10 February 2011

The government's promise to "turn government on its head" is being put into practice through reforms to the NHS and other public services. How's it going?

Eight major charities wrote to The Times this week complaining about "a gap between rhetoric and reality" in the proposed NHS reforms. They argued that plans to make GP consortia accountable to the public are "far too weak".

If true, that's concerning, because the NHS reforms, as well as reforms in schools, policing and other public services, are premised on the idea that services can be improved by strengthening local accountability and removing top-down controls. If the local accountability part of that formula is missing or weak then the reforms may fail to deliver the hoped for improvements.

Understanding accountability

There are two main challenges that any decentralising government must face. Firstly, can sufficiently robust devolved accountability mechanisms be put in place? Secondly, can Ministers and Whitehall 'let go'? The Institute has been exploring both these questions but for the purposes of this blog I'll focus on the former (see our work on Ministerial Accountability for the latter).

Accountability implies that one group (let's say the public) can ask another group (GPs) to justify their actions or performance. Consequences (positive or negative) can then follow. Academics have identified as many as eight different types of accountability: democratic, administrative, political, managerial, market, legal, moral, and professional – each with their pros and cons.

While the concept is relatively simple, the current argument about the NHS reforms highlights how complex accountability can become in reality – and the devil is in the detail.

Five key questions

There are five main questions that need clear answers for any accountability regime to work.

1. Accountability for what? At the risk of stating the obvious, it is important to be clear what the accountability is for. Is it for outcomes, such as reduced cancer mortality; for managerial decisions such as closing an A&E department; or for financial propriety such as avoiding fraud? Doubtless all these are closely related, but they don’t all have to be held to account through the same mechanisms.

2. Who is being held to account? Public services are often delivered through a web of interrelated organisations. Under the proposed health reforms, GP consortia will be responsible for commissioning most health services but local authorities will be responsible for prevention services. Clarity of responsibility will be required for accountability to work effectively.

3. Who is doing the holding to account? Different constituencies will have different interests, for example, patients with long-term conditions will have different priorities to members of the public. Being clear about who has a legitimate voice will be important to ensure those with the sharpest elbows don’t carry too much sway.

4. How will accountability operate? One challenge will be making some of the less direct mechanisms feel real to the local population – does the freedom to choose your GP feel like a sufficiently strong form of accountability? Transparency is the essential ingredient that enables citizens to play their role to the full whichever mechanisms are put in place.

5. What consequences flow from the accountability? Ultimately, accountability must imply consequences. In a democratic model this can mean being voted in or out. In a pure market model it can mean growing a business or going bust. Consequences provide the teeth that give accountability bite so if they are weak (or non-existent) that’s a problem.

Some way to go

The health reforms were used here for illustration but these questions are relevant to other current policy debates such as free schools. At the moment it feels like the government has strong answers to some of the questions, in certain policy areas, but is still a long way from a complete package that makes sense across all public services. A good proportion of the public (along with the charities who wrote to The Times) remain to be convinced.

Even, with answers in place, implementing the required changes will take time, and it will take even longer to really understand if devolved accountability is working as hoped (i.e. leading to better services). For that reason alone there will inevitably be a gap between ministerial rhetoric and reality on the ground.


This is great stuff Adrian but I think it misses one crucial dimension of accountability: time. Most discussion of accountability assumes a retrospective, post hoc, form - holding account after the event. But some of the current reforms are not just about retrospective accountability but also prospective accountability - who steers?

Take GP Consortia - there is an underlying assumption that patients will express their preferences for commissioned services and these will be transmitted via the GPs to GP Consortia. In even the simple version of patient to GP to Consortia, each of these links is problematic. Of course in many cases they will be even more complex - patient(s) to GP to GP Practice to Consortia to groups of Consortia and/or external Health Management Organisations, etc.

The heroic assumption that this complex sets of links will end up representing "the patient" is, as Sir Humphrey would say, "a brave assumption, Minister".

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