Having the right people involved in the right discussions is the key to keeping the NHS in check, says Anna Coote, while Jessica Crowe argues for a wide form of accountability that leaves no voice unheard

Anna Coote

Involvement and accountability can be complementary. Without involvement, accountability can be a 'thin' and sterile process. With inappropriate involvement, independence can be compromised.

It depends how patients and the public are involved in planning and decision-making - what mechanisms are used and to what extent they manage to include a wide range of interest groups.

For example, if only a limited number of patients and the public are involved and the same group holds the executive to account, they cannot play a genuinely independent role unless the decisions affect that group alone.

What really matters is the quality of engagement and participation. This applies both to involvement and to accountability. Involvement can cover a range of possibilities that have been well documented and are often described as a 'ladder' or spectrum ranging from providing information to direct action.

The form of involvement can be a one-off or a continuing and iterative process. Different methods of involvement are appropriate in different circumstances and there is nothing intrinsically wrong with 'light touch' involvement that may, for example, stop short of conventional methods of consultation.

However, the method of involvement does have implications for accountability. Where involvement is iterative and more, rather than less, participatory, statutory organisations and their communities can exchange information, engage in shared dialogue and decision-making, and build knowledge together over a period of time. This can develop an important set of relationships.

Holding executive decision-makers to account can be part of this iterative and participatory process. So instead of the executive deciding and acting more or less unilaterally, and then being scrutinised by another body, there is a continuing flow of information and discussion between providers and/or commissioners of services, and those who use the services.

Compromised scrutineers

What matters in this case is who is involved and whether relevant groups are excluded. In the worst case, a small group of people with a strong vested interest claiming to speak 'for patients and the public' are involved from start to finish. This way, planning and decision-making cannot benefit from being informed by the views and experiences of many other groups.

And there is no genuine accountability where the scrutineers are compromised by being part of the decision-making process. If one small group of people is involved from beginning to end of a planning or decision-making process, the group may be too limited in its scope to carry out effective accountability. Where early involvement is exclusive, there is a strong case for separating it from accountability, so that different people do the latter.

Much depends on the issues at stake. Take, for example, planning a service for people with diabetes. The only sensible way to do this is to involve people with diabetes in planning and decision-making
and then find out from them whether implementation works for them. This is a real form of accountability to people who are using the services.

But here we must pay attention to different aspects of accountability. Commissioners and providers of services must be held to account for meeting the needs that have been identified and spending money wisely. Where service users hold an organisation to account for delivering services for people with diabetes, there should be separate accountability for legal and financial probity.

In other instances, for example where measures are taken to tackle traffic congestion in an area, we can consider a different approach. A range of people in the community can participate in planning and decision-making. If a sufficiently inclusive range of people are involved and have an informed dialogue over time with decision-makers and 'experts', they can also give feedback about the results. How far do they think that the decisions they have helped to make have been implemented to provide an effective outcome from their point of view? This can be one of the most useful ways of holding decision-makers to account.

But if only a small group has been involved, a separate mechanism for 'effectiveness' accountability will be necessary. If involvement extends to shared decision-making and direct action by the participants, they are, in a sense, accountable to themselves. But if a small group takes action on behalf of a larger group, the former should be held to account by the latter. In any case, there would need to be separate accountability for legal and financial probity.

But where there is continuing, iterative participatory involvement, participants should be well-informed about the legal and financial implications.

Involvement and accountability can be entirely complementary if both are designed as part of a single process. Often, we don't think about designing involvement and accountability systems so they fit together coherently and are mutually reinforcing. The integrity of either can be undermined by inappropriate methods. However, independent scrutiny is always necessary for financial and legal probity.

Anna Coote is head of the patient and public engagement team at the Healthcare Commission.


Jessica Crowe

Anna Coote has made some very helpful distinctions and cleared some thorny ground in doing so. The metaphor of the ladder of involvement is a useful one as it suggests a continuum from what she calls 'light touch' consultation with service users and others to a much more continuous process of serious long-term engagement.

We might see the relationship between involvement and accountability as being a series of greater or lesser trade-offs along this continuum. Essentially, the more a patient is involved - and therefore, to an extent, shares responsibility for a decision - the less they are independent of decisions and the less they are in a position to hold decision-makers to account.

However, patients can be wholly independent of decisions, in the sense that they are ignored when decisions are made, but this type of independence hardly goes along with great accountability. As Ms Coote points out, involvement itself can be a form of accountability for the effectiveness of services. For example, where all the users of a particular service are fully involved and active in a re-design of a service and in its evaluation, this must count as one form of accountability.

But actually this is not right either, because there are different forms of accountability and patients and the public are not a homogeneous group, as Ms Coote also points out. So the real picture will be a multi-dimensional one in which some groups, such as the users of diabetes services, are holding NHS decision-makers to account through being involved, while others, such as those currently without access to services, may not be involved at all.

We need a model of accountability and involvement which recognises this complexity. The diabetes services example is one in which involvement of service users goes hand in hand with accountability to them and independence does not seem to be an issue: this example could be generalised to all individual services and groups of service users.

Seldom-heard voices

But when we come to groups other than service users and other levels of decision-making, for example decisions about distribution of resources across a local health economy, accountability is not so simple. In such cases, other forms of accountability will be needed to supplement direct involvement of service users.

Local authority health scrutiny is a case in point. Here we have a form of accountability through elected members who are not involved in decision-making and are, in that sense, fully independent. If they are doing their job well, they will represent the views, not only of current service users, but of those who currently do not have access to services and those who will need access in the future.

They will take extra care to ensure that the voices and interests of those who are seldom heard get a hearing. They will be aware of the role of NHS commissioners and the influence they have on the nature and quality of services and the distribution of resources. And they will look across whole communities and interest groups, trying to balance the interests of each and mediate between them where this is necessary.

It is unrealistic and unfair to expect a group of users of a service to be responsible for thinking about the equitable distribution of scarce resources and quality standards across all services. What they can do by their involvement is to influence the quality of the service they and other users receive. It is for others, such as our elected representatives in Parliament and on local health scrutiny committees, to complement this form of involvement.

By providing the necessary independence and overview, they can hold to account those responsible - particularly commissioners - for quality and equity across the country and within communities.

Jessica Crowe is executive director of the Centre for Public Scrutiny.