Where does the buck stop? Understanding accountabilities and structures in the national health and care system in England
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The Health and Care Act 2022 and concurrent reforms to the public health system have introduced a range of changes and some simplifications to the landscape of national bodies in the health and care system.
Here, we explain the core functions of the national bodies with the most significant role in setting policy for and shaping the operation of the health and care system. We also look at how these organisations are held accountable for carrying out those functions and the extent to which central government can direct them.
A simple guide to how accountability flows across the national health and care system in England
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Recent changes
In 2021 two concurrent sets of health and care reform began that have had an impact on the number of national bodies and where responsibility for some key activities sit.
The Health and Care Act 2022: the Act created significant change at a local system level, but also reorganised some national accountabilities. The Act allowed the incorporation of NHS Digital, NHSX and Health Education England’s into NHS England. NHS Improvement had been working closely with NHS England before the Act, which now formalises this relationship.
Reforms to the public health system: following a significant shake up of the public health system in 2021, Public Health England was disbanded and its core responsibilities were split between two new organisations. Its health protection functions moved to the United Kingdom Health Security Agency (UKHSA). Responsibility for health promotion, health improvement and addressing health inequalities now sits with the Office for Health Improvement and Disparities (OHID), which is a new directorate within the Department of Health and Social Care.
Central government departments
The Department of Health and Social Care and the Department for Levelling Up, Housing and Communities have the most direct oversight of and accountability for health and social care in England. Government departments work to support their ministers to deliver the government’s priorities and objectives. In this section we set out some of their key functions.
Common terms and features of central government departments
Ministers: departments are usually led by a Secretary of State, who is supported by several ministers of state and parliamentary under secretaries of state. Collectively, they are known as a department’s ministers.
Principal accounting officers: the most senior civil servant in any department is its permanent secretary. They hold the role of the department’s principal accounting officer and are responsible for ensuring the department, and all its arm’s-length bodies, are using resources effectively.
Accountability to parliament: each department’s ministers and principal accounting officer are accountable to parliament. Their work is scrutinised by select committees, and their spending is scrutinised by the Public Accounts Committee.
Funding and auditing: HM Treasury allocates each department a budget to meet its agreed plans and objectives at a Spending Review. Departments prepare an annual report on their activities and accounts, which are then audited by the National Audit Office, and the Public Accounts Committee may call the Secretary of State and the permanent secretary to give oral evidence on the NAO’s findings.
Department of Health and Social Care
The Department of Health and Social Care (DHSC) is a central government department, with responsibility for policy, legislation, funding and delivery of health and care in England.
What does DHSC do?
DHSC’s overarching objective is to ‘lead the nation’s health and social care to help people live more independent, healthier lives for longer’.
When Public Health England was disbanded in 2021, DHSC took on its ‘health improvement’ function and the Office for Health Improvement and Disparities was established as a new directorate of DHSC.
DHSC also has oversight of a range of executive agencies and non-departmental public bodies, which are collectively known as arm’s-length bodies. There are framework agreements in place between DHSC and each of its arm’s-length bodies to set out how they will work together and how the department will hold each to account. The department usually reviews and approves each body’s business plans and priorities. DHSC’s own corporate plan sets out the Secretary of State’s priorities and objectives for the department and its arm’s-length bodies.
DHSC also has responsibility for the delivery of local government’s public health and adult social care functions, but not the related spending (responsibility for this sits with the Department for Levelling Up, Housing and Communities (see below).
Department for Levelling Up, Housing and Communities
The Department for Levelling Up, Housing and Communities is a central government department, with oversight of local authorities whose responsibilities include delivering social care and public health services for their communities.
What does the Department for Levelling Up, Housing and Communities do in health and social care?
The Department for Levelling Up, Housing and Communities allocates resources and audits local authority spending on adult social care and public health services, as well as the broad range of the other services delivered by local authorities.
