of those offering the perspective of the judiciary should not be dismissed out of hand.

The debate in the Lords continues.

Pressure for political reform begins in new era for Ireland

Political reform proposals are emerging thick and fast in the wake of the Irish election to try to ensure that never again will such an existential crisis catch the whole country unawares. For outsiders the process just beginning will provide a new and fascinating test  of the relevance of political reform to  real life concerns, rather than a dry as dust theoretical exercise for elites.

It’s quite a  relief to see that the debate so far avoids blue skies constitutional ruminations and focuses instead on practical machinery to strengthen scrutiny and enhance government accountability. The general complaint emerging from the crisis that in a small country like Ireland it was all too easy for a “ golden circle”  of politicians, bankers and businessmen to create the self-regarding and mutually reinforcing nexus that led to disaster. A Dail seminar of former TDs last week made a number of suggestions reported in the well regarded Political Reform.ie  website to improve Dail scrutiny. Some of these will find their echo in Westminster experience. They include:

  • The establishment of  the equivalent of the Office of Budgetary Responsibility
  • Greater scrutiny by the Public Accounts Committee
  • The restoration of Green and White Papers
  • The end of blanket ministerial responsibility for all civil service actions
  • The restoration of the Dail’s power to hold public inquiries (recently curtailed by the Supreme Court).

In a separate list of proposals in the Irish Times, a group of political scientists who edit Political Reform ie  remark that public demand for political reform was “far less foreseeable” than reform of economic and financial management. They submit five specific proposals:

  • The Dail not the government should choose the Speaker
  • The Senate should be used more as a for appointing more experienced and able ministers ( this in the teeth of many calls to scrap the nominated Upper House)
  • Select Committees should be appointed proportionately and legislation placed before them before reaching the floor of the House
  • More power to initiate debate for backbenchers and the curtailment of use of the guillotine (used even more in Leinster House than at Westminster).

These early tranches of reform proposals will by no means be the last.