MPs' inability to hold the NHS to account may be more of a problem than the 'democratic deficit'. Mark Crail reports

MPs' frustration at their inability to hold ministers and officials to account for what goes on in the NHS peaked when chief executive Alan Langlands appeared before the public accounts committee over the Read codes affair.

Noting that this was not the first time Mr Langlands had been caught up in PAC investigations of NHS IT projects, Labour MP Maria Eagle suggested that he should 'consider his position'.

Mr Langlands is unlikely to resign.

Nor does the PAC have the authority to force him to.

But the gap between what Parliament - or even ministers - can control and what the NHS can do is likely to prove a source of growing concern as The New NHS reforms continue, say leading academics.

In a King's Fund pamphlet, Professor Rudolf Klein of Bath University and Bill New, the Fund's senior research officer, argue that throughout the history of the NHS there has been tension between local autonomy and national control.

The main thrust of the pamphlet is to cast doubt on claims that the NHS suffers a 'democratic deficit', arguing that other values such as equity and fairness compete with and may take precedence over democracy.

But Klein and New also point out there are weaknesses in central control, since 'the chain of command has some crucial missing links', which means not even ministers can discipline doctors and managers for malpractice.

This is important, they say, because proposals in The New NHS for national service frameworks, a Commission for Health Improvement and the accountability framework for primary care groups all tend to centralise control.

Upward accountability to ministers is not the only weak point. Ministers in turn can often escape proper scrutiny - in part by taking advantage of the tension between local control and central accountability.

'Indeed, ' argue Klein and New, 'successive secretaries of state have exploited this ambiguity in order to claim credit for successes and to diffuse blame for failures'.

They suggest that the shortcomings of accountability start with the parliamentary question, to which 'civil servants are artists in providing bland replies for ministers'.

More important in calling ministers to account are the select committees.

But while the PAC has a narrow remit to ensure that rules on spending public money are followed, the health committee 'works under constraints'.

Klein and New say pressure on the committee to produce unanimous reports means it may avoid divisive issues, while 'the convention that all committee members must have their turn' means issues are rarely pursued.

The health select committee also lacks professional support. Serviced by a small staff from the Commons clerks office, it 'relies heavily' on part-time advisers.

PAC member Maria Eagle admits: 'Other committees would love to get the support we get from the National Audit Office.'

Klein and New conclude: 'The interest of MPs in making ministers answer for the performance of the NHS may be intense, but it is also. . . sporadic.

'The searchlight of parliamentary interest flickers through the sky, but seldom provides a complete picture.

'The ability of ministers and officials to obfuscate issues, and to retreat behind smoke screens of verbiage is considerable.'