The question of who is 'accountable' in the NHS sounds abstract: the sort of thing that could keep a political science tutorial busy, but perhaps not a priority for a service with hospitals billions of pounds in deficit and doctors out on strike. Yet when we organised a seminar recently on the question, several attendees commented that it was one of the most interesting they had attended – that it drew out some deep reasons that explain why the service functions in the way it does.
Accountability means being responsible for success or failure, and experiencing the consequences. Almost everybody who works in the NHS, from porters to chief executives, is held accountable for some part of it. But our question is who is accountable for the system itself that connects all those parts?
Is it politicians?
This can seem the obvious ultimate answer. Parliament mandates the existence of an NHS, and grants its funding. The public holds politicians responsible for the service: people consistently tell pollsters that the condition of the NHS is one of the most important factors in determining who they will vote for.
Reforms for 25 years have tried to pass responsibility downwards to commissioners and arm’s length bodies. But when public controversy erupts, politicians feel forced to step in: overseeing contract negotiations, starting clinical initiatives, and enforcing standards where they believe they have to. One parliamentarian at our session said “the reality is that although politicians sometimes pass responsibility onto other bodies, the Secretary of State is running the show”.
Is it clinical commissioning groups?
Writing for us last year, Ben Jupp described commissioners as the theoretical "foundation stone” of accountability for local NHS systems through multiple rounds of reform. But as one attendee at our seminar said, “no-one has ever used the system properly”.
Local clinicians making the decisions is, in theory at least, popular with the public. But clinical commissioning groups (CCGs) are far less visible to them than national politicians or even local councils, and their authority to make difficult decisions on reconfiguration or rationing can be challenged. They are accompanied or overseen by national bodies in much of their work – by the Care Quality Commission (CQC) in assuring quality, by NHS Improvement on provider performance, and by NHS England for their own performance.
For small organisations with limited staff the burden of responsibility for large and complex care systems can be intimidating. One commissioner at our event described feeling like “a pilot for a dodgy airline”. Ben’s paper laid out how the ongoing shift to even larger health care providers uniting general practice, community care and hospitals calls will only intensify this, seeming to call for larger local bodies to exert accountability. Meanwhile, the increasing inter-reliance of health, public health and social care implies a case for more pooling of funding and power with local government.
Is it the regulators?
NHS Improvement and the CQC have considerable power over trusts. There are ongoing steps to broaden the scope of each so that it covers more of what matters to the NHS – with the CQC assessing efficiency as well as quality, and NHS Improvement absorbing quality improvement.
Yet neither has a remit to secure the overall path of the health service as NHS England, CCGs locally or political leaders do. They are there to support, measure, and regulate parts of the NHS – but not to take systemic decisions about how they relate to one another, or whether their goals are right.
Is it NHS England?
NHS England is at the sharp end of key legal duties to provide health care. Each year, its Mandate lays out a specific set of targets for the NHS, designed to allow for transparent accountability.
But this accountability is to Parliament and political leaders, who serve as far more visible figureheads and issue NHS England with new directives when they see fit. At the same time, it does not have the remit to oversee individual service lines as CCGs do (except in specialised services).
Among providers, there is often a sense that NHS England, too, can make its powers felt most clearly where a short-term crisis is being managed. One former trust board member described his experiences of interacting with “30 to 40 people, all of them trying to protect their own reputations rather than improve patient care. So I think managers should say to NHS England 'no – we’re not going to take your calls'”.
Essentially, the question we posed has no clear answer.
Does it matter?
This complexity at the top has a real impact. For a start, the sheer number of bodies standing over NHS trusts and employees multiplies the time that has to be spent reporting upwards. The Department of Health has recognised this problem, ordering a review last year.
The presence of multiple power centres also means that different and even conflicting strategies can be passed down. Following the Francis report, the Department of Health strongly emphasised safe staffing, enforced by the CQC, leading to a strong demand for more nurses. With financial deterioration, though, NHS Improvement and the Treasury are emphasising the need to push down agency staffing even if it pushes some out of the nursing workforce, and to closely control staff numbers generally in future. Maybe this pressure on both sides is right in the pursuit of balance – but the different bodies involved mean it can feel as if nobody above trusts themselves is guiding them as to where this balance should lie.
Both the division of responsibility and the level of politicisation contribute to what one attendee described as the “closed” nature of some, although not all, of the NHS leadership structure – where key decisions emerge fully formed, with little chance for those working in the service, or anybody else, to see and feed into how they have been made.
The hostility and mistrust that are often felt to characterise NHS internal politics may also not be helped by the division of roles. Politicians and central bodies focus on the responsibility to enforce minimum standards, but step back to leave much of the work of identifying savings and making difficult changes to local commissioners and providers. This surely contributes to the sense in some quarters that they are not on the side of local NHS bodies, and to the 'cognitive dissonance' raised by so many at this year’s Nuffield Trust summit.
What should be done?
Public opinion and the realities of the purse string mean politicians will always be accountable for the health service’s direction of travel. But they have been right to realise, through repeated reforms, that their limited knowledge and the invariable politicisation of their actions means they cannot directly take responsibility for planning and deciding across an organisation with well over a million employees. Clinicians, arm's length bodies with the advantage of independence, and leaders closer to the front line are better suited to doing so.
Perhaps the corollary is that they should limit their responsibility to directly create and enforce the finer detail of goals and standards. That, in turn, might enable other central bodies to take ownership of responsibility on a longer timescale, rather than chasing new targets and initiatives.
Accountability must also reside at some local level. Commissioners are the logical starting point. But the growing scale and power of providers and the increasing inseparability of social care means that they need to become larger, and to blur some of their roles with those of NHS providers and local governments.
There may never be a short answer to the question of who is accountable for the NHS. But our seminar left us with the impression that we could at least work towards a better one.
Dayan M (2016) ‘Who is accountable in the NHS?’. Nuffield Trust comment, 13 May 2016. https://www.nuffieldtrust.org.uk/news-item/who-is-accountable-in-the-nhs