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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


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.


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.


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.


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
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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