National Health Service Landscape Review - Public Accounts Committee Contents

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.[2] The proposals involve major changes to the role of the Department of Health (the Department) and many parts of the NHS.[3] 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.[4] 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.[5]

2. Accountability to Parliament for health spending needs to be more clearly spelled out under the reforms.[6] 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 arrangements[7].

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[8].

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[9]. 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.[10]

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 lies.[11]

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. [12]

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 services.[13] However, 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.[14] 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.[15]

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. [16]

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.[17] The Department expects to publish its information strategy in 2011.

2   C&AG's report, para 4 Back

3   C&AG's report, para 2.4, 2.7 and 2.11 Back

4   C&AG's report, para 2.4 Back

5   C&AG's report, para 2.17, 2.18 Back

6   Qq 2-7, 20-23 Back

7   Ev 40 Back

8   Ev 40 Back

9   Ev 40 Back

10   Q175 Back

11   Ev 40, Q178 Back

12   Ev 40 Back

13   C&AG's report para 2.32 Back

14   Q276 Back

15   Q277 Back

16   Ev 40  Back

17   C&AG's report para 2.39 Back

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© Parliamentary copyright 2011
Prepared 27 April 2011