The view from Healthwatch: Reconsidering accountability in an age of integrated care

It is perhaps apt that a local Healthwatch response to Ben Jupp’s thought-provoking paper, recently published by the Nuffield Trust, should come from Staffordshire. The public here are still living with the consequences of the historic Mid Staffordshire NHS Foundation Trust Public Inquiry mentioned in the report, and some of the problems it uncovered can be linked to governance issues around the Trust board’s push towards foundation status.

From the viewpoint of a local Healthwatch dealing with [a number of] issues, there does indeed seem to be an ever-increasing blurring of the lines of the commissioner–provider split, just as Ben predicts.

Staffordshire is also a good test case for the other trends Ben identifies. We are a financially challenged health economy; we experienced the worst A&E performance this winter; and we have a multiplicity of CCGs all striving to bring forward new approaches to commissioning. The cancer/end-of-life programme in the north and the ‘Improving Lives’ programme in the east both embrace the service integrator model. And from the viewpoint of a local Healthwatch dealing with these issues, there does indeed seem to be an ever-increasing blurring of the lines of the commissioner–provider split, just as Ben predicts.

Maybe that is timely. Too rigid an adherence to the model can result in decision-making being divorced from the frontline, and can lead to duplication. For example, public consultation has to be carried out by both the lead Trust making changes, and by the commissioners. There is also evidence of duplication in public and patient involvement – patient participation groups, NHS Citizen, Trust governors and patient engagement groups and Healthwatch itself. We are not yet skilled at drawing these resources together to enable a strong patient voice holding the system to account.

From a public perspective, the NHS is still seen as one organisation, and many are unaware of the myriad businesses that actually constitute today’s health service. This is really made clear when we deal with patient complaints – most do not know where to complain due to the complexity of the system. Ben foresees a world of more strategic commissioning and more integrated provision. We should ask whether that might also unlock efficiencies in terms of accountants, contract management, business development officers  and so on.

Social care poses a real and present challenge. While integration may not yet be proven as the ‘magic bullet’, we see evidence that social care cuts can lead to more costs and pressures in health care.  The role of the local authority is therefore key. While it will be interesting to see the impact of Devo Manc, from a Healthwatch standpoint there seems to be clear logic in strengthening the role of Health and Wellbeing Boards as strategic commissioners. As well as bringing democracy to the table, these bodies have the independent voice of the public through Healthwatch, thereby strengthening accountability. They also bring in public health, controlled by local authorities and vital if we are to truly tackle prevention and early intervention.

However, strategic commissioning will need to be backed up by strong standards across all services – not just the headline-makers like A&E and hospital mortality. We have recently been reminded of this in Staffordshire through the work of one patient campaigner on orthotics (the splints, braces and devices that support muscles and bones to promote rehabilitation). It could be seen as a Cinderella service, but, if done badly, risks more suffering and much greater expenditure down the line. Without detailed commissioning specifications, service standards will be the main tool for continuing the drive towards excellence.

In summary, Ben’s article echoes many of the thoughts and feelings we pick up around the system: no appetite for organisational change, but a recognition that things are not currently fit for purpose and that the world is moving on. Just don’t forget the most important factor for real accountability: the voice of the public and patient is vital for great services.

This blog is part of a series of responses to Ben Jupp’s Viewpoint paper ‘Reconsidering accountability in an age of integrated care’. Share your own response in the comments below or on Twitter with @nuffieldtrust.

Please note that the views expressed in guest blogs on the Nuffield Trust website are the authors' own.