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As the government's listening exercise on the Health and Social Care Bill draws to a close, those leading the NHS Future Forum say they have faith that the government really has been listening; more cynical commentators say the government is really busy horse-trading. The truth is no doubt some combination of the two.
We have already set out our thoughts on how the NHS reforms should be reconfigured, and have now undertaken more detailed analysis of what the reforms mean for the accountability of the NHS, published in our report today.
Although the term 'accountability' may not have featured heavily in debates around the Bill, it has been an undercurrent in many of the concerns about the reforms: if the government is cutting the service loose from central managerial control and opening up the market for provision, what kind of assurance will patients, carers and taxpayers have that commissioners and providers will be acting in our best interests? How will we know if they are? And what can we do if they are not?
We analysed the current accountability arrangements for commissioners and providers of NHS-funded care and looked at how these would change if the Bill is implemented as it stands. One of the starkest findings is the weakening of accountability requirements for hospitals. Gone would be the strong performance management from the Department of Health and strategic health authorities and the quasi-performance management role played by Monitor for foundation trusts – leaving accountability in the new system to rely on regulation, local scrutiny arrangements, internal governance challenges and the requirements of commissioners.
The reliance on regulation focuses only on securing minimum standards – how do we ensure that we encourage providers to do more than that? Is it going to be possible for local individuals and organisations to hold providers to account for offering a good or excellent service to patients and value for money for the taxpayer? Evidence on those who hold providers to account at a local level, in the form of overview and scrutiny committees and local involvement networks (to be re-branded as Local Health Watch), suggests that their efficiency is pretty patchy. We don't yet have reason to believe that new – and sometimes really quite small – GP consortia will be well placed to triumph in tough contract negotiations with major acute hospitals – where even their predecessors struggled. This leaves a lot riding on the role of boards and foundation trust (FT) governors to act as effective account holders for their organisations. Previous evaluations of the influence of FT governors call into doubt whether they are ready and able to step up to this challenge.
These are not arrangements to be rushed into: if we are not absolutely confident in the power of FT boards, commissioners and other local scrutinisers to hold hospitals to account, we need to consider what additional assurances might be required. For example, in the new system the Care Quality Commission or Monitor could be granted powers in relation to FTs to monitor their governance, and indeed to make licensing dependent on them having strong governance arrangements in place. The pause and the possibility that the Bill may be revised provide an opportunity to ensure that strong and appropriate accountability mechanisms are in place.