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Shared Decisions in a Democratic NHS

Author: Shaun McBride

Shaun McBride (@kernowshaun) is a paramedic, health inequalities campaigner and Socialist Health Association Central Council member from Manchester. All views expressed are his own.

Many are currently engaged in the fight regarding ownership of our health service. They rightly argue that a health service, whether in part or in full, owned by private companies mean that the primary output is profit, with health gain taking a secondary role. It is a fight that, if I may be optimistic, may soon be won. Private companies are not making the profits they expected, public opinion is steadfastly in favour of collectively-owned models of healthcare, and the current government’s agenda lies in tatters.

They also correctly recognise the principle that “you can’t plan what you don’t control, and you don’t control what you don’t own”. As a result of private ownership, health services are exclusively planned and controlled by unaccountable private individuals, from managers to shareholders. However, a collectively owned health service, finally free of the anchor of profit to pursue only health gain, also introduces the opportunity to implement alternative forms of planning and control, and the fight for the ownership of our NHS has forced us to challenge old management paradigms for the first time.

Having removed managers and shareholders from command over the means of health gain production, who is to take over the ship? Politicians? Civil servants? Doctors? Previous models have largely been variations of the aforementioned in differing amounts, but does the public really wish to return to the stale, unresponsive and bureaucratic management, however well-intentioned, of the past? I wish to use this short article to argue that, not only is a democratic method of management the best form of management, it is the only ethical option.

Since the birth of the NHS and its dominant doctor- and politician-led management system 70 years ago, huge advances have been made in individual patient-level decision ‘management’. The clinical professions have abandoned old paternalistic models of “doctor’s orders”, and the vision of patients as co-producers of health is being realised, albeit slowly, through shared (patient-clinician) decision making.

Shared decision making hinges on the ethical principle of autonomy, and in essence means that, not only does the clinician consider the balance of risks and benefits from a purely medical (and often medico-legal) perspective, but also the patient - an expert in their own individual health and lives - from the perspective of their wider lives, priorities and beliefs.

In short, the clinical professions have accepted the principle that it is unethical to expose a patient to any risk without their active and informed consent, no matter the perceived balance in the mind of the clinician, or put differently: that patients should take an active role in any decision regarding their care that could possibly expose them to risk.

However, this principle has not yet been accepted to apply to communities and nations, as it has been to individual patients. Where we see communities of patients being exposed to risk through the reconfiguration of hyperacute stroke units, or the centralisation of GP surgeries, or the decision whether to conduct breast screening, we see the archaic paternalistic model, encouraging patients to leave it to the experts, trusting that clinicians in positions of management or politicians will act in their best interests. No matter how well intentioned the decision makers (and I am in no doubt that the great majority are), and no matter the balance of risks and benefits in their minds, the ethical principle previously outlined would mandate that communities also take an active role in these decisions. These patient representatives would be elected from the general population, however, the exact design of any democratic decision making system would require much greater consideration than can be given here. Alongside these patients should be a range of frontline clinicians who always make much better informed experts on how services could be ran than managers extracted from the frontline.

Democratic decision making at every level from community to nation is the only way to gain the active and informed consent of patients for any planned change in care. The NHS could lead the way in pioneering the first industry not only socially owned, but socially & democratically controlled and planned, a third way between the uninspiring state-ran industries of the post-war period and the unacceptable pursuit of profit above all else demonstrated in the same industries by corporations since Thatcher’s premiership.

Not only would a democratic NHS unleash the untapped potential of patients and frontline clinicians, but also, as I have argued here, it would be unethical to continue making health service decisions in any other way.


The publisher is the Centre for Welfare Reform.

Shared Decisions in a Democratic NHS © Shaun McBride 2018.

All Rights Reserved. No part of this paper may be reproduced in any form without permission from the publisher except for the quotation of brief passages in reviews.