Looking for a place to hide? Try the massed ranks of organisations currently holding the NHS to account. Jessica Crowe suggests clarity lies in resolving what it is accountability structures should be delivering

'The life of society is not the product of coherent thinking by a single mind. On the contrary, many customs and institutions, which make up social life, have grown up in a detached, sporadic, unconscious, often unreasonable fashion.'

The words of sociologist Leonard Hobhouse, spoken in 1918, will strike a chord with anyone grappling with the framework for NHS accountability and patient and public involvement. This crowded goldfish bowl is populated by non-executive directors, patients' forums, local authority overview and scrutiny committees, foundation trust governors and members, clinical governance committees, inspectors and regulators. Each has their own remit and approach to holding the service to account.

At the first of four Centre for Public Scrutiny round tables, senior decision-makers from health and local government concluded that the sum of all this activity is often a 'collusion of anonymity'. Far from increasing accountability, it can be easy to hide in the goldfish bowl.

So how can PPI reforms (see below) make the system clearer, more effective and more accessible? The round table concluded that a key question needs to be answered: what do we actually want accountability structures to deliver?

To resolve this, four overarching tensions need to be addressed.

National versus local accountability

There is a need for national standards and upwards accountability in the NHS to avoid the inequities of a postcode lottery - this is why the NHS was created as a national service. But new forms of local accountability have developed - not just in the health arena - to reflect the different needs and expectations of local communities and individuals. The best way to address inequality and ensure that national standards are met across the country is not to treat everyone the same but to design services that specifically address the issues within and between communities that are at the root of inequality.

The recent local government white paper, Strong and Prosperous Communities, recognises this and makes a commitment to cut hundreds of nationally imposed targets in favour of targets agreed in local area agreements by a wide range of partners, including the NHS. The LAAs will set out local areas' priorities. Round table participants suggested two practical additions to this change of emphasis.

First, at least some of the targets and duties of NHS chief executives should be agreed locally, based on LAA priorities. Second, the regulatory system currently enforced by a variety of national agencies should be adapted to focus on local accountability.

Consumer or citizen?

Two parallel models of PPI are now in operation.

On the one hand is the market model of the patient as consumer, where patients are encouraged to 'vote with their feet' and choose the best-quality healthcare.

In this model, democratic accountability would not be a concern, since patients would drive improvement and shape services through their actions as consumers. But there is not a perfect market in healthcare in this country at present, and our round table highlighted concerns about those who are unable to make the most of an extended patient choice programme.

On the other hand, patients are seen as citizens, with rights of access and control derived from the public ownership of the health service, giving them an entitlement to be involved in decisions.

This is the vision originally presented for the governance structures of foundation trusts. Many people, notably patients' organisations but also some clinicians, passionately believe involvement is needed to improve the quality of services.

Key to making involvement work, regardless of the model followed, is its independence from decision-making. Patients' groups must be genuinely independent from the NHS, in both processes and support. Allowing support for new local improvement networks to be commissioned by local authorities seems a positive step in ensuring that autonomy.

What sort of democracy?

Many question whether the two (or more) models of democracy operating in health - representative and participatory - complement or clash with one another.

The participation industry - including consultations, neighbourhood forums and, in health, patients' forums - was largely born from a feeling that representative democracy was necessary but not sufficient for good governance in public services. Opinion polls have shown that if people do not feel institutions are properly answerable or effectively run, they want to be more involved in running them. One round table participant said that residents only accept the 'discomfort of not quite knowing' how decisions are made if they trust their services.

Do new systems actually fill this gap? Many perceive flaws in the electoral arrangements in the new foundation trusts, for example, pointing out they are often much less competitive than local authority elections, with a small, self-selected electorate and minimal challenge or scrutiny of those seeking election.

The balance between participation and professionalism was also questioned: why should patients have to become experts and spend time telling specialists how to do their job?

A third, 'deliberative' form of democracy was also discussed, which would allow a constant dialogue between the elected and the electorate. A range of engagement mechanisms are available but not used widely enough, including new technologies and reaching out to patients in their own environment. The aim would be a deeper understanding of their communities by elected representatives and public-sector managers, and a collective, informed view from those they serve.

At the moment, the success of these mechanisms varies but it seems clear that no system will work unless the NHS at a local level is more responsive to those who are affected by the services it provides. This may mean not only a duty on the NHS to consult but also a stronger duty to act as a result.

Outcomes versus processes

Some forms of accountability in the NHS emphasise process. For example, NHS managers might argue rigorous process is essential for ensuring accountability and safety through risk management or clinical governance. However, for patients and the wider public, their absolute focus is on outcomes in terms of quality of service.

A strict distinction between outcome and process is an artificial one. Those who focus on process do so because it will lead to better outcomes; those who concern themselves with outcomes want processes that will deliver the right objectives.

One area lacking at present, on both processes and outcomes, is a robust accountability system for commissioning procedures.

Patients' forums structured around providers are not best designed to deliver this and, whatever the new PPI system looks like, it will not be effective unless it reinforces accountability in this important strategic area.

The resolution to these tensions may be hard to achieve.

However, an increasing desire to have clear water in the goldfish bowl is apparent and reflected by the variety and seniority of round table attendees.

A further timely opportunity to address the key question 'what do we actually want accountability structures to deliver?' is provided by the Commons health select committee's new inquiry into PPI proposals.

Jessica Crowe is the executive director of the Centre for Public Scrutiny. For more information on the Centre's work e-mail info@cfps.org.uk.

PPI proposals

  • A stronger local voice takes forward ideas first mooted in the white paper Our Health, Our Care, Our Sayto introduce community-facing local involvement networks to replace organisation-focused patients' forums.
  • The local government white paper Strong and Prosperous Communitiestrails new scrutiny powers for local authorities and greater emphasis on strategic scrutiny of commissioning. It also commits the government to cutting nationally imposed targets in favour of those agreed locally by local area agreement partners, including the NHS. Legislation to enact these changes is expected in 2007.

How accountable is the NHS?

The round table began by outlining five principles of effective accountability, provided by Professor Stuart Weir, director of democratic audit at the University of Essex. How does the NHS measure up?

People should be able to seek entitlements through the courts - nearly absent from the NHS at present, according to Professor Weir.

How well is local authority scrutiny succeeding in introducing representative democracy to healthcare?

Public activities of trust boards and local authority overview and scrutiny committees have sometimes brought unprecedented openness. However, are systems still too complex to ensure ordinary patients are aware of opportunities to influence decision-making?

This is receiving the most attention, with a whole PPI industry emerging since the Kennedy report on infant deaths in Bristol.

This should take the form of an independent system not, as at present, a system largely under the control of the professional bodies.