This article was written in May 2016 and originally appeared in The Health Service Journal
One year as MP and still none the wiser about lines of accountability in the NHS
When I started my NHS career as a planner in 1988, I was clear that Kenneth Clarke as Secretary of State was my boss. His intent was pretty evident. Back then, and in the 20 or so years that followed, the lines of accountability were straightforward. But by 2014, working for Bristol Clinical Commissiong Group (CCG), they’d collapsed – swept away by the biggest structural reform in the NHS’s history.
As Primary Care Trusts disappeared, it was often hard to know – working on the inside – who the immediate boss was and who was in charge of the NHS.
Was it the CCG? The Department of Health? NHS England? The CQC? Monitor? Or a combination of them all and the myriad other bodies to emerge from the upheaval of the 2012 Health and Social Care Act?
Going backward
It wasn’t just structures that were affected – patient care was too. The progress we had made in diabetes, end of life care and urgent and emergency care started to go backwards during the period of transition to CCGs in 2013. Managers and clinical staff did everything they possibly could to keep the show on the road and ensure patient care was the priority, but that commitment came without proper leadership from the centre.
Lack of public accountability had always worried me in my professional NHS role. Its collapse in the health service was a key factor in me seeking selection in 2012 as Labour Party candidate for Parliament in my home city of Bristol.
I always believed members of the public need to know and understand the routes they have, via the democratic process, to people who are clearly accountable, both at local and national levels.
Organisational re-structures led to those routes becoming muddied for me as a NHS manager and when I was elected as a Member of Parliament I had hoped things would become a little clearer.
And yet, one year on I’m still no clearer, either in my capacity as MP or as a member of the body that oversees taxpayer value, the Public Accounts Committee (PAC).
As an MP I see the impact on patients of the terrible upheaval, the absence of accountability, and an inability of local services to deliver urgent reform. Those all-important accountability routes have not just become muddied, they’ve been wiped away.
And as a member of PAC, I am now seeing the opaque nature of the NHS at a whole new level. I’ve attended numerous hearings on a range of healthcare-related topics with the senior leaders of all organisations. But even in this value-for-taxpayer role, I still don’t have the answers to the most basic questions: Who is accountable when things go wrong? Who is the boss? Where does the buck stop?
Deep challenges
Ask who is responsible. The Department of Health says NHS England; NHS England says NHS Improvement; NHS Improvement says the Department of Health. And when it comes to the deep problems in workforce recruitment and retention we throw in Health Education England.
It’s a ‘pass-the-buck’ merry-go-round. In fact when PAC discussed accountability for the Trust overspend with the Cabinet Office, Sir Jeremy Heywood told us that accountability lies “somewhere between the Department of Health and NHS England.”
So why does accountability in the NHS matter so much? Well, it’s vital in any publically funded service. When people cannot, even through their democratically elected MPs, find their way through the system when things go wrong then why should they cheerily support the service through the taxes they pay? Critically why should they pay more?
Arguably clear accountability is even more important when that public service expects everyone to make healthier choices and to take responsible decisions.
This absence of accountability is also important because it is compounding the deep challenges currently facing the NHS. Deficits are spiralling out of control, blamed on a soaring agency bill, but in reality it’s much more multi-factorial than that but with no mechanism to resolve. Waiting time targets have been missed so often now that failure is becoming the norm as it was in the 1990s. And as happens in any other walk of life, professionals and the public are looking for clear leadership to get things back on track. It’s nowhere to be seen.
Jeremy Hunt is telling providers that patient care must be improved, but signals from NHS Improvement are that the books must be balanced. Magic, and a fair degree of pressure, is being worked by the Department to bring the deficits under the control total. NHS England is pressing ahead with vanguards and sustainable transformation plans, and reintroducing a population-based approach.
At heart I’m an optimist, so I’ll end on a positive note. The current challenges facing the NHS are a chance to restore some real accountability into the system. The public will not stand by and allow Ministers to wash their hands of responsibility of a service on its knees. I believe there is hope for the future of an NHS whose lines of responsibility are clearly understood by all those we serve – and I hope in a few years’ time I’ll be a little clearer about who is running our NHS.