Why Making The NHS Accountable Might Save It

Today, against a background of reduced funding, change on a huge scale is being driven through our NHS by groups (Sustainability and Transformation Partnerships (STPS)) that have no legal basis, have a leadership that is unelected and unaccountable, operating mostly in secret. 

My professional career in the NHS and my activity within the Labour Party dealing with local councils has left me deeply concerned about the lack of accountability within NHS. It has also convinced me of the benefits of meaningful accountability, in its wider sense, as a route for change and improvement.


We need to somehow bring democratic accountability into how major decisions are made, allow true representation on the bodies that deliver care and to allow elected representatives, MPs like me, a proper channel to represent our electorate.  And we have to have true openness and transparency – publish everything.


A key issue around accountability results from the complex fragmentation of the NHS making it wholly unclear where responsibility and accountability reside. 


From the bottom up, there are literally hundreds of bodies involved.  The 200 odd Clinical Commissioning Groups (which in theory control over £60bn of NHS expenditure) are members clubs and have no element of either democratic or representative democracy.  They are also plagued with conflicts of interest.


Of the 250 plus NHS bodies which provide services some still have fully appointed boards and are controlled directly while the others (the Foundation Trusts (FTs)) have a kind of membership structure and elected Governors. Sadly, the FT model (however well intentioned) has not done much for public and patient involvement.


And, of course, a significant proportion of NHS services are provided by non-NHS bodies – like GP practices, pharmacies, ophthalmologists and dentists; to which must be added the 8% of the NHS Budget spent with for-profit private care providers – where commercial confidentiality overrules any accountability.


With the closely connected social care we have the illusion of democratic accountability for “commissioning” and an almost entirely privatised service delivery.


Somehow Health and Wellbeing Boards, Healthwatch and Joint Health and Wellbeing Strategies fit into the picture.


At the top, the current Secretary of State sees the job as chief patient representative as if he had no role at all in the services and systems that the patients have to experience – sometimes badly. At the top are not just the Department and Minsters but a raft of arm’s length regulatory bodies. 


It’s a total unaccountable mess.


One reason for the mess is the disaster of the Health and Social Care Act and the marketisation of the NHS.  In a market there is no “accountability” in the sense we as democrats use the term.  But the NHS has always been poor on accountability and always been fragmented in ways that make accountability harder, always seen itself as having a separate role from the rest of the (democratically accountable) local authority led public services.  And the NHS was and is riven with powerful vested interests that distort genuine accountability to the taxpayer.



Back in the present, in a recent article, Chris Ham of the Kings Fund looked to closer working at the top of the NHS, reducing the number of commissioning bodies and closer working between the NHS and Local authorities - leading to better oversight of money and performance.  His challenge to politicians is to let that happen with some legislation but without any toxic top down redisorganisation. 


Under the current system the role of MPs like me is relegated to an annual vote on the national plans (through the Mandate) and the total budget.  Yet local MPs are expected by constituents to stand up for local services, make sure they have right resources, be able to make a difference when things go wrong. MPs are where the national policy meets the local reality.  As well as bringing our local experience to parliament we should not be let off the hook for the decisions we make in parliament when we are local. We need to understand local impact and for that to happen we need greater local accountability and transparency of decision making.


I know local politics can make things difficult when tough issues like service changes are necessary.  But excluding MPs is not making this any easier.  It's challenging work for NHS managers and clinicians making the case to local people and their MPs, but without it decisions gain no legitimacy. 


MPs should be demanding a local role to be able to follow the money from our vote in Parliament to GP surgery door and back again. Local people should have a way of recognising or linking the taxes they pay to the service they get. What NHS managers rarely experience is that taxpayers or voters or the public are quite rational.  Presented with a well-made case supported by (dare I say) experts or informed leaders and clarity on costs they will accept decisions.


It is no secret that the money the NHS now has is not sufficient to do all promised in the constitution, to the quality expected by the public.  Even Tory MPs are being confronted by reality - GP list closures, trolley waits, absence of mental health beds and delayed dates for operations as well as the reality of being bounced around the system trying to understand who is in charge.


On behalf of our constituents we should be considering how to improve the NHS, not just tidying up national bodies but by putting the public centre stage. Reorganisations from 1945 onwards have focused on organisational or geographical alignment from London.

 We can keep the N in NHS but to save it we need to give local people far more control.