How to score public accountability points

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Ruth Thorlby and Richard Lewis discuss the public accountability of primary care trusts.

PCTs have long been accused of a 'democratic deficit'. Critics have claimed that the crucial role of setting priorities and commissioning services should be subject to some form of local democratic control, as is the case for local authority services. In recent months the ante has been raised with a number of politicians, in particular Hazel Blears, Secretary of State for Communities and Local Government, calling for a fundamental reform of PCT accountability. The accountability question has now found a place on the agenda of Lord Darzi's NHS Next Stage Review.

But what would it mean for PCTs to be more locally publicly accountable? Public accountability involves two separate but linked concepts: a system of control over the operation of the PCT (accountability) and local public involvement in that system of control. Drawing on a conceptual framework for accountability developed by Ashworth and Skelcher, we suggest that an effective system of local public accountability would ensure that PCTs do three things:

  • take into account the views and needs of local people, through public involvement mechanisms and other techniques
  • give an account of its actions and decisions at a local level so that they are clearly understood
  • be held to account at the local level, with some degree of power being exercised by local people or their representatives to challenge the decisions of the PCT.

So to what extent does the current system of PCT accountability meet these desirable objectives? The answer is only in part.

Current accountability of PCTs is largely upward, through strategic health authorities to the Department of Health. While PCT management is accountable to a publicly appointed board (with members drawn from the local community), non-executive directors are not intended to be ‘representative’ of their local communities. Nor, unlike foundation hospitals, do local people play any role in their hiring or firing.

However, since 2001, local authority Oversight and Scrutiny Committees (OSCs) have had their scrutiny role extended to the planning and delivery of health services and must examine any substantial variations in services. OSCs have powers to summon NHS staff and request information. By 2005, a study of OSCs found that 92 per cent of local authorities reported having conducted some sort of health scrutiny in the previous 12 months and 11 per cent of local authority officials surveyed felt that services had improved as a result. Moreover, 45 per cent of NHS respondents to this survey said that their organisation had changed its policies, procedures or services as a result.

The experience of patient and public involvement forums would appear to be less happy with the Forums perceived to be bureaucratic and unrepresentative of local communities. These Forums are currently being replaced by Local Involvement Networks (LInKs) which will be commissioned by local authorities, cover local geographical areas rather than individual NHS trusts and engage a wider section of the population than a forum based on a small number of volunteers.

But before any wholesale reform is countenanced, it is important to be clear as to what specific benefits are being sought from the system of accountability. The goals for local public accountability can be broadly divided into two: instrumental goals (ie, that by involving local people in systems of accountability services will be better attuned to people's needs and therefore give greater satisfaction and even greater effectiveness); and political goals (ie, the promotion of democratic values and legitimacy which are held to be intrinsically good things).  These goals are very different in nature (although they are often conflated) and the reform strategies adopted will vary according to the strength with which each is pursued.

We have suggested a range of potential reforms to PCT accountability. These have been grouped these into systemic (ie, requiring fundamental change to governance) and incremental (ie, building on current structures and can be targeted to particular issues). No one option is superior in terms of its delivery of benefits or costs.

Getting local public accountability of PCTs 'right' is no easy task, but nor is it obvious that there is a major problem that needs to be solved. As things stand, evidence of an accountability gap is ambiguous and experience suggests that widespread local public engagement is possible but expensive. Some parts of the machinery such as OSCs appear to be working, at least in part. Other parts, such as LInKs are as yet incompletely implemented. How (and if) this system should be reformed depends on whether instrumental or political goals are predominant.  If the former, some combination of the incremental changes suggested here may be sufficient to imbue the work of PCTs with a stronger patient and public voice and expenditure on public accountability mechanisms can be justified on the grounds of making NHS services better. If the latter, more radical change may be required.

The new assurance framework for PCTs based on earned autonomy, together with recent exhortations by David Nicholson for them to look 'out not up, suggests that PCT accountability is already in transition. This itself raises a significant political challenge that demands an answer: If accountability to politicians at the centre is to diminish, what will replace it? If power is to be devolved to local communities, will it be democratic? And is the public ready to accept the local variation in NHS services and policies that might follow?