Show us the money! Let's make the NHS accountable to the people it serves

The Kings Fund’s Chris Ham recently wrote about tighter working at the top of the NHS, reducing the number of commissioning bodies and much closer working between the NHS and local authorities. He argues this would simplify a complex system and could release resources. His challenge to politicians is to let that happen without a top-down reorganisation but with some legislation.

The end of an era

The challenge is likely to fall on deaf ears, even though just about everyone accepts that the Health & Social Care Act was a disaster. The government has no appetite and little time for non-Brexit enabling legislation and they control the legislative timetable.

My own view is that we desperately need more than an adjustment of the superstructures. We are at a critical point as we approach the 70^th anniversary of the NHS, as we come to the end of the era of markets and competition exemplified by the disaster of the Health and Social Care Act. To make our whole care system better and to ensure our NHS thrives for the next 70 years, the principle of accountability has to be put centre stage.

All these NHS bodies spend taxpayers’ money and it is little wonder the taxpayer is both mystified and suspicious as to how they decide what to do with it

My pre-MP professional career in the NHS, combined with years of activity in the Labour Party dealing with local councils, led to concerns about the lack of accountability within the NHS. This background showed me that better accountability is a key driver of change and improvement as well as being necessary in a functioning democracy.

The complex fragmentation of the NHS in recent years has muddied things when it comes to accountability. There are literally hundreds of bodies involved. The 200-plus Clinical Commissioning Groups are in effect private members’ clubs.

And of the 250-plus NHS bodies that provide services, some still have fully appointed boards and are controlled directly. Foundation Trusts have a pseudo-membership structure with elected Governors, but the model hasn’t done much for public and patient involvement.

And then we have the Sustainability and Transformation Partnerships (STPs) with no legal basis, a leadership that is unelected and unaccountable and operating mostly in secret.

All these bodies spend taxpayers’ money and it is little wonder the taxpayer is both mystified and suspicious as to how they decide what to do with that money.

Where’s the local voice?

The current Secretary of State operates in his role as if he’s some sort of Chief Patient Representative, with no active role in leading and shaping any plans, services or systems.

Local MPs are expected by constituents to stand up for local services, ensuring they have enough resources, and to be able to make a difference when things go wrong; but the reality is that MPs have been restricted to an annual vote, in Parliament, on the national plan via the Mandate and the budget. We have no role locally in how the Mandate is delivered or on the alignment of the voted national budget with local delivery. And critically neither do local people.

MPs are pivotal: they’re the point where national policy meets local reality. As well as bringing our local experience to Parliament, MPs need be made accountable for our decisions in Parliament. They should not be let off the hook for decisions made in Parliament that impact locally.

MPs should be demanding a local role to be able to follow the money – from our vote in Parliament to the GP surgery door, and back again. Local people should have a way of recognising or linking the taxes they pay to the service they get or indeed, do not get.

We have to give patients and the public genuine influence over decisions affecting the care they, their families and their communities receive

It’s no secret that the money the NHS is allocated is insufficient to do all that’s promised in the NHS Constitution, to the quality that’s rightly expected. Even Tory MPs are being confronted by the reality of GP list closures, trolley waits, too few mental health beds and delayed dates for operations. And these MPs themselves are being forced to come to terms with the reality of being bounced around the system, as they try to help constituents, trying to understand just who is in charge.

Chris Ham’s proposals have some potential for short-term benefits but unless we sort out both national and local accountability we won’t be able to sort the long term. On behalf of our constituents we should be putting the public centre stage, considering how to actively improve the NHS and understanding what the money can deliver. We have to give patients and the public genuine influence over decisions affecting the care they, their families and their communities receive and the responsibility that goes with that influence. 

Publish everything. Let voters follow their taxpayers’ pounds all the way to the services they receive. Real comparisons could be made with other areas which may have better outcomes, have implemented better pathways or achieved lower costs. This allows an informed voice into the decision-making process, also giving a proper channel through their elected representatives.

Being able to follow the money is a big part of accountability. It’s a key part of the path to true openness and transparency in our NHS and a more informed discussion about resources.

And we should all want that.