This audit includes expenditure from core grant funding, such as the Social Care Grant and the Public Health Grant, as well as of revenue raised by local authorities, for example, the adult social care Council Tax precept. If a local authority is failing to deliver services or is using public money incorrectly, the Secretary of State for Levelling Up, Housing and Communities can intervene and run local services directly.
Arm’s-length bodies of the Department of Health and Social Care
Like all government departments, the Department for Health and Social Care has oversight of executive agencies and non-departmental public bodies that support the department’s work, collectively known as the department’s arm’s-length bodies.
Definitions: Types of arm’s-length body
Executive agencies act as extensions of their sponsor department. They generally do not offer policy advice, but focus on delivering specific services for the department. They have separate management from their sponsor department, but their chief executives are accountable to the sponsor department’s ministers.
Non-departmental public bodies are not part of a government department and are more independent from ministerial control than executive agencies.
Source: Institute for Government 2022
Most of the arm’s-length bodies referred to here are non-departmental public bodies and are governed by a board, led by a non-executive chair and other non-executive members appointed by the Secretary of State for Health and Social Care, following the public appointments process. Each board appoints a chief executive, who sits on the board as an executive member alongside other senior executives.
Healthwatch England is an exception. It is led by an independent committee of the Care Quality Commission (CQC) board. The chair of Healthwatch England is appointed by the Secretary of State and also sits on the CQC board, though Healthwatch England has budgetary and operational independence.
Common terms and features of arm’s-length bodies
Framework agreements: there is a framework agreement in place between DHSC and each of its arm’s-length bodies. These agreements set out the relationship between the two functions, including how accountability and governance arrangements work.
Senior departmental sponsor: every DHSC arm’s-length body has a named senior departmental sponsor. This is a senior civil servant who acts as the day-to-day point of contact within the department for each body. A sponsor ensures that the arm’s-length body is working effectively and using its resources appropriately; they then provide assurances to the principal accounting officer, or permanent secretary.
Accounting officer: usually the chief executive of an arm’s-length body is appointed as its accounting officer. Accounting officers are responsible for providing assurances to the senior departmental sponsor that their organisation is operating as it should.
Funding and auditing: each arm’s-length body receives funding from DHSC. Each body’s accounts are audited by the National Audit Office (NAO) and are then formally presented to parliament. The NAO can also choose to conduct an inquiry into the work of any arm’s-length body, which would see that arm’s-length body scrutinised by parliament’s Public Accounts Committee.
Written ministerial direction: if an accounting officer believes a spending proposal they have been asked to take forward is improper or does not represent good value for money, they can request written ministerial direction. This is a rare occurrence and allows accounting officers to demonstrate that some spending decisions are taken under direction, rather than independently. For example, recently NHS England’s Chief Executive requested written direction on the decision to block-contract independent sector hospital beds in response to the emerging Omicron variant of Covid-19.
Arm's-length bodies: strategy and commissioning
NHS England
NHS England is an independent non-departmental public body, responsible for providing national leadership and direction for NHS organisations in England. With a budget of £147.8 billion in 2022/23, it is the largest of DHSC’s arm’s-length bodies. Its objectives are set annually by the Secretary of State for Health and Social Care via the NHS Mandate.
NHS England is led by a board. The Secretary of State for Health and Social Care appoints a non-executive chair for the board. The board appoints a chief executive, with the consent of the Secretary of State, who sits on the board with other senior executives.
What does NHS England do?
The core function of NHS England is to promote and support a comprehensive health service in England. It does this by allocating funds to integrated care boards (ICBs), so ICBs can arrange and commission services to meet the needs of their local populations. NHS England commissions some specialist services itself.
NHS England also produces, in consultation with the government, annual operational planning guidance for ICBs that sets out its priorities and expectations for the year ahead. Performance managers in NHS England’s regional offices monitor the operational and financial performance of all ICBs, and the NHS organisations within each ICB, to ensure that they deliver these.
