Who shall we hold to account?

Blog post

Published: 30/10/2013

In the old days at the start of this century, the Chief Executive of the NHS was the man in charge, clearly accountable for NHS success or failure at national and local level.

True, politicians occasionally ‘interfered’, as well they might given their direct accountability to Parliament and the electorate. Some did so more than others. Alan Milburn famously filled all the executive positions from CEO to HR Director. His writ ran to the operation of a hospital morgue in Bedford.

This may not have been the best way to run the service – it certainly had its limitations and faults – but one knew who was accountable.

Now power has been divided. Six national organisations have responsibility for my health and health care – NHS England, Care Quality Commission (CQC), Monitor, The Trust Development Authority, Public Health England (do they count as an agency of the Department of Health?) and the Department itself. Perhaps I should also now include the Competition Commission.

Reasonable questions any tax payer should ask are who is in charge and who is accountable for what is provided for me in return

Each will rightly say they are statutorily accountable for what they do. But quite where their responsibilities begin and end isn’t so clear and is shifting.

Last week the CQC published their assessments of hospitals and will shortly publish their annual ‘state of care’ report. They aren’t responsible for the quality of care provided by individual trusts.

But two or three years down the line, after Francis inspired regulation, more vigorous inspection and star ratings, poor care in a hospital might be seen to be just as much their responsibility as that of any other national organisation, probably more so than NHS England which might commission few if any services from it.

But, perhaps surprisingly, NHS England was commissioned by the East Anglian Quality Surveillance Group to undertake a rapid review, following a CQC inspection into Queen Elizabeth Hospital King’s Lynn. They also chaired the risk summit involving nine statutory organisations.

It seems a very complicated way of doing things: a ‘commissioning’ remit from a non-statutory body without any formal status, and a ‘summit’ chaired by an organisation with no formal accountability for its operation or responsibility for what followed. Maybe this is a sign of how difficult it will be to get a grip on major reconfiguration proposals.

And then there is the Department of Health and Secretary of State, intended to take a step back under the Lansley reforms. But Jeremy Hunt’s proposals for refreshing the Mandate and the seeming competing policy activity make this look less rather than more likely. A different Secretary of State would see yet a further change, whatever the law originally intended.

I draw two conclusions from this. First, we have no choice over the taxes we pay to fund the NHS. Reasonable questions any tax payer should ask are who is in charge and who is accountable for what is provided for me in return. The answers are currently opaque and changing under the fog.

Second, the job of NHS Chief Executive has changed significantly over the past decade. Some think it has become smaller, being one of several at the top table. But, we will continue to demand the Chief Executive to be visibly accountable for the NHS and on that score the role is in danger of having responsibility without power.

Simon Stevens has a tougher prospect than past Chief Executives if only because of that.

Suggested citation

McKeon A (2013) ‘Who shall we hold to account?’. Nuffield Trust comment, 30 October 2013. https://www.nuffieldtrust.org.uk/news-item/who-shall-we-hold-to-account