In the UK healthcare is primarily funded through taxation, and so must be held to account for the way that money is spent. Over time the way that we have attempted to ensure accountability has changed quite considerably, but without perhaps widespread awareness of the implications of changing the means of accountability. This issue is regarded as less glamorous than whichever system-level reforms are presently being proposed or implemented, but is a key element of them that often gets rather overlooked.
At the creation of the NHS, accountability for the NHS was meant to reside firmly at its centre, with the Department of Health. Hence Bevan’s aphorism that every bedpan dropped in the corridors of the health service rang through the corridors of Whitehall. However, this was never really the case. People might have been content to blame the government (which is not quite the same thing as the Department of Health) for the NHS’s failings, but whether health services were accountable through this means is doubtful. If people wanted a change in the stewardship or colour of the government, they could certainly, once every five years or so, vote to try and achieve this, and it is remarkable that the government that created the NHS, Attlee’s Labour government of 1945-1951, was voted out remarkably quickly after the founding of the NHS in 1948. But this isn’t really an accountability mechanism – it is more a means of changing government with bigger implications than reforming healthcare and of little use between elections, or for dealing with the day-to-day problems of making sure healthcare is accountable. Of course, elections also don’t just depend on our views on healthcare, but on the government performance as a whole. They are rather a blunt weapon for ensuring accountability for any individual public service.
The model of Parliamentary accountability tries to deal with the issue by opening healthcare decisions open to scrutiny and question through open debate. As such, Parliamentary accountability can work more frequently than electoral accountability, but depends on whether the opposition of the day are engaging and challenging the government appropriately, and whether the government are prepared to change things if their approach to healthcare is being found wanting. We would hope both are the case, with the ultimate sanction again being that a government seen to be running the NHS poorly would leave itself open to attack from the opposition and so more likely to lose a general election.
The issue of elections links to the idea that health services are accountable to Parliament on behalf of the citizens of the country. This implies a citizenry paying attention to Parliamentary debates and making informed decisions about who to vote for on the next election based upon their view of what is happening there. If citizens are paying no attention to debates on healthcare, then their vote can’t really make any political party accountable for their decisions in that area. It is possible that, during a general election, claims and counter-claims can be made by political parties and assessed by the citizenry, but this, again, reduces accountability to a once in every five years event. Unless the citizenry are paying attention in between these dates as well, they are unlikely to make good voting decisions.
Extending the notion of citizenry gives other means by which health services might be more accountable. Individual members of the public can get in touch with their local hospitals or Primary Care Trusts and become members of them, so attempting to become representatives and affect decisions ‘on the ground’. Health organisations should then become more responsive and accountable to local people. However, again, the NHS has not traditionally been very good at achieving local accountability through these sorts of means. The membership schemes are still fairly new, but have been subject to strong criticisms of whether they achieve very much more accountability of any kind at all.
If citizen-type means of accountability have struggled in the NHS, how about the alternatives? Two have been tried, accountability through performance management and accountability through consumer mechanisms.
Accountability through performance management is a relatively recent invention. Performance indicators for healthcare have existed in various forms since the 1970s, but only in the 2000s were formal league tables constructed of performance and sanctions imposed upon poorly performing organisations. In this system, data is collected from NHS organisations and assessed against both benchmark standards and against other NHS organisations. Ratings (originally based on stars and now on normative statements) can then be issued based on benchmarks, and comparisons made with other healthcare organisations to see where yours ranks.
The problems of performance management have become well documented. Managers have been accused of adopting target focus rather than looking to systemically improve performance as a whole, of game-playing to try and find ways of making performance measures improve without necessarily achieving anything new, or even of simple misrepresentation and lying in their performance returns. There is a great deal of sense in measuring health service outcomes to see if they are getting better, but always with the risk that it skews patient care in terms of the measurable at the expense of less tangible aspects. A danger of seeking quantity about quality. However, achieving accountability through performance management is now with us to stay, even if it does carry risks of managers losing sight of why such systems were introduced in the first place, and even though such systems need to be supplemented by more discursive systems to allow managers to explain what is happening, how and why, as well as the ‘what’ that numbers are likely to be able to provide.
Finally, there is the consumer route of accountability. This attempts to create markets in healthcare, with funds following patient choices, and so automatically giving greater resources to the highest performing organisations. Accountability comes not through ‘voice’ mechanisms, as it does in citizen-type mechanisms, but instead through ‘choice’. This is very much the vogue in the NHS at present.
However, choice mechanisms resemble voice mechanisms in a number of ways that are often over-looked. If expecting citizens to follow Parliamentary debates to make health services accountable seems to ask a lot, equally it is asking a lot to ask sick people to choose the best healthcare provider to meet their needs. Most people want to go to a good local service rather than choosing between potential providers. Equally, evidence from Barry Schwartz suggests that whereas most people say before they are sick that they want to choose their healthcare provider, when they actually fall sick, they would prefer their doctor chose instead. Now, it is certainly possible that doctors might be better choosers than their patients, and for health services to be accountable to local doctors through this mechanism, but the evidence of the 1990s, of the Conservative internal market, is rather ambiguous as to whether Primary Care doctors were prepared to take this role on.
So accountability hasn’t really worked through voice mechanism, or through performance management, or through choice. Are health services doomed to be unaccountable? I hope this isn’t the case. It seems to me that the NHS is a collective good that must be accountable to people collectively. When we try and treat it as consumers, big mistakes get made. We demand, on behalf of our families, that the NHS pay for new drug breakthroughs without thought as to which part of its budget is going to be no longer available if that decision is made. The NHS is a public good, and requires collective public decisions about what it should spend its money on.
It seems to me that the appropriate place for such decisions to be made is in local government. Local government, to be sure, has a pretty poor reputation after thirty years of neglect. But as healthcare seems to be one of the few public services that people feel strongly about, perhaps putting the NHS under greater local government control could both regenerate debate in local government, and make health services more responsive to local people’s needs. One implication of this approach is that health services would differ from one area to another – the dreaded ‘postcode lottery’, but the decisions made locally would be open and transparent, and available to everyone. So long as which health services, subject to national limits about basic provision, were made clear to local populations and to those considering moving to such areas (through means such as upmystreet.com) then there is no reason why the range of health services shouldn’t change from one area to the next. Such a process would allow greater collective accountability, responsiveness, and potential enliven the rather stifled world of local government.