The Health and Care Act 2022 and its associated reforms allowed several arm’s-length bodies – NHS Improvement, Health Education England, NHSX and NHS Digital – to be incorporated into NHS England. All these bodies will be subsumed by directorates of NHS England, accountable, via the NHS England chief executive, to NHS England’s board.
NHS England already has a joint working arrangement in place with NHS Improvement, the Act now formalises this.
The merger of Health Education England into NHS England, will see NHS England take responsibility for workforce planning, training and development from April 2023. With the merger of NHSX and NHS Digital, NHS England takes on role of setting standards for use of technology in the NHS, maintaining technological infrastructure across the NHS and providing data.
As well as reducing the number of arms-length bodies, these mergers will also see a substantial reduction in the number of staff working in NHS England, with 30-40 per cent of posts (6,000 to 8,000 posts) expected to disappear.
Who is NHS England accountable to?
NHS England is accountable to parliament and the Department of Health and Social Care. It has a senior departmental sponsor who sits within DHSC, and its chief executive is also its accounting officer.
The Secretary of State sets the annual NHS Mandate, which outlines the government’s expectations, priorities and financial settlement for the NHS.
The Health and Care Act introduces new powers for the Secretary of State to direct NHS England beyond the objectives set out in the Mandate and to intervene in local service reconfigurations. The expectation is that the Secretary of State will not routinely use these powers, and NHS England will retain its day-to-day operational independence.
Arm's length bodies: quality, safety, standard setting and public involvement
Care Quality Commission
The Care Quality Commission (CQC) is a non-departmental public body. It is the independent quality regulator for health and adult social care in England.
The CQC’s regulatory functions are funded in part by the Department of Health and Social Care and in part by registration fees paid by all regulated health and social care services providers Government policy requires the CQC to fully recover the costs of regulation.
The CQC is led by a board, and the Secretary of State for Health and Social Care appoints a non-executive chair to lead the board. The board appoints a chief executive as well as chief inspectors of adult social care, general practice and hospitals, all of which are executive members of the board.
What does the CQC do?
The core business of the CQC is to register health and care providers as well as monitor, inspect and regulate health and adult social care services. The CQC routinely publishes performance ratings for all registered providers and may also undertake thematic reviews across a sample of services. The Health and Care Act 2022 gives the CQC new functions to assess the performance of ICSs and to review local authorities’ commissioning of adult social care.
The CQC also has a role in monitoring the use and application of the Mental Health Act 1983 and the use of Liberty Protection Safeguards.
The organisations the CQC regulates and the fundamental standards expected are set out in legislation so are not determined by CQC. The CQC has independence over how it regulates, as it sets thresholds for how it rates services and designs its own inspection methodology. The decisions about the quality, safety and effectiveness of care that the CQC makes, are entirely independent and DHSC cannot intervene in a specific case or inspection.
If the Secretary of State for Health and Social Care has grounds to believe that the CQC is routinely failing to carry out its duties correctly, they can direct the CQC, effectively removing its independence.
The CQC also has oversight of Healthwatch England, as Healthwatch is set up as a Committee of the CQC’s board. This means that Healthwatch England has to consult the CQC when developing its annual business plan and strategic priorities.
Who is the CQC accountable to?
The CQC is accountable to parliament and to the Department of Health and Social Care. It is allocated a senior departmental sponsor, and the CQC’s chief executive is also its accounting officer.
Every three years, CQC develops a new strategic plan, which is refreshed annually. This plan sets out its objectives and strategic direction, and is developed in consultation with the Secretary of State to ensure it supports the objectives of the department.
Healthwatch England
Healthwatch England is an independent committee of the CQC. The chair of Healthwatch England is appointed by the Secretary of State and is a non-executive member of CQC’s board. Healthwatch England’s budget is ringfenced within the overall CQC budget and it speaks independently of CQC.
What does Healthwatch England do?
