A Manchester Health Service… MHS or NHS?

At what scale are things best organised? That is at the heart of so many of our big debates today – Scottish independence, UK independence, devolution. 

And yet the debate rarely takes place with a deep look at scale and what should be done at different levels. That is not to say that there is not informed debate, even if some of that is rooted in an emotional sense of the desire to regain control in a complex world, and the perennial promises and illusions of nationalism and regionalism. But scale is something, ever since Leopold Kohr argued for the breakup of nations in the last century, that is hard to pin down.

Herman Daly, the great ecological economist, for example argues that economics has focused on the twin goals of distribution and efficiency, when it should also have focused on scale. Fritz Schumacher, the doyen of “Small is Beautiful” agreed. His argument was never that we should do everything at the local level, but that “we need freedom and order: the freedom of lots and lots of small units and the order of large-scale, possibly global, organisation.” He pointed in the 1970s to the catholic tradition of subsidiarity, or devolution as a working principle – as small as possible.

The world has moved his way. Every national politician seems to profess localism. Devolution has spread and won its spurs, changing for good the national settlement at the UK level.

The latest variant is Devo Manc. This is the proposal (albeit without the legislative basis of the nations within the UK) to devolve spending to the Greater Manchester authorities. It is recognition, on the one hand, of the centrifugal dominance of London as close to a city state, and, on the other, of the widely praised governance and leadership of Manchester.

By chance, I met with two dozen leaders in the health and social care system in Manchester on Tuesday evening, just as the rumours hit the wires of Devo Manc taking on health spending across the region, devolved from NHS England. I was just one participant in a room full of passion and expertise. One of the reasons I was there though was to talk to the potential for genuinely participatory approaches to health and care – not least the social co-operative model now emerging in Wales, which offers an ownership model fit for the concept of co-production, of a partnership between service users, carers, community and the precious teams of professionals.

None of Devo Manc (health and care) is going to happen quickly and it is right to prepare the ground and to think through very carefully what needs to be done at different scales. There are still very good reasons to have an NHS, possibly even a European Health Service, for example around negotiating with Big Pharma on product and price or around aspects of food regulation. Public health ought to be easier in a national system than in the fragmented landscape of providers in the US – we need to be careful not to lose that in a devolved system.

But the consensus from the evening was that here was an opportunity to get things right. A statement prepared for the Manchester Evening News by Martin Rathfelder of the Socialist Health Association later that evening captured the mood:

“Under the right conditions this can be an opportunity to ensure that our Manchester Health Service – MHS  – brings much greater benefits to patients and communities. 

MHS patients must be equal partners in decisions about their own care and of their families.  The MHS should be much more democratically accountable than the NHS has been in the past.  Manchester still has huge inequalities in health.  The average age at death of people living in the most deprived parts of the conurbation is ten years less than among those living in the most prosperous areas.  The NHS has never been able to tackle inequality on its own but the MHS will be the biggest employer in the region and with local councils must use its muscle to reduce inequality.  At the same time we want to see an end to wasteful and damaging competition between hospitals. 

MHS should bring much closer working  between social services, citizens, patients, carers, families, communities, hospitals, family doctors, pharmacists and other clinicians, researchers and the voluntary sector. and to establish real parity of esteem between mental and physical health.”

The key to success in devolution seems to me to be one that many co-ops would recognise – you do things together only those things that are done better together, and if you prove that you can do that, you can build the mandate and collective will to do astonishing things for the common good.

Rebooting democracy? The case for a citizens constitutional convention.

I was part of a messy Moral Maze programme on Radio 4 this evening. The focus was whether there was a duty to vote.

My sense is yes, in the simple sense that if you vote, you are entitled to feel good about it. You are getting involved. If there was no sense that voting was right to do, then there might be no voting and if no voting, then we will have no democracy.

It is like giving blood. It is a good thing to do and we are better off as a society if enough people give blood. But no one is going to put you in the stocks if you don’t do it. It is a civic duty, not a new addition to the Ten Commandments.

But to say that it is a civic duty doesn’t mean to say that the way to tackle the evident woes of today’s representative democracy is by framing it in moral terms.

Firstly, you can be active and engaged in political issues and choose not to vote. As one person said to me in the run up to the programme, is it a moral duty to vote if you believe the people you are voting for are immoral?!

Second, we oversell voting. The focus on voting as the sole way people can express their democratic will is not useful. That’s not to dismiss it’s importance, but to say that we need a much more rounded view of what democratic participation does/can entail. We need to be looking at what can be done to provide meaningful opportunities for people to participate.

That’s where Involve’s work, a democracy charity that I chair, has been for over ten years – exploring the extraordinarily rich portfolio of techniques that are possible for what we can call participative democracy.

That’s not to assume that everybody gets involved in every decision, or that we don’t need experts to be experts, but it is a way of getting better decisions and better buy-in because people are given a voice, given a choice.

The BBC panel assumed that this was all about town hall meetings and flip charts – and perhaps that’s the caricature – but as the cooperative sector knows, there is plenty of everyday democracy at work across the UK beyond voting in politicians to parliaments and assemblies.

