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Clear and accountable leadership is essential for success in any organisation. For the NHS in England, which treats more than 1 million patients every 36 hours, success and failure can mean life or death. So, it is vitally important that accountability arrangements are properly defined.
Unfortunately, since the passage of the HSC (Health and Social Care) Act in 2012, accountability and oversight within NHS England has become so complex that in November 2014 one MP, Bernard Jenkin, compared the architecture of the system to the popular film The Matrix.
Six years on from the introduction of the Act, the rapid introduction of new institutions, new models of care, new planning regimes and new funding flows have only served to confuse arrangements further, and it is clear that the NHS is suffering as a result.
The complexity of the system is illustrated in the diagram below:
In an attempt to limit political interference and devolve accountability to the local level, the HSC Act awarded power to a number of new bodies (e.g. CCGs, NHS England, the Care Quality Commission, and NHS Improvement). Since the enforcement of the Act, these bodies have amassed a tangled web of priorities, strategies and goals. Some of these conflict, and many are arbitrarily imposed upon commissioners and providers, who are then forced to navigate between national priorities and local need.
To complicate matters further, Commissioners and providers must now grapple with the impact of new integrated care structures like STPs, ICSs, ACPs and ACOs. These structures have created additional layers of decision-making power and confused existing responsibilities. For example, under an ACO contract (which is yet to be tested), a single provider is commissioned to deliver the majority of healthcare services in one area. This means that a provider will – to some extent - take on the role of commissioning health care. Where that is the case, it is not clear whether and how the existing statutory duties of NHS Commissioners will be performed. Who will be ultimately accountable? The commissioner or the provider?
In addition, STPs, ICSs, ACPs and ACOs are yet to be given any statutory footing. This means that they do not have a single legal identity, but rather they are ‘collections’ of organisations. This is particularly concerning, as it has not been made clear who or what will be accountable in the event of failure. In addition, before these bodies become separate legal entities, the individual responsibilities of each organisation are likely to be prioritised over common goals – limiting the likelihood that they will succeed.
The Government’s devolution agenda – under which regions are being given the chance to bid for full control of their health and social care budgets – is also causing some confusion around accountability. Thus far, devolution deals (including Manchester) have made clear that accountability remains with NHS England and CCGs rather than being transferred to combined local authorities. However, for better or worse these arrangements have blurred the boundaries of accountability for those operating within and for those looking on from outside.
Of course, all of these new structures, including combined local authorities like Manchester, require new and better aligned models of regulation. The Care Quality Commission and NHS Improvement are already making efforts to coordinate their approaches to oversight. However, having had limited time to catch up, duplication of work is common, and the resultant burden of information and assurance requirements on commissioners and providers has been described as overwhelming.[ii]
So, what is to be done? At a time in which NHS England is being asked to implement fast-paced changes to deliver services in new and better ways, a clear and transparent accountability framework is more important than ever. At the very least, better alignment between national and local bodies with the NHS will be necessary, regulatory frameworks will need to be updated and formal accountability arrangements will need to be established for STPs, ICSs, ACPs and ACOs. However, these measures may not go far enough to resolve the confusion caused by the HSC Act.
Nevertheless, there is a small light at the end of the tunnel. If the current Government delivers on its pledge to bring forward the long-term funding plan for the NHS - and if that plan delivers much needed investment - it is possible that the reduced burden will allow the NHS enough breathing room to properly cement new accountability arrangements, heightening the chance that efforts to integrate and improve care will succeed. We will have to wait and see…
Pulse. 'Confused and opaque' NHS England insufficiently accountable to the public, says MP report. November 2014. Available at: http://www.pulsetoday.co.uk/news/commissioning-news/confused-and-opaque-nhs-england-insufficiently-accountable-to-the-public-says-mp-report/20008434.article
[ii] The King’s Fund. Devolution. November 2015. Available at: https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/devolution-briefing-nov15.pdf