Accountability: how to walk the local talk

Cross-party consensus in British politics can be difficult to find, but the three main parties appear to agree about one aspect of healthcare - that primary care trusts need to become more accountable to the communities they serve.

In a speech on the NHS in January, prime minister Gordon Brown spoke generally of devolving more responsibilities to a local level, while both the Conservatives and Liberal Democrats appear to favour giving local authorities greater influence over PCTs - although they differ on how it should be achieved.

This political accord is unsurprising, given the size of the budgets controlled by PCTs, says Richard Lewis, a director at Ernst and Young's health advisory practice and a senior associate at the King's Fund. The average PCT budget is£230m a year and between them the 152 PCTs in England received£70bn in 2007-08 - over 80 per cent of the total NHS budget.

"Given the public accountability of foundation trusts, it could be seen as an oversight that this has not already been done for the organisations commissioning their services," says Mr Lewis, who co-authored the King's Fund report Should PCTs be made more accountable?, which was published in April.

Foundation trusts were set up with accountability to an independent inspector. Local people are also able to become trust members and elect governors who can hold managers to account. This means service users can exert a real influence over the trusts' leadership.

PCTs have diverse lines of accountability, none of which directly involve the people they serve. In addition to their strategic health authority, they are answerable to the Healthcare Commission for the quality of the care they commission and provide, and to the Audit Commission for financial management.

At a more local level, they are open to scrutiny by the local authority and are also accountable to their publicly appointed boards, whose members are drawn from the local community. However, while non-executive board members may come from the local community, the Department of Health says they are not appointed to represent the local community but to use their experience gained in other fields and as local residents to govern the PCT.

Mr Lewis sees local accountability as having both political and instrumental advantages. "Politically, it's about generating a greater sense of legitimacy about the work of PCTs," he says. "The instrumental benefit is that it will, in theory, ensure better quality services."

An example of how it might improve services is by involving local people in deciding how services are provided. While this is unlikely to lead to solutions that suit everyone, people feel their voices have been heard. They may also have invaluable insights that are only obvious to service users but that make the difference between a service succeeding or failing.

Patients Association vice-chair Michael Summers is in no doubt that more local accountability is needed. He acknowledges that engaging local populations will be challenging but emphasises stronger local links are the only way to ensure the health service is accountable.

"If accountability is national, it becomes very bureaucratic. If it is local, then we can deal with problems directly," he says.

Local accountability makes sense when it comes to improving service and securing value for money, says Mr Summers. "Different areas require different financing and they have different needs. Local accountability will mean money will be better spent and it will drive up standards."

But Ruth Thorlby, who co-authored the King's Fund paper with Mr Lewis, points out that local accountability has its downside, because it will inevitably mean more disparity in services, which may be unwelcome to many people.

"People want a nationally guaranteed NHS and they don't like variation. Yet local devolution will mean it varies greatly," she says.

This may become a driver for PCTs to get the local population involved in decisions. Lack of rancour may also become a measurement of the success of accountability, she says.

Ms Thorlby believes politicians need to provide greater clarity about what they mean when they talk about increasing local accountability. The aim of accountability - whether it is to give more democratic validity to the NHS or to improve the quality of services - will determine how it moves forward.

However it is achieved, Ms Thorlby says local accountability will raise the profiles of PCTs.

She says there is a lack of understanding among the public about what a PCT is and does. If this were changed, PCTs might find more support for their role.

"The public focus tends to be on hospitals or GPs. I don't think people understand PCTs at the moment. If they do, their understanding is minimal and they think PCTs are bureaucratic structures.

"Having an awareness of who's spending the money on your behalf can only be good," she says.

But do local people actually want to be actively involved? Public engagement with initiatives to extend democracy is notoriously difficult to achieve, and this may be the case with PCT accountability if the model adopted requires active public involvement. One proposal is to introduce foundation PCTs - but would these achieve real engagement?

Members would have ownership of the PCT in much the same way as with foundation hospital trusts and, similarly, elect governors to represent their interests. A council of governors would be established to advise on the strategic direction of the PCT.

However, the King's Fund report identifies some problems with the model. Improved services would only come about if governors had the time, expertise and support from the board to develop knowledge, it says.

It might be hard to attract members, particularly in areas where there are foundation hospitals, and even trickier to ensure there was representation from minority groups.

Ms Thorlby says all of this means that foundation PCTs might find it tough to get the local accountability they want. "It's to make sure there's a local voice. You have to go after a large representation of people."

Low visibility

Mr Lewis says: "It is too early to say whether public involvement has worked with foundation trusts - certainly many people have become members of their local trust, but this does not necessarily translate to them being actively involved."

Hospital trusts have some major advantages over PCTs in gaining public involvement - they have a high level of local recognition, and people tend to feel a sense of ownership about their local hospital. In contrast, PCTs achieve far less recognition, and it is arguable whether they could generate the same level of enthusiasm as the hospitals from which they commission services.

People are aware of specific NHS facilities, whether they are large hospitals or single GP practices - and proposed changes that involve closing these are often fiercely opposed. It is difficult to imagine PCTs inspiring the same emotional reaction - indeed, the reconfiguration of primary care services in 2005 halved the number of PCTs in England yet it was virtually ignored by the media and the wider public.

The quality of hospitals' work is far easier to evaluate than PCTs'. Major failures such as those that led to scores of patients dying due to MRSA infection at Maidstone and Tunbridge Wells foundation trust make national headlines. Local media also covers less catastrophic problems, while people admitted to or visiting hospitals gain first-hand experience of how well it works. Evaluating the quality of commissioning in a way that is meaningful to service users is harder.