The examples are now fairly well known.

– Open government means that decisions are taken in the public eye rather
than behind closed doors.

– Citizens juries are examples of deliberative voting. Time and effort goes into getting the facts straight and understood and then you canvas peoples views.

– Participative budgeting gives the public the power to decide where money is spent. In the UK, so far, at a neighbourhood level we have only had small change ‘participatory pocket money’.

– New technology makes it easier than ever for people to get involved.

NHS England operates a programme called NHS Citizen that Involve has helped to design, which is all about bringing the voice of the patient into the culture and leadership of the NHS. It is work in progress, but it is a much richer conception of democracy than voting once every five years for a party of political representatives to decide everything for you.

I was present at one session in which Board members of NHS England listened to patients with mental health troubles. When you are a Board member, you are responsible for culture and values of the system, but it is the paperwork and finance that dominates formal meetings. Participatory projects like this bring in the voice of the patient and is starting to change how things are run.

When people in Merseyside were asked by the police what mattered to them, it wasn’t that police got there fast, which is what the managers had always thought, it was that the police came when they said they would.

The treatment of breast cancer, the availability of language services have been improved by citizen campaigns.

By using imaginative ways to get people involved, five wards in Birmingham have cut crime at twice the rate of other areas in the city – saving money for the taxpayer.

Some of the BBC panel were looking for the single shots to reboot democracy – compulsory voting, votes for over sixteen year olds, state funding. (The transcript of my evidence, by the way, is here). All these are options, reasonable options to be argued through but if they don’t carry sufficient consensus, they are tinkering with the democratic mandate rather than renewing it. We have other issues that are flaws to address as well and that won’t wait forever:

– the West Lothian question of who votes on English matters

– the postcode democracy of devolution beyond the nations to the regions and cities, which implies profound changes not just for people in those areas but also those just outside them

– the case for our representatives to reflect better the people they represent in terms of gender and class

– whether we need a written constitution or whether we continue with our tacit and evolving settlement.

What we need, to look at all of this, is a citizen-led constitutional convention. Scotland had one back in the 1990s. Ireland and Iceland have experience, including crowd sourcing a possible new constitution.

How will this work? One option is to build on the citizens jury model, keeping politicians at bay. If so, it would be randomly selected but a representative sample of the population – similar to a jury, but on a bigger scale. The number of people could range from 100 to 1,000, or perhaps even 2,000 at the most. Over something like eighteen months, say, you would go through a design phase, and then, gathering expertise and evidence, a deliberation phase and then a recommendation phase – all with satellite grassroots discussions and debates feeding in.

The recommendations can go to Government, or on to a referendum. The constitutional convention is there to present a programme, but the decision to change the framework of democracy is one that has to be decided in an exemplary way, if it is to last.

My sense is that, with all due respect to the political class represented on the panel I met tonight, we need to rescue politics from the political experts.

Democracy is more than voting, and why should we not in future expect more opportunities to have a say on the decisions that affect us, easier participatory opportunities in the neighbourhood and, radically, more economic democracy in our workplaces?

Engage people in these ways, the evidence shows, and they are anyway more likely to vote.

Farmer co-ops – a new programme starting soon

The first co-operatives formed around food and it is a source of new co-operation today. Later this year, Co-operatives UK will be starting a new programme of support for agricultural co-ops.
There are around 222,000 farm holdings in the UK. As a nation, we eat around half of what we produce, and if crisis hit, we could produce much, but not all of what we would need to get by.
While three quarters of agricultural land is farmed by the larger operations, the vast majority of farm holdings are small or relatively modest in scale. The south of Great Britain tends to have fertile soils, amenable climate and topography, while the north has something of the opposite. Scotland may be beautiful, but 85% of it is, according to European Union classifications, ‘less favoured area’. The south is therefore majority crops, while the north is majority livestock. Agriculture has always been devolved.
Agricultural co-operatives are farmer-controlled businesses, which offer the opportunity for members to benefit from economies of scale, to share the cost of overheads and to improve their ability to negotiate and compete along the value chain. Agricultural co-ops can play an important role in purchasing and marketing, providing their members with specialist services to get the most from relationships with suppliers and customers.
The business areas typically covered by agricultural co-operatives in the UK include: milk marketing and processing; crop marketing; potato co-operatives; horticultural produce; livestock marketing; crop storage and primary processing; input supply; and machinery rings.
A strength of the model is that agricultural co-operatives can benefit from mutual taxation status. Here the co-op acts as an agent on behalf of its members. The co-operative can accumulate reserves and hold them without incurring the corporation tax liability that would be payable if it was a private company, or if its members were holding the reserves as individual businesses.
As with co-ops more widely, the key to long-term success is business strategy and leadership allied to high quality governance and member engagement.
As a first step, we are recruiting someone to work with our farmer coop members to develop our work to back Britain’s farmers. If you know of anyone with a passion for food and co-operation, do pass the word!