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Public accountability needs to be at the heart of NHS reform

The need has never been greater for transparency and community involvement in decisions about how to manage changes to health and care services, says Alex Baylis.


NHS Improvement has now acknowledged, as many people expected all along, that the plan to clear trust deficits by next year is probably not realistic.

Financial pressure is not going to end any time soon: our analysis shows there will still be at least a £1 billion gap after the promised additional £1.8 billion. A deficit of this size will have implications for services and for patients. The need has never been greater for transparency and community involvement in decisions about how to manage this.

Change is a constant in the NHS, but the changes currently underway have a unique set of features.

  • Until recently, the mark of a high-performing trust was to achieve foundation status and earn its autonomy, with local accountability rather than central direction and performance management. That is no longer the case. Now, not only is there is no elite group whose performance is insulated from the challenge of financial constraints, but all trusts are subject to control totals, centralised planning and accountability to NHS Improvement.

  • Sustainability and transformation plans (STPs), new care models such as vanguards and GP federations, and devolution mean that the whole system is changing. It’s not just hospital trusts: changes in primary care, community services and commissioning are at least as significant but they are not getting the same level of public and media scrutiny as the acute sector.

  • The pace of these changes is so fast that some plans are not always credible – eliminating deficits and involving local communities in developing STPs being cases in point. Significant change is being managed through local agreements without legislation and the national debate that goes with it, sometimes even (for example, in relation to foundation trusts’ duties around competition) seeming to downplay or blur statutory responsibilities.

All this comes on top of the 2012 changes, which The King’s Fund raised concerns about at the time in relation to public accountability.

But it’s not all bad news.

The NHS five year forward view does put a major focus on involving communities and ensuring accountability to them. And even a change as major as devolution in Manchester does not necessarily require diverting effort into yet more reorganisation of how the public are involved: they have decided in Manchester that existing structures for public accountability and involvement can be made to work effectively.

This is encouraging because we know that public accountability can be powerful for designing and, above all, sustaining systemic change.

The King’s Fund’s study of healthcare reform in Alaska is an example, where the service’s purpose and relationship with local people have been fundamentally reinvented so that instead of referring to ‘patients’, the local community are ‘customer-owners’. However, when we studied this system last year, we noted that its maturity and success had developed over 17 years of following a consistent strategy.

It all comes back to what The King’s Fund said in our report Reforming the NHS from within. Top-down performance management, regulation and competition are not the most effective levers for sustainable, high-quality care. Leadership, staff engagement and structured improvement plans – including community involvement – are the key, along with sufficient time to see those plans through rather than chopping and changing policy direction.

There are clear messages here for the NHS.

  • Involving the public and being accountable to them is essential as we enter the next round of change – and not just in relation to hospitals.

  • This is well recognised in the STP process, but timetables must be realistic. It can’t be done on the quick: doing so risks reducing it to tick-boxes.

  • Local NHS leaders need to take ownership of public accountability. There is much already there to build on. But they need to work out a timetable that works for their local area and plan for a long-term, ongoing process. STP deadlines should be seen as milestones in this long-term approach, not completion dates.

This piece was originally published on the NHS Voices blog. Alex Baylis will be speaking on this subject at the NHS Confederation annual conference and exhibition on Thursday 16 June.

See the NHS Confederation website for information about the Annual Conference and Exhibition.