How much public accountability is there in OUR NHS?

All those responsible for health policy and the running of our NHS are accountable to the public through the Nolan Principles of Public Life and duties laid down in law to account for their decisions and actions.


BUT – the word ‘accountable’ is being used to describe many new structures being created in the NHS – these do not follow the legal duties or, always, mention the Nolan Principles .

What do we mean by public accountability?

It’s about whether the people who make the big decisions that affect our lives are  ‘accountable’ to us – the ‘public’ – or not!  It has been defined as follows:

What is PUBLIC ACCOUNTABILITY? definition of PUBLIC ACCOUNTABILITY (Black’s Law Dictionary) – which says it’s:

The obligations of agencies and public enterprises who have been trusted with the public resources, to be answerable to the fiscal and the social responsibilities that have been assigned to them. These companies and agencies need to be accountable to the public at large and carry out the duties asked of them responsibly.”

So – Accountability must be:

  • all about the decision-makers being answerable to us for the decisions they make.
  • and all about the public trusting that the decision-makers are making decisions in ‘our’ best interest.

Who are the people making decisions about OUR NHS?

The NHS is a public service and is funded by public money. But who decides what it looks like?

Health policy is decided by government politicians, who decide how our NHS will work and how much public money will be put into it.

  • the government then puts this policy into the law – that NHS managers have to abide by
  • the government also decides how much public money goes into the NHS – giving NHS managers budgets that they have to keep to

At least it was!

  • But in 2013 NHS England was created to run the NHS on behalf of the Government, as stated in the Health & Social Care Act 2012.

The government still decides what money the NHS has to work with, but has frozen NHS funding since 2010.

  • This frozen NHS budget means that there is not enough money to fund the increased costs of the NHS year on year
  • These increased costs are because of using more technology (in treatments and diagnostics) and for the growing population and increased need for services

So now NHS England uses this funding ‘gap’ as a reason to reorganise NHS service delivery, and to provide us with cheaper NHS services with fewer staff and in fewer places – as a way of making ends meet.

How are all these NHS decision-makers actually accountable to us – the public?

Our UK government and politicians are held accountable to the public by our democratic vote every few years – apparently:

  • so we can vote out the government politicians if we don’t like their health policies
  • but we can’t vote out NHS England managers if we don’t like what they’re doing

The NHS England and NHS Trusts akk have a Board of Directors which include Non-Executive members of the Board who are appointed to protect the public interest, paid for their time, and are supposed to act in the interests of the public.   NHS Non-Executive Directors have patient involvement and public accountability within their responsibility – but the appointment process has no requirement that they have either knowledge or expertise in these areas.

We can write to the Non Executive Directors on the NHS England and NHS Trust Boards, and to the Lay members of Clinical Commission Group Governing Bodies.  And they may reply to us. But they don’t have to take any notice of what we say!

Non Executive Directors at NHS England and NHS Trusts, and the CCG Lay members, are NOT accountable to the public in any way! 

And what about Senior NHS managers in the NHS, whether at NHS England or at all the other NHS bodies?

Well – the reality is that NHS senior managers are appointed by other senior managers and approved by the Directors of the relevant NHS body’s Board of Directors.  They are paid very large salaries but are only accountable directly to the people who appointed them.  Only these people can decide if they are not right for the senior responsibilities they have. Only they can sack them.

NHS senior managers are NOT accountable to the public!

NHS Trusts also have a Board of Governors, some of which are elected by members of the public – but they have to sign up to be a ‘member’ of the Trust to get a vote.  The NHS Trust Board of Governors can appoint, and can deselect, a Non-Executive Director and are supposed to check that they act in the public interest in their role.  The Governor meetings are partly held in public, but the public cannot remove an unsatisfactory Trust Governor.

NHS Trust Governors are not accountable to the public either!

What about the NHS Annual Reports that are Presented in Public?

It is a legal requirement for all Trusts and all Commissioners to publish an Annual Report, which is presented to the public each year at a publically advertised event. This Annual Report has to show the meeting attendance of Trust Directors and CCG Governing Body Members and what payments they received.

Commissioners (NHS England and CCGs) also have to say in their Annual Report exactly how they involved the public in their work that year, again as a legal requirement.

Well.  Is this real public accountability? It’s just saying what they did last year.  There’s nothing that allows the public to influence what they do next year.

What about the health scrutiny function of local authorities?

A local authority has statutory (legal) powers to scrutinise a particular matter about the planning, provision or operation of health services in their area.  These powers include:

  • inviting interested parties to comment on the matter
  • taking account of relevant information available to it
  • making reports and recommendations to the responsible person in the relevant NHS body, including detail and explanation of the scrutiny process
  • creating joint health scrutiny committees to share their powers to scrutinise health service matