For the first half of the 2000s, the Chief Executive of the NHS was the man in charge, with clear accountability for the NHS's success or failure at national and local level. There was of course a degree of political interference, most notably in response to evidence of national failures, for example the introduction of waiting list targets, health inequality targets, and latterly the Vital Signs targets. There was also political interference at the local level, with MPs accountability to their electorate leading to them campaign vigorously to over-turn proposals to close NHS facilities, often despite overwhelming clinical evidence. Nevertheless the system of accountability for the use of NHS resources seemed clear.
The seeds of change were sown in the mid to late 2000s. Firstly with the establishment of Foundation Trusts, with their own accounting officers, followed by initiatives aimed at enabling the Department of Health and the NHS Executive to devolve responsibility for decision making to the front line. But in exchange for increasing freedoms, came an increase in the role and responsibilities of regulatory bodies, particularly for Monitor and the Care Quality Commission (CQC). There then followed what has been a more seismic shift in accountability and responsibility, with the election of the Coalition Government and Andrew Lansley's vision for "Liberating the NHS" and the Health and Social Care Act 2012.
All was clear, reforming the health system was going to remove central day-to-day strategic management and control of the NHS. The Department was to be responsible simply for the stewardship of the system as a whole with the permanent secretary of the Department having sole accounting officer responsibility for the proper and effective use of resources voted by Parliament; supported by a system of assurance around the commissioning, provision and regulation of healthcare. So that's clear, or is it? The reality of the last 12 months looks somewhat different.
The first blow to liberation was the extended period of austerity, with little or no real term growth in funding in the face of increasing demand. Then winter pressures collided with austerity, staffing pressures were exposed and the ability to maintain quality and leadership throughout the NHS was severely tested. There also emerged a lack of clarity and complex divisions in power between the six national organisations with responsibility for policing healthcare - NHS England, the CQC, Monitor, the Trust Development Authority, and Public Health England and, of course, the Department. There was also the Competition Commission and its increasing influence over proposals for service reconfiguration. Each is statutorily accountable for what they do, but for providers it is increasingly confusing as where their responsibilities begin and end. Together, these organisations have increased the size and intensity of the spotlight on provider organisations but the accountabilities for improving performance seem even more confused.
So how are providers performing in this new NHS? GPs are increasingly under fire for not seeing enough patients quickly enough and for the lack of out of hours care, even though they were legally allowed to opt out in 2004. The problematic roll out of the 111 service has increased the clamour for GPs to take back responsibility for this care even though these problems were not of their making. Hospitals are being pilloried for too many people turning up at their front door and for admitting too many patients and then holding on to them for too long. When they have little or no control over the availability of or access to alternative care provision; and would be the first to be criticised should they fail to admit or similarly discharge too early and something bad happens. At the same time commissioners, who are still finding their feet, along with providers are being subjected to the recommendations of numerous critical reports, telling them what to do without the resources or tools, space and time to actually to do much of anything.
It's difficult to argue with the Francis report (all 500 pages and 297 recommendations) and its call for a 'fundamental culture change' across the health and social care system. Nor the Government's initial response, Patients First and Foremost, which set out plans to prioritise care, improve transparency and ensure that poor care is detected; and its final response, last week, Hard Truths: the Journey to Putting Patients First, (137 pages) with its accompanying response to all 290 recommendations. But who has the time to distil, reflect on and implement at provider level and how will we know when they have? Especially when you consider the other seminal, reports in the last few months targeted at the beleaguered leadership of NHS organisations (for example: Keogh; the Cavendish Review of HCAs; Berwick review of patient safety; Clwyd/Hart review of complaints handling; and CQCs annual 'state of health and social care 2012-13' report. With so many cooks stirring the NHS pot the NHS hardly looks, or feels, free!
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