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Acceptance of NHS reform could hinge on accountability

As the Government’s NHS modernisation exercise ends the question emerges - how do we reconcile accountability to Parliament.

As the Government’s listening exercise on NHS modernisation ended this Tuesday, a central question has been how to reconcile accountability to Parliament with decentralising the allocation of spending and resources.

If the Government's listening exercise can encourage ministers to clarify the lines of accountability, the decentralisation introduced in the Health and Social Care Bill may be more widely accepted. The Institute's recent report, Nothing to do with me? put forward guiding principles on ministerial accountability within decentralised services. The report argues for a new consensus about the accountability of ministers, as well as officials, as services are devolved. Greater clarity is needed on two fundamental points: what a minister should properly be held accountable for, and how Parliament can best play its role in holding ministers and others to account. Guiding principles The report suggests two guiding principles:
  1. the use of public money should always be subject to ultimate scrutiny and oversight by elected public representatives, acting on behalf of taxpayers
  2. accountability should be aligned with effective responsibility, with scrutiny and oversight focused first on the person or body with the most appropriate remit and powers (see page 9 of the report).
Putting these principles into practice implies an end to top down accountability by default. But changing perceptions of who is accountable takes:
  • time
  • clarity about who is responsible for what actions within decentralised services
  • political skill and discipline
  • Government commitment to engage with the concerns of those with legitimate – if sometimes inconvenient – voices (as has occurred during the listening exercise).
Decentralisation will struggle to stick if those who hold government to account end up in a running battle with the system. Such a change also requires those running decentralised services to be much more open publicly in explaining, and, if necessary, defending their actions. How to help consensus develop In the NHS and elsewhere, the Institute suggests 'accountability maps' be drawn up as part of the consultation process for decentralisation. These maps would help foster constructive debates about accountability in advance of change. Once the report on the recommendations put forward during the listening exercise is published and consequent changes clear, such a map would inform debate about the Health and Social Care Bill. It would highlight the specific powers retained by ministers, and those lying elsewhere. Ministers should continue to be held to account for the overall effectiveness of a decentralised service, but as services are decentralised, MPs are likely to get better leverage by more direct questioning of arm’s length bodies and local decision-makers. The role of select committees The Institute’s report suggests departmental select committees should play a pivotal role in scrutiny of decentralised services. Select committees have the powers and remit to deliver scrutiny of the right individual at the right level. But select committees have limited capacity. One challenge for Parliament is how, realistically, to hold accountable hundreds of local bodies. Returning to the health reforms, the department’s evidence to the Public Accounts Committee suggests potentially over 200 individual Foundation Trusts will be individually accountable for local performance or financial failure. One possible solution to this problem of scale might be the creation of an ad hoc, cross-party 'local interest committee' of interested MPs. This could examine failures within an individual Foundation Trust, which would affect a specific geographic area. Concerned local MPs could question public officials and other decision makers without automatically focusing activity through ministers. The ‘pause’ in the progress of the NHS reforms offers the ideal opportunity for these challenges to be addressed, which is vital if the eventual reforms are to gain lasting public and political acceptance.
Institute for Government

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