Healthwatch England’s primary function is to provide leadership, advice and guidance to local Healthwatch organisations. Local Healthwatch organisations are funded by, and accountable to, local authorities. Local Healthwatch organisations gather public views and insights about local health and care services. They then use this insight to shape, scrutinise and make recommendations about services. If a local Healthwatch organisation is not operating effectively, Healthwatch England can revoke its Healthwatch branding, meaning the local authority will not have a functioning Healthwatch and will therefore be in breach of the legislation.
Healthwatch England has a statutory responsibility to escalate any concerns raised by local Healthwatch organisations to the CQC. It also provides advice to the Secretary of State for Health and Social Care, NHS England and to English local authorities where it is concerned that local services are inadequate.
Healthwatch England is also formally consulted by DHSC on the NHS Mandate.
Who is Healthwatch England accountable to?
There is a senior departmental sponsor for Healthwatch England, though the National Director of Healthwatch England is not an accounting officer. The chief executive of the CQC is accountable for Healthwatch England’s use of public money and must seek assurances that Healthwatch England’s resources are being used effectively and appropriately. This is done via formal accountability meetings between the two organisations.
Healthcare Services Safety Investigation Branch
The Healthcare Services Safety Investigation Branch (HSSIB) is a new non-departmental public body, established as a statutory, independent body by the Health and Care Act 2022. It will become operational in April 2023.
HSSIB effectively replaces the Healthcare Safety Investigation Branch (HSIB), which under the previous arrangements was part of NHS Improvement. Under interim arrangements, to be in place between July 2022 and April 2023, HSIB will sit as a division of NHS England.
What will HSSIB do?
When it becomes operational in April 2023, HSSIB will investigate reported incidents of poor care that have an impact on patient safety. The Health and Care Act 2022 allows HSSIB to investigate both NHS and independent sector providers. Anyone will be able to report an incident to HSSIB, though to merit an investigation the incident will have to meet certain criteria.
HSSIB’s investigations will focus on learning: it will not be a regulator and will not attribute blame for failings it uncovers. The Health and Care Act 2022 provides HSSIB with new powers to enter and inspect premises as part of an investigation.
It will also be responsible for promoting a culture of learning within the NHS and may also provide advice, training or guidance in relation to an investigation on request.
Who will HSSIB be accountable to?
As a non-departmental public body, HSSIB will be accountable to the Department of Health and Social Care. The Secretary of State and the permanent secretary will be accountable to parliament. As HSSIB will not become operational until April 2023, there is currently no formal framework agreement setting out how this relationship will work.
National Institute for Health and Care Excellence
The National Institute for Health and Care Excellence (NICE) is a non-departmental public body, responsible for setting standards for practitioners, commissioners and managers across health and social care. This includes both the clinical effectiveness and cost effectiveness of health technologies (including medicines and medical devices) and medical procedures. NICE is funded by the Department for Health and Social Care.
What does NICE do?
NICE’s core role is to provide guidance and support to providers and commissioners of health and care services to help them improve outcomes for people who use the NHS, public health or social care services.
It provides guidance to the NHS in England on the clinical value and cost effectiveness of medicines, medical devices and procedures. Only medicines and medical devices that pass NICE’s clinical- and cost-effectiveness thresholds can be provided by the NHS. NICE also produces advice and quality standards to support quality improvement in public health, social care and health services, but these are not mandatory.
NICE’s guidance has to be commissioned by NHS England or by ministers at the DHSC. Its work programme is usually set several years in advance, and decisions on which topics are referred to NICE are based on NICE’s capacity.
NICE reviews its strategic priorities on an annual basis, so that it can manage its work programmes to best meet the objectives of DHSC and NHS England.
Who is NICE accountable to?
NICE is accountable to parliament via the Secretary of State for Health and Social Care. NICE has a senior departmental sponsor and its chief executive is also its accounting officer.
Acknowledgements
With thanks to Matthew Gill and Grant Dalton from the Institute for Government for their comments and insights, which helped shape this explainer. Any errors are the author’s.