Where should health services go: local authorities versus the NHS?

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Abstract
The Association of Metropolitan Authorities has recently proposed that responsibility for the NHS should pass from health authorities to local authorities. One of the fiercest debates at the outset of the NHS was whether the hospitals should be run by local authorities. In the end the minister for health, Aneurin Bevan, decided against local democracy and in favour of a national health service. His arguments included the fact that equality of treatment could not be guaranteed if facilities varied with local finances and that even the largest authorities were not big enough to pool risks and expertise. All these arguments still apply today, and the recent changes in community care provide an insight into how a market model of local authority control might work. The changes have been accompanied by a shift from public to private sector provision and the introduction of charges for services that the NHS once provided free. As important, the willingness and ability of local authorities to raise extra revenue from local taxes and charges affect the service they can provide, so leading to inequalities of provision. Local authorities have yet to make the case that they can preserve the fundamental principles and benefits of the NHS, including its reliance on central taxation and unified funding formulas. From both ends of the political spectrum the case for local authority control of health services is gathering momentum. Birmingham (Labour) and Wandsworth (Conservative) local councils are actively pursuing this policy, and in 1994, the Association of Metropolitan Authorities, the body representing the authorities responsible for running Britain's cities, published its proposals for transferring health services to local authority control.1 Central to it and other models2 is the retention and institutionalisation of the market. One wonders whether the Association of Metropolitan Authorities realises the extent to which …