The Anatomy of Accountability

01 June 2007

This publication is the result of a series of seminars organised by the Centre for Public Scrutiny in late 2006/early 2007 on the theme of health and accountability as part of its health scrutiny support programme. In the context of recent NHS reform which requires patients and communities to be involved in local decision-making; and forthcoming legislation which will create new patient and public involvement structures for the NHS, the time seemed right to reflect on experiences from local government health scrutiny, the wider patient and public involvement framework, inspection and regulation and to consider their contribution to democracy and accountability. Our aims were to:

• map out the interrelationships between different kinds of accountability
• clarify the roles of the different players
• assess the capacity for existing and proposed structures to make a real contribution todemocracy and improved services

The introduction sets the issue in the wider context of what we mean by accountability in the public services generally. We then consider how this applies to the NHS in particular, who it is that holds the NHS to account and for what. We discuss issues of national versus local accountability and the implications of greater ‘localism’ in health decision-making and scrutiny, arguing that a localist approach combined with a core set of national standards is needed to address health inequalities.

We discuss the role of patients as customers and as citizens and the distinctive role that local authority scrutiny committees can play in ‘holding the ring’ between the interests of different groups and bringing an element of local democratic accountability to health issues. We consider whether different ‘domains of accountability’ are more appropriately scrutinised by one group or another, concluding that there are indeed different roles to be played by different monitors and scrutineers.

Following to some degree the structure of our seminars, we consider issues of demarcation between accountability and professional judgement and the ethical and professional dilemmas this may throw up; how public accountability and patient and public involvement should relate to the different stages and levels of the NHS commissioning cycle; and the synergies and tensions that may arise from the distinction between patients’ involvement in the design of health services and the job of holding the NHS to account. Finally, we consider how well the new and forthcoming accountability and involvement structures will be able to meet the challenge of holding to account the public service that matters most to the people of this country.

Our discussions raised a number of issues on which we believe there is scope for further consideration and policy development while new legislation is being introduced. These issues are highlighted throughout the document and summarised at the end. We hope that they will make a contribution to the debate about the best forms of accountability for the NHS.