Without [a democratic authority], it will always be possible for everyone to blame somebody else without taking responsibility. Ministers can blame local bureaucrats, when those ministers have give the bureaucrats very little independence. Health care bureaucrats can point to rigid central controls, but can also blame the public for making supposedly unrealistic demands, when the bureaucrats have little incentive to engage with the public. The public can blame 'them' - usually the government or bureaucrats - despite the fact that the system allows the public to make demand after demand for high levels of local service without ever having to face their real cost.
The suggested solution is local democratic accountability.
Crucially, these elected local people need to have the power to raise [or lower] funds for the NHS so that any demand made by the public for higher quality [or lower taxes] can have a real price attached.
I have been a little mischeivous with my additions there. But I am not clear to what extent Richard is arguing that local accountability will make higher taxes more palateable. This is not such a useful line at the moment, when the NHS has just seen a massive cash input, much of which has not led to noticeable improvements. It would seem sensible to pursue efficiency gains to at least pre-splurge levels before seeking higher funding.
Anyway, Richard is at this point about to launch into an advocacy of adopting something like the radically decentralised Danish health system. However, it turns out that the Danish system has only just been reformed - January 2007 - and is now somewhat less decentralised than it was, although still one of the most decentralised systems around.
I must say that for me this leaves something of a question mark over the proposal. Shouldn't we give a new system some years to bed in before we praise it or emulate it? And why did the Danes centralise, even if only a little? But this is just a question mark.
The idea is to turn PCT duties over to county/city/unitary councils or elected health boards covering the same boundaries. Small authorities might choose to set up joint health boards. This seems sound enough.
I am a little puzzled still, because in the section on funding, Richard talks about a new tax - the NHS contribution - almost identical to, and partially replacing Income Tax, which would, along with NICs comprise NHS funding. Suddenly there is no mention of the locally raised share of NHS funding. This along with my loathing of hypothecation and of extra complexity in the tax system, made this a very disappointing conclusion to a good chapter.
And while localism is a big idea and a good idea, I don't think it is as big or as good as the expectation we have of it. Many people will be unimpressed with a policy that doesn't on the face of it change anything. What do we expect the different bunch of politicians to do differently? Are there no more ideas? Richard's pamphlet with Nick Clegg on education (pdf) was full of ideas.
This is a good retort to the Orange Book simply by opposing social insurance. And yet could not a local health board choose social insurance? It is pretty half-baked localism if it can't.