If their lack of public visibility means the government decides against giving PCTs foundation status, an alternative route to local accountability may be to channel it through local authorities. This might mean having council representatives on PCT boards, which could work in different ways.

A designated post within the cabinet for health might have an automatic membership to the PCT board. It could go further by replacing non-executives with other local authority cabinet members. Again, there may be downsides. Cabinet members would need a new knowledge base, which would take time. And there would be the danger that the true lines of accountability would continue to flow upwards to SHAs.

Local Government Association senior policy consultant Jenny Finch says channelling accountability through local authorities may give local people perceived greater influence, because many are familiar with their local council but know little about their PCT. However, this would not necessarily translate into reality.

"Many people do not take up existing opportunities to take part in local consultation mechanisms, so it doesn't necessarily follow that channelling accountability of PCTs through local councils would lead to local people having greater influence over their PCT," she says.

But one potential benefit is the opportunity to improve co-ordination of health and social care. However, Ms Finch believes mechanisms for this are already in place in the form of local strategic partnerships and local area agreements, and that local authorities and PCTs should be given the opportunity to make these work effectively.

How well these partnerships work in improving the health and well-being of local communities is not clear, but there is certainly variation. There is probably a case for a nationwide evaluation to identify examples of good practice that could be replicated elsewhere.

Ms Finch points out that while they may be accountable through strategic partnerships and local area agreements, PCTs are also answerable to SHAs. This is likely to affect how much they can effectively co-ordinate their services with those provided by local authorities. "It's not that they clash. The targets are different," she says.

The Local Government Association is keen to increase the local accountability for health services, and has established a cross-party commission to look at how local councils and NHS providers can best work together to achieve this and reconcile it with national funding. The commission will also consider how local people can be engaged in decision making about resource allocation.

The commission is peopled by experts in health, local government and patient interests, such as chief executive of the King's Fund Niall Dickson, who chairs it, Mencap chief executive Dame Jo Williams and independent MP Dr Richard Taylor, and will publish recommendations in June.

If PCT accountability is channelled through local authorities, could this lead to difficult but necessary decisions being avoided for political expediency? Ms Finch believes not.

"All organisations have to make these decisions sometimes and I don't think local authorities would avoid them any more than national government does if it's the right thing to do," she says. "All public service organisations have to make difficult decisions, based on factors such as the resources available, or evidence that a particular intervention is better or a service isn't viable. One important aspect is to ensure service users and local people can have an effective input to the decision-making process, if they wish to."

Mr Lewis has a slightly different view: "It has to be a possibility, but having said that, the NHS doesn't exactly have an illustrious history of taking difficult decisions, so a reluctance to do so at a local level would not necessarily constitute a great change."

Giving people the chance to have effective input into decision making involves setting up structures that are open and inclusive enough to encourage those whose voices are rarely heard. Real public involvement goes beyond listening to the "usual suspects" - the confident, articulate and usually comfortably off - and making genuine efforts to represent the whole community. It is just possible that a brand-new type of organisation can do this.

April this year saw the introduction of local involvement networks in each local authority area. These replaced patient forums and are charged with providing a stronger voice for local people in the planning, design, commissioning and provision of health and social care services. Their structure can be defined locally, as can their ways of working. However, they are required to be open and inclusive, accessible to all and to reach out to gain the views of the wider community. They must also communicate the information they receive to service planners, commissioners and providers, and feed back responses and outcomes to the wider community.

National Association of LINks Members vice-chair Ruth Marsden says closing one body and replacing it with another every few years is unhelpful in encouraging involvement from local populations. There is a dearth of people willing to invest their time and energy in their local NHS in the way the government wants, says Ms Marsden, who was vice-chair of the National Association of Public and Patient Involvement Forums before it disbanded on 31 March.

"The problem is finding people who are knowledgeable enough. Commissioning and the health service in general are hugely complex areas and it's not the kind of thing that people immerse themselves in for bedtime reading. It's a full-time job," she says.

The recent pace of reform to an area which changed little in 30 years is not helping.

"All this tweaking and alterations followed by new initiatives is no good. Things need to be left alone," says Ms Marsden.

PCTs seem to agree. NHS Confederation research published earlier this year shows that more than 80 per cent wanted the current system, which includes LINks, to be given a chance to develop before any more changes.

The same research, Principles for Accountability: putting the public at the heart of the NHS, found almost 40 per cent of PCTs would support foundation trust-style membership. And a quarter liked the idea of appointing council representatives to PCT boards.

Agreeing a model

So will LINks be able to fulfil their challenging brief? "It's too early to tell," says Mr Lewis. "The NHS has struggled to find an appropriate forum to represent users since the abolition of community health councils in 2003. The Commission for Patient and Public Involvement in Health appears not to have fitted the bill, but we now need to give LINks time to bed in before commenting on their effectiveness."

While politicians may agree that PCTs need to have greater local accountability, it remains to be seen what form that should take. However, if local communities are to be motivated to engage with the process and local people are to be persuaded to get involved, the government will need to listen to their views on what model to adopt. It may also have to give individual communities the option of choosing the model that works best for them rather than imposing a single solution.

If local accountability is introduced well, it should make PCTs more responsive to the needs of the people they serve. It may also make those people learn to love their PCT.

Time line

1974 Community health councils were set up.

2003 CHCs were replaced by public and patient involvement forums. There were 394 forums - one for each PCT.

2008 PPI forums were replaced by local involvement networks. There are 150 LINks - one for each council - and they have a broader remit to cover social care as well as health.