1 Accountability and assurance in
the new NHS model
1. The Health and Social Care Bill, published on
19 January 2011, proposes a new model for the NHS, focusing on
patient outcomes and aiming to empower and liberate clinicians
to innovate. The proposals
involve major changes to the role of the Department of Health
(the Department) and many parts of the NHS.
The two significant structural changes proposed in the Bill are
the abolition of the current structure of commissioners of health
services and the regional organisations that oversee them, and
the creation of the NHS Commissioning Board and GP commissioning
consortia to make commissioning more clinically led.
The Government also expects all health service provider trusts
to become Foundation Trusts by 2014 and to compete with private
and third sector providers within a market-based model.
2. Accountability to Parliament for health spending
needs to be more clearly spelled out under the reforms.
The Accounting Officer for the Department told us that she will
be responsible for making certain that an overall system of control
is in place for ensuring proper stewardship of public funds and
that she would expect Parliament, through this Committee, to hold
her to account for any control failures in the system, such as
those arising from deficiencies in the policy framework or legislation.
The Department proposes that the accountability relationship between
the Department and the NHS Commissioning Board will be set out
in a detailed framework agreement covering the Commissioning Board's
purpose, governance and accountability, management and financial
responsibilities. The Department recognises that there is further
work to do to specify, describe and communicate the accountability
3. GP consortia will be accountable to Parliament
through the Chief Executive of the NHS Commissioning Board. The
Department expects that consortia Accountable Officers will be
responsible for ensuring that adequate systems of control are
in place within those organisations, and they should expect to
be held to account for any failures in quality, safety and performance.
4. Foundation Trust Accounting Officers will continue
to be directly accountable to Parliament. The Department sees
individual Foundation Trust Accounting Officers as accountable
if financial failure should occur in their own trust, but the
Department's Accounting Officer would be accountable should any
such failure in Foundation Trusts result from a deficiency in
the policy framework or legislation.
The accounts of Foundation Trusts will in future be consolidated
within the Department of Health's accounts, which the Department
believes will improve accountability to Parliament.
5. The regulators, Monitor and the Care Quality Commission,
will have dual accountability to Parliament, directly through
their chief executives and also through the Department's Accounting
Officer, who retains responsibility for the appointment of the
chief executives of the two bodies. As Accounting Officers in
their own right, either or both chief executives could be called
to this Committee alongside trust chief executives. It is not
yet clear to us how those relationships will work in practice,
however, given the changing structures within the health service
and their respective roles within it, or where ultimate accountability
6. Monitor will be required to report annually to
Parliament to demonstrate value for public money. The Department
will monitor the Care Quality Commission's financial and operational
performance, and risks at a strategic level, but the NHS Commissioning
Board will be responsible for assessing and ensuring the quality
of its inspection or monitoring of specific providers on a day-to-day
basis. The Commission will be accountable to Parliament.
7. Local planning and partnership working is a key
part of the reforms. New statutory Health and Wellbeing Boards
in each upper-tier local authority will bring together the NHS,
public health and social care services to assess needs and plan
the powers and influence which these bodies will have on GP consortia
commissioning decisions is not clear. Dr Shane Gordon told us
that while his consortium had a duty to engage with the local
Health and Wellbeing Board, it was not accountable to it.
The King's Fund told us that under the proposed legislation there
would be no formal accountability from GP consortia to health
and wellbeing boards; the formal accountability would be upwards
to regional offices of the NHS Commissioning Board. The King's
Fund considered that this was a logical way of making the commissioning
side work, but one consequence of this would be a much weaker
role for local authorities in relation to GP commissioning than
was anticipated in the White Paper published in July 2010.
8. The Department intends that greater accountability
to patients will be a key part of the reforms, whereby new HealthWatch
organisations will act as 'patient champions'. Local HealthWatch
bodies will carry forward the functions of Local Involvement Networks
(LINks) and will continue to be funded by local authorities and
accountable to them for effectiveness and value for money. In
addition, Local HealthWatch will have a role in decision-making
for commissioning through a seat on Health and Wellbeing Boards.
9. Accurate, relevant and timely information flows
will be an important element of the reforms, and the NHS Information
Centre will have an important role in providing the information
that local decision-makers, the public and health regulators need.
The Department expects to publish its information strategy in
2 C&AG's report, para 4 Back
C&AG's report, para 2.4, 2.7 and 2.11 Back
C&AG's report, para 2.4 Back
C&AG's report, para 2.17, 2.18 Back
Qq 2-7, 20-23 Back
Ev 40 Back
Ev 40 Back
Ev 40 Back
Ev 40, Q178 Back
Ev 40 Back
C&AG's report para 2.32 Back
Ev 40 Back
C&AG's report para 2.39 Back