A lack of accountability is causing the quality of NHS services to crumble, according to some of the most respected trust chief executives.

They said the problem arose from four factors: the lack of an operating model for how NHS England should oversee the service, confusion over what integrated care systems should be responsible for, the lack of clarity on which standards providers should be seeking to meet, and trust leaders not holding each other to account.

The views were expressed at a roundtable to mark the publication of HSJ’s annual ranking of the NHS’s “top 50 trust chief executives”.

The most strongly worded contribution came from Milton Keynes University Hospital Foundation Trust chief executive Joe Harrison.

He told the roundtable: “I’m really concerned about where we are at as an NHS. I think we’re in danger of all sitting around the campfire singing ‘kumbaya’ as the Titanic sinks.

“We are presiding over a failing NHS. There’s no question about it. And if we carry on like this, people have every right to say, ‘what on earth are we spending £150bn on?’”

He added that Amanda Pritchard had now been in post a year and needed to address the lack of an “operating model” and “clarity between the region and the national team”. He also said “we, as a community of chief execs have to come together” with NHSE to determine a way of working that would deliver the necessary improvements.

“I think we [trusts and NHSE] are just being really nice to each other and that’s great on the one hand, but on the other we are sinking,” he said.

Mr Harrison, who is married to the prime minister’s Number 10 chief operating officer Sam Jones, said there needed to be “more challenge” in the system. The pace of reform in the NHS was “unbelievably slow”, he said.

Northumbria Healthcare FT chief executive and NHSE’s elective recovery director Sir Jim Mackey said confusion over which emergency care targets the NHS was operating to was a significant contributor to the accountability gap.

NHSE medical director Sir Steve Powis undertook a review of clinical performance standards, which – among other recommendations – said the four-hour accident and emergency target should be replaced by a suite of other access standards. However, despite ministers expressing support, the government has yet to confirm the switch.

“We’ve lost the consumer offer in the blurring out of the ED standards,” said Sir Jim. “It’s our biggest worry. They never actually bought and signed off Steve’s proposals because there wasn’t a retail offer.”

He added that this “failure” to have clear standards that the NHS was held accountable to would “over time” undermine public and political faith in the service.

“There need to be some guide rails again,” said Sir Jim. “Is it four hours? Is it four hours just for the sickest patients? We just need to work it out. Because at the minute it [the goal] is just to be slightly better than the person next door. It’s not good enough.”

Asked what the NHS should do in the face of government inaction, Sir Jim said: “Why don’t a group of us get together and agree this is the standard? Because [it would be] better than [the] crap we’re doing at minute.”

Glen Burley, chief executive of South Warwickshire FT, Wye Valley Trust, and George Eliot Hospital Trust, said there was no “expectation” that providers would meet the standards “we used to pay our mortgages on and go into board meetings and talk about”.

Mr Burley agreed with the assertion he was not being held to account and added – referring to the ICS reforms – “this ‘everyone’s accountable’ bit often means no one’s accountable. And I think we need to get clearly back into [knowing] who’s accountable for what.”

He concluded: “We’ve got to get back to a standard of delivery” suggesting this would be achieved by “focus” on systems providing support for individual organisations that were beginning to “slip”.

Barking, Havering and Redbridge University Hospitals Trust chief executive Matthew Trainer said: “The service we provide in our part of London is not good enough on most fronts.

“I watch my inbox fill up with emails from people who have been in ED 14 to 16 hours. That’s the public’s perception of the NHS, isn’t it? Everyone’s got a story now about how long they’ve waited. We’ve got to change that narrative.”

Mr Trainer added there was a danger of the NHS accepting lower standards because staff felt hard done by and exhausted.

“One of the things I talk a lot about with my team is that it’s entirely possible that we’re underfunded and that we’re wasting money as well. I think that’s an important thing for us to look at.

“I’ve got a lot of friends who don’t work in the health service who had a really tough pandemic and who think we’ve had a pretty rosy time, [that] we’re relatively well protected. Those people who were losing jobs, who’ve seen businesses go to the wall, their view [of the NHS has] rapidly moved.

“There is no doubt that the NHS played an amazing role in the pandemic, but patience for protecting the NHS from the broader economic context we’re in ended some time ago.”

On staff exhaustion, Mr Trainer recognised the stress the NHS workforce had been under, but said: “We possibly talk too much about how tired everyone is after the pandemic. If you say to people ‘you look tired’ it makes you tired. There’s a risk that we’ve entered up into quite a cyclical conversation that how tired everyone is.”

Royal Berkshire FT chief executive Steve McManus said: “We, as a group of [provider] leaders, have got to be both very clear about individual [and] collective accountability to drive up standards and performance.”