Foundation Hospitals

This important debate rumbles on, with the growing prospect of another major Labour Backbench revolt in the Commons.  But this time, the backbenchers are broadly wrong, and Milburn broadly right.  I gave you my views, way back in November, and they have not changed.  I don't like some of Milburn's details, but I agree with his broad sweep of principle.

Milburn's simple aim is to shake up the gigantic Health Service system, which has become institutionally immobile.  Ever since the Keith Joseph reforms of the early 1970s, politicians have tried to address this institutional inertia by re-organisation after re-organisation.  But the dominant medical professions remain "conservative" in their methodologies, and resist change.  They defend "consultant status" as vigorously as my profession of the Bar defends the indefensible system of "Queen's Counsel", and its attendant flummery and cost. The medical and para-medical professions all rejoice in high social status, derived from their healing role, and they are reluctant to jeopardise it by experimentation. Like the Magic Circle, they are secretive and defensive about the mysteries of their professions.  As a cadre, they are intensely popular with the public, unlike the politicians who attempt to "manage" or reform them.  And they have seen most politicians packing, whether of the Left or the Right.  What is a reforming politician to do?

Milburn is now, quite simply, playing the democratic card.  He is rightly resisting the growing pressures to "bring in the local authorities".  They are already in serious decline as democratic institutions, and that decline may yet turn out to be terminal.  In his vision of democracy, he plans to bypass the conventional residential electorate (i.e. the Electoral Roll), and promote the concept of the membership electorate.  Individuals throughout each local community will be entitled to "join the hospital electorate", as members of a public interest company running their hospital.  They will elect Directors to the Board of the company, and may have other participative rights: the draft Bill is now promised for the end of March, as Easter Recess reading.

The concept of a membership electorate is new to the state sector, although common throughout the voluntary sector - indeed, it is there the norm, rather than the exception.  It is of course vital that such electorates should remain open, with minimal entry requirements.  I can imagine a communal membership electorate working well, both in health and education.  For other functions (e.g. town planning, transportation or highways) I think the full residential electorate would be preferable.  But I favour the idea of breaking up the monolithic mandate of the conventional "local authority", particularly the unitary authority beloved of Westminster - which has now been hi-jacked by the political salariat.  For example, I favour the old School Board system, which was displaced by all-purpose local authorities in1902.  A diverse network of functional elected agencies would facilitate the involvement of a very wide range of citizens in public affairs, without imposing upon them the demands of full-time professional commitment.  There could be huge gains in terms of participatory democracy.

There is, however, a huge flaw in the Milburn model. The membership electorate will only elect a proportion of the Board members: others (managers, doctors) seem destined to take office automatically, by appointment or statutory designation. Thus the lay Members will be confronted by a phalanx of "professional colleagues", and will always be out-gunned by them - just as non-Executive Directors in business are out-gunned by executive management.   Or School Governors out-gunned by the Headteacher and Teacher Governors.

Role-sharing of this kind, between lay elected representatives and professionals would not only be a failure - it would consolidate beyond recall the power of the professionals.   The lay members would be crushed, subordinated to mere cyphers. The same phenomenon is already apparent on Boards of school governors.  What is needed is a conventional "local authority" differentiation between Elected Members (i.e. a 100% elected Board) and the Executive Officers who serve the Board, in running the Hospital.  Full public responsibility should vested only in those who have been elected.