Imagine if almost £100bn of England’s health and social care budget was controlled by communities of less than 8,000 people.

That is a reality in the Faroe Islands.  Almost 35% of the Faroe Islands’ health and social care budget is controlled by local councils covering populations ranging from 2,000 to 7,000.  Give or take, the Faroes spend a bit more per head on health and social care than we do in England.

The Faroes are, to all intents and purposes, a separate county.  The islands are under the protectorate of Denmark but they have total autonomy over their own tax and spending plans, including those covering health and social care.  I was recently there on holiday and lots about the place left a deep impression on me.  One of the most astonishing facts about the Faroes is that almost the whole archipelago is connected by tunnels.  They go under the sea and through mountains and make journeys across the 18 main islands a breeze.  How they pay for this is a mystery.

I was curious to find out how their health and social care system worked.  The total population of the Faroes is around 50,000 people. I’ve not done a detailed analysis of the health demands and prevalent long-term conditions that exist on the islands, but I suspect they are not going to be that different to much of England.  Although, because a large percentage of the population are descended from the same small group, there are some special genetic diseases that are off the charts in the Faroes.  For example, Carnitine Transport Deficiency (CDT) which 1:500 people have in the Faroes compares with the world average of 1:500,000.  Obesity is not a big issue in the Faroes. Nevertheless, heart disease and cancer are, like almost everywhere else, significant killers.

In broad terms, the way they have set up their health system is like ours in England. Primary Care, covering local GPs (of which there are c. 20) prescriptions and community nursing, is run by central government.  Secondary care, covering the three hospitals on the islands as well as c.20% of specialist treatments, which they buy in from abroad (i.e. by sending patients overseas) are all, again, covered by central government.  What we would describe as social care – covering costs of domiciliary and residential care is organised, delivered and paid for by local government.

However, that’s where the similarities start to break down.  Of the overall budget of c.£150m a year nearly 33% is controlled by local government.  What’s extraordinary though is that when we think of local government in England, and its influence on health and social care, we are talking about population sizes of well over 100,000, and in some cases above a million people when looking at some county areas.

When I described my local situation to Símun Hansen, from the Faroe Islands’ Government and how the budgets are separated in most local areas in the UK he said “when you talk it sounds like a crazy budget!”.

Comparing the two:  In the White City (West London), a community where I am involved, across a population of 13,000 people we consume about £35m – £40m per annum of health and social care spend.  The local community, through local charities, our neighbourhood forum and other groups has direct control over effectively zero per cent of this budget.  We must get to an administration covering 190,000 people (London Borough of Hammersmith and Fulham) before one can, through the ballot box, influence spend.  At that level, the council nominally controls around 25% of the spend, although there’s a strong argument to challenge the degree of control they actually have, versus central government pulling the strings.  The tables below try to show how small the individual’s voice is in my community (White City, West London) compared with Símun’s voice in his community, Runavíkar Kommuna in the Faroes.

Local Government

Location Approx. spend per head Of which controlled by local government Population covered by local government Value of one person’s voice
Runavíkar Kommuna, Faroe Islands £3,000 £1,000 4,000 25p
White City, London £3,000 £750 190,000 0.4p

National Government 

Location Approx. spend per head Population Value of one person’s voice
Faroe Islands £3,000 50,000 6p
England £3,000 50m 0.006p

 

So, on the basis of the above if you live in Runavíkar Kommuna, in the Faroe islands, your voice is over sixty times louder someone’s in the White City, when trying to influence local government and 1,000 times louder when trying to influence national government.

This is not an argument about economies of scale or comparing different health and social care demands.  We could easily get bogged down in trying to unravel the different systems and the pressures they are under and doubtless someone could set out a compelling justification for how efficient the NHS and our attendant health and social care systems are.  There would be room to question that argument and put the case that significant diseconomies of scale exist and flourish in our health and social care systems.  That though is the subject for a different piece.

That would also be missing the point of this piece which is that if essentially, I have virtually no control about how my money (raised through tax) is spent in my community, why would I bother to get involved?  However, in Runavíkar Kommuna as one of 4,000 people who live there, I can have a big say in what our priorities, as a small community, should be.  What do we need?  A place to worship?  A new harbour? A new care home?  An extension to our school?  Maybe even another tunnel?   If that degree of control and empowerment were available to local communities in the UK it would transform our communities into stronger and more resilient places.  Places where people are heard – because for many of us, if we felt we had a meaningful say in how our money was spent, we would be keen to make sure our voice was heard.

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