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


The government's health reforms propose radical changes to the structures and processes within the National Health Service in England.

One of the core issues is how providers and commissioners of care will be held to account in the future if many of the existing lines of accountability are removed, and there are deep concerns about whether the proposed substitutes are adequate for the task.

The reforms could significantly reduce the day-to-day involvement of politicians, civil servants and managers in health care. Localisation, GP empowerment and patient choices will be the new priorities.

Accountability in the NHS: Implications of the government’s health reform programme seeks to inform the debate around the nature of accountability relationships in the NHS and how these will change under the reforms. The authors identify five types of accountability most relevant to health care – by scrutiny, management, regulation, contract and election.

Current accountability relationships, of both providers and commissioners, are considered and these are compared and contrasted with the proposed new forms. The authors then assess whether the reforms will meet the government's policy aims and whether the new system is workable.

The report concludes that the proposals carry significant implications for:

  • secondary care providers, whose accountability will shift to see a greater reliance on regulation and internal governance

  • GP practices as providers, who will see an increase in accountability requirements

  • GP commissioners, who may face managerial and political accountability requirements, with the NHS Commissioning Board having potentially wide-ranging powers of intervention in relation to consortia.

There is a real risk that the accountability of secondary care providers will be underpowered in the new system. The authors contend that this may be politically unacceptable in the medium to long term. Overall, they raise concerns about a shift towards a reliance on local accountability mechanisms that are, as yet, unproven.