Whether it comes to running a large-scale bank, running a country or managing health and care, there is general agreement that ‘accountability’ is a good thing and that efforts should be made to improve it. We all think we know exactly what accountability means, but we rarely check that we are talking about the same thing. The problem with that is that one doesn’t need to go into dictionary definitions to know that accountability means different things to people at different times. So if we are going to discuss improving accountability in the NHS let’s start by agreeing what we are talking about.
People and bodies are/should be accountable – have to answer for – what they decide and what they do to another party. But there are degrees of accountability that mean qualitatively different things in practice. At one level accountability might just mean the obligation to tell someone what you are doing and might have little impact on how business is conducted. At the other end of the scale, being accountable can mean being legally liable for the quality and availability of services.
If we are going to discuss improving accountability in the NHS let’s start by agreeing what we are talking about.
Specialist advisor (Governance)
In addition to differences of interpretation, the NHS has a track record, at least informally, of separating the power to take decisions from being accountable for the subsequent outcomes. Historic examples include Strategic Health Authorities pressurising trusts to act in a certain way but being nowhere to be found if things went wrong. Or regulators insisting that a trust commissions a review from a specific consultancy but then taking no responsibility for the quality of that review and its recommendations. One of the more unpleasant manifestations of this can be when individuals feel they are bullied into actions that they would not otherwise have taken, and this can evidently happen at a local level as well as through national or regional pressure.
For the boards and individual directors of NHS provider organisations the need for accountability to be tied to the ability to take decisions and to act is crucial.
Specialist advisor (Governance)
For the boards and individual directors of NHS provider organisations the need for accountability to be tied to the ability to take decisions and to act is crucial. The legal responsibility to decide, act and the consequent liability of boards and individual directors is set out in statute as well as in common law. Trusts as bodies corporate and directors, collectively and as individuals have legally defined powers and powers of delegation. They are rightly held to account for the exercise of those powers. This is the blunt end of the accountability spectrum. Individuals accountable in that way can lose their reputations, their jobs, be financially liable and even subject to prosecution if they fail to carry out their role with sufficient diligence. So the stakes are high.
As we move towards system working, we need to be vigilant and understand the risks that once again the power to decide could become separated from those answerable for decisions. This could occur if ‘system leaders’ with no individual standing in law in that capacity take unilateral decisions with no legal accountability or liability for the outcome. This will leave provider boards of directors legally liable and therefore accountable for the outcomes -an invidious position for boards and individual directors to find themselves in if things go wrong: being held to blame for decisions that they did not take and might not have agreed with.
Of course it doesn’t have to be that way in a genuinely collaborative working environment. It is perfectly feasible for decisions to be taken lawfully and with the consent of those who will be liable for them using delegations to individual, committees in common, pre-decisions by boards or reference back for confirmation. This might not be streamlined, and it doesn’t guarantee compliance across a system, bit it does mean that accountability and decision-making lie in the same place – that those who decide carry the can if things go wrong. And that important decisions affecting healthcare and the lives of thousands of patients, are taken following due debate, challenge and scrutiny. In reality most good ideas will receive support and be implemented in any case because there is synergy, obvious benefit for patients, service users and staff, and a common goal. Ideas that one or more parties are wary of should probably raise warning signs in any case, even if that is to slow down the pace of change, commission additional research or adopt a more incremental approach. The beauty of voluntary collaboration as a basis for effective partnership and system working is that it requires little or no new legislation.
For the future it remains crucial that accountability is rooted alongside the legal power to decide and act.
Specialist advisor (Governance)
For the future it remains crucial that accountability is rooted alongside the legal power to decide and act. The power to make decisions divorced from challenge, scrutiny or being held to account is unhealthy and, in the medium term, a recipe for poor decisions and bad outcomes. And to be held to account for decisions one did not make is invidious and unfair. If this means a rethink about systems: looking at them as bureaucracy light collaboratives rather than traditional NHS hierarchies then so be it. Better that than a legal fudge that leaves local board directors exposed or extensive legislation to produce new infrastructures without evidence that they will add sufficient value to justify the effort and expense.
To conclude, when we talk of accountability, we need to ensure that we are all having the same conversation about the same thing. Most importantly we need to ensure decisions are taken by those with legal liability and accountability for the outcome. To do otherwise is to undermine the ethos of public service in which we remain accountable to local people for the decisions we make and leave local directors and boards unnecessarily exposed.
This comment piece was first published in the HSJ.
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