Balancing liberation with accountability?

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How should a multi-billion pound quango be held to account? This is the challenge that faces the Department of Health in setting out a mandate for the NHS Commissioning Board which will take over responsibility for the majority of the NHS budget in April 2013. The Board will be responsible for directly commissioning services worth around £20 billion and for allocating more than £60 billion to more than 200 clinical commissioning groups.

The creation of the Board has its origins in debates that have raged throughout the past decade about the separation of politicians from the day-to-day running of the NHS. All NHS providers will be taken out of direct control of the Department of Health and will be regulated in much the same way as NHS foundation trusts and private providers of NHS-funded care (by the Care Quality Commission and Monitor). The creation of the NHS Commissioning Board also separates commissioning from direct political control.

Previous attempts at separation, such as the NHS Executive (which was located in Leeds to underline the point) and the NHS Management Board before it, were not sustained and politicians quickly reverted to type, intervening when public and political concerns about the NHS arose (see our publication on governing the NHS for more). So will it be any different this time?

Certainly the architect of the reforms, former Secretary of State Andrew Lansley, believed it would be. One of the reasons for enshrining the separation in legislation was to make it harder for his successors to reverse it. The critical challenge is whether it is possible for the government to set out in the mandate its priorities and objectives for the NHS Commissioning Board in such a way that it is ‘liberated’ (ie, the government doesn’t tell it how to do its job), but also satisfies the public that the Board is delivering value for money.

Setting objectives for the NHS is not an easy task. Politicians have drawn parallels with the decision to give independence to the Bank of England – at the time seen as a great success. However, it is not possible to capture the heterogeneity of health services in a simple objective or formula – there is no equivalent to the inflation or interest rate.

As we argue in our formal response to the Department of Health on the draft mandate, the attempt to reduce the range of outcomes that the NHS has to deliver (and are important to patients and users) to five high level measures is neither feasible or desirable. The methodology that underpins these measures runs to over 650 pages and is so opaque that even a trained statistician would struggle to make sense of it. Setting levels of ambition for the ten overarching indicators in the NHS Outcomes Framework would be a more transparent and meaningful way of measuring whether the Board is delivering improvements in care.

Even if the objectives and measures in the mandate are revised, when performance starts to deteriorate, politicians will be tempted to step in. They may want to set the goals low or revise them down to reduce the perception that the NHS is performing badly. We argue for a stronger role for an independent group of experts to advise both on the levels of ambition and whether the progress made by the Board is acceptable.

The Board has made it clear that it wants the mandate to contain fewer objectives. While we agree there are objectives that should be in the framework agreement or dropped, the Board cannot escape the fact that there must be a clear set of measurable and stretching objectives if public accountability is to be effective. How the battle between the Board and the Department of Health over the mandate ends will determine where the lines are drawn in the balance of power between the politicians and the NHS.