Reforming the NHS: accountability

Last week, Reform published its 2011 public service reform scorecard. It judged each major government department against the three criteria set out by David Cameron: accountability, flexibility and value for money. The report finds the Home Office’s policing reforms succeeding on all three fronts, but inconsistency across other government departments. The Government’s health reforms are awarded grade D overall, with an E for accountability, a D for flexibility and a D for value for money. Here’s how the coalition can get its NHS reforms back on track.

The government has recognised the need for fundamental reform of the NHS. The proposals announced in the July 2010 White Paper are substantial. However, the government’s plans leave accountability divided between patients, doctors and local authorities. Healthcare delivery continues to be centralised: Andrew Lansley has placed a moratorium on hospital closures, and the government will maintain national direction of the workforce. The decision to ring-fence health spending means that health policy is based on increasing inputs and not value for money; significant waste has been identified, but it should still be protected.

The government is reorganising the NHS’ commissioning structure. Clinicians will have to commission healthcare services from a plurality of providers and put patients at the heart of the NHS. However, rather than consumer choice, the NHS White Paper sees professional empowerment and localisation as the key drivers of change. This has divided accountability: the reforms make GPs responsible for commissioning medical services on behalf of patients; consortia are accountable to the Commissioning Board; local authorities will be responsible for public health, joining up commissioned services and leading strategic needs assessment. Moreover, the Health Bill gives the Commissioning Board significant powers over consortia. But it also gives the Secretary of State power to direct the Commissioning Board not only in what it does but in how it does it. Consequently, accountability runs to the centre with “the Secretary of State…hold[ing] the NHS to account for improving healthcare outcomes.”

Sitting before the House of Commons Health Select Committee, Sir David Nicholson stated that “we’ll have to centralise more power in the very short term to deliver benefits”. The Commissioning Board, which Sir David has been chosen to chair, will be able to wrest funds from allocations to commissioners for the purpose of creating risk-sharing arrangements and to bail overspending consortia out – implying that surplus generating consortia might not have their full underspends returned to them each year. This disincentivises success and indicates that the desired healthcare market may advance no further than it did under the Primary Care Trust structure, which was subject to such top-slicing under the previous Government. In addition, having abolished targets, the Department of Health’s technical guidance for the 2011-12 Operating Framework runs to 261 pages and contains more than 100 indicators “against which the NHS will be held accountable”.

Existing proposals would see a new national workforce strategy for NHS employment. Despite a stated desire “to empower healthcare providers, with clinical and professional leadership, to plan and develop their own workforce”, the proposed strategy calls for “sector-wide oversight of key aspects of workforce planning, education and training” and “mechanisms that allow the NHS Commissioning Board to have strategic influence on the national picture for education and training.”

Broadly speaking, the reforms aim to liberate the NHS from central control and create “the largest social market in the world”. However, providers’ freedoms continue to be curtailed. The Secretary of State has imposed a penalty upon hospitals that continue to house patients in mixed sex wards. The government also acted immediately to stop NHS London’s proposed reorganisation of its healthcare services and introduced new tests for redesigning hospital services.

If the government really wants to deliver a revolution in healthcare, it must make doctors and hospitals accountable to patients, not to multiple points within government. Doing so would create a real market for health and the government must remove regulatory barriers to ease access for new entrants, while restrictions on how providers deliver their services must be lifted. Above all, the ring-fenced budget must be scrapped to incentivise a real focus on value for money.