Holding the NHS to account

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.

Read our report: Accountability in the NHS: Implications of the government's reform programme

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#451 Dean

Good report all round. Re: local accountability: the Localism Bill will allow councils to revert to the archaic "committee system", with an associated loss of local and democratic health scrutiny. That's exactly what's going to happen where I live, so there will be one less group providing accountability.

#454 tim gilling
deputy executive director
centre for public scrutiny

There's a lot in this report that reflects our own thoughts about the 'web of accountability' and the submissions we've made and amendments we've suggested throughout the White Paper, Bill Committee and 'listening exercise' process.

The health scrutiny arrnagements have been particularly long lasting given the other reforms and changes that have taken place in healthcare since 2003. We were pleased that the Government siad that health and well-being boards were the wrong place to locate scrutiny powers and we welcome the extension of powers over all commissioners and providers.

We are worried that council executives could water down their local scrutiny arrangements and that the powers to refer contested changes to services will be restricted - our submission to the Future Forum picked up on these issues.

The one area where I'd take issue with the report is where the health and well-being boards have been described as having a scrutiny role - what they will have is a co-ordinating role, which is in effect an executive function. As you've pointed out elsewhere in the report separate scrutiny arrangements will remain. This may just be a question of symantics but does flag up the importance of getting the language right.

#455 Barbara Harris
Save Frenchay Hospital Group

Dear Jo,
There is no real accountability in the NHS. Nor are there standards. NICE issues 'guidance' which implies an element of choice as does 'Improving Outcomes Guidance.' We need standards, rigorously applied.
I've watched Health Scrutiny committees over the last seven years and they are not up to the job. They ask for reports from the NHS for their next meeting and those reports and the bearers, never turn up. HOSC are held in contempt by the NHS. Just a joke. HOSCs have heavy powers but are counselled out of using them by officers.
NICE and IOGs should become standards. I know something about this as my husband died in hospital two years ago after 5 weeks of an appallingly low standard of care. I complained and the reviewing surgeon found 9 instances of below standard care: I added another 9 for below standard nursing care. Onwards to the Ombudsman.
Accountability in this Bill will be non-existent. That's why politicians are stuck.
The SFHG took the PCT, SHA, DoH to the Court of Appeal in 2007 because they failed to consult us about implementing Emersons Green Treatment Centre. We won. They were astonished that we had stuck up for our rights and won! How dare we?
GP commissioning is merely a smokescreen for shepherding in the private sector - nothing more. How will the Gov force consortia to allow us to have our statutory rights to be consulted on substantial changes to our healthcare provision? Answer = they can't so we will have to take them to Court to rectify that but they still cannot make a private business throw open their books to see where the money is going. Our money.
If you want to see my views, which I gave to the Future Forum and Clegg, Cameron, Lansley, Dorrell, Skidmore and Lopresti, then email me and I will attach the statement.
They have raised our expectations and what the Govt will find is that the public has had enough of being ripped off and is now taking the gloves off and expects to be heeded. Govt is out of step because they have ruled by dictat up to now but ignore us at your peril, Lansley.

#456 John Kapp
SECTCo www.sectco.org

I agree with Barbara that there is no accountability to speak of in the NHS at the moment, but believe that removing the SHAs and the PCTs will improve it, because they were the problem. The GPs will be accountable to their patients their consortia and to Healthwatch.
The diagnosis of the NHS is that their treatments (drugs) tend to do more harm than good. Opening the market to Any Willing Provider could include complementary therapy centres offering NICE-recommended Mindfulness Based Cognitive Therapy courses for depression and IBS and spinal manipulation for low back pain, which are cost effective, and could deliver the Nicholson challenge. See my website for details.

#460 Mel Hobbs

Current experience with the Local Out of Hours Service has led me to believe that despite ALL the So Called Regulatory Authorites they either cannot or will not take firm and proper action against wayward
Nowhere am I able to find any disciplinary code which can be used
to deal with these people. Most Doctors that I have met in the last seventy years have been outstanding in their attitude and treatment of patients but the odd ones are arrogant and rude. There should be a system that fines them and the sooner the better.
Leaving the problem to be dealt with by way of "Training"! by the local PCT is a waste of time and will not work.
It is time their pedastal was removed.

#492 Suvarna Sansom
patient advocate

As a nation we spend a lot of money on our health service and the standard delivered is well below other comparable countries. The role of the Ombudsman is crucial in ensuring the standards we expect are delivered. According to the Ombudsman’s Annual Report, In 2009/10 the Ombudsman received 14,429 health service related complaints of which 180 were investigated and 112 were fully or partly upheld, i.e 0.8%. Such a low level of upheld complaint is symptomatic of either an extremely high performing organisation or a poor performing complaints investigator. Current reports in the media echo these findings e.g. BBC and other sources. I don’t think many would believe that the NHS is a high performer and so the answer is more likely that the Ombudsman is not doing a very good job.

I accept that many complaints are probably resolved locally but even so such a low level is extremely suspicious. There is a complaints process but this entails the Ombudsman investigating itself which cannot be considered independent. As a consequence there does not appear to be any independent review of the performance of the Ombudsman and so perhaps we cannot be surprised with the poor performance of our NHS. I think this is very worrying indeed and I hope that Steve Dorrell is genuinely interested in creating a workable complaints system and Ombudsman reforms, so that we can say that we have a world class health system. This may come as a surprise but my dad goes to India to gain advice over his care due to lack of confidence in the UK health care. Particularly as my brother died of mrsa after heart surgery in a major hospital in London. We came to the UK because we believed we would have world class health service for my young brother who had lupus, but in the end he died a most traumatic death due to neglect. Likewise I hope to go to China as I have steroid-induced diabetes after medical blunders, in Sussex, to receive stem-cell therapy in the hope curing my diabetes.

#504 Suvarna Sansom
patient advocate

I have contacted Health Select Committee Mr Dorrell, over my lived experiences at Royal Sussex County Hospital, no response.

I have contacted Department of Health, no response.

I was involved in a discussion of my medical care in Nursing Times- the contributors agreed that patients like myself who blow the whistle on poor care can expect to be treated badly. When a kind nurse or doctor blows the whistle - they are punished as I am as a patient. There certainly is no accountability. It is like we are surrounded by mafia culture, criminal syndicate that emerged in the mid-nineteenth century!

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