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

The Government’s promise to avoid further large-scale reorganisation of NHS structures has been widely welcomed, but ministers will soon need to clarify exactly what this means, and what it does not mean.

It cannot mean a period of stasis. 

Every ministerial speech which offers reassurance that there is going to be no blockbuster attempt at ‘NHS Reform’ includes another passage which rightly stresses the need to develop more joined-up health and care services. They argue that, instead of rationing access to health care services  in cases where avoidable acute need has arisen, we need to develop more supportive services that allow us to enjoy lives which are healthier as well as longer. 

Accountability structures don’t exist to justify the status quo – they exist to facilitate change. Measured against that test, Ben Jupp, in a new paper published today by the Nuffield Trust, is right to question whether current commissioning structures are fit for purpose.

This will require a process of sustained evolution. Services that were developed to meet different needs in a pre-digital age will need to be re-imagined so that they meet tomorrow’s needs, using tomorrow’s technology. 

The question is: who is going to make sure that happens?

All too often, discussions about accountability focus on structures and processes, emphasising the importance of reconciling different interests. All of that is important, but it is in danger of confusing method with purpose. Accountability structures don’t exist to justify the status quo – they exist to facilitate change.

Measured against that test, Ben Jupp, in a new paper published today by the Nuffield Trust, is right to question whether current commissioning structures are fit for purpose. 

Are they able to look across the statutory silos which divide hospitals from general practice, mental health from physical, and the NHS from other services people rely on? Can they test outcomes achieved in one area against those achieved in similar communities elsewhere in the world? Are they able to coordinate resources effectively to create services which reflect the needs of citizens? The questions are almost rhetorical. Through no fault of those who work in them, they cannot. 

The integrated care structures proposed by the Five Year Forward View certainly help. The Vanguard sites all aim to demonstrate how Multispecialty Community Providers and Primary and Acute Care Systems can use resources more effectively and improve service integration within the NHS. 

But these evolving provider structures do not answer the accountability questions; indeed, in some ways they make them more urgent as they create larger NHS organisations which will be dominant providers of health care with the attendant risk that they become absorbed by an internal agenda which may not reflect the broader views and interests of their local communities.

From the citizen’s perspective it isn’t merely that NHS services need to be better integrated; there is also a requirement for their effectiveness to be regularly tested and for the services provided by the NHS and other agencies (most obviously, but not only, social care) to be better coordinated.

NHS England cannot allow itself to default to becoming ‘Head Office’ for a group of health care providers; it exists to work with local commissioners to ensure that providers are held to account. This is why the key relationship for NHS England must be with local government – and vice versa. 

Neither side can do its job without close engagement with the other. There can be no meaningful concept of local government which does not have the principle of equitable access to high-quality public services at its heart. Similarly, the modern NHS needs to re-engage with local communities in order to ensure that its services reflect the considered priorities of those communities. 

There is widespread consensus about the requirement for health and care services to evolve towards a more integrated model. Ben Jupp’s paper represents an opening salvo in a necessary parallel debate about the shape of commissioning required to facilitate these fundamental changes. As the pace of change is quickening all the time, someone must speak for the public to insist that providers keep up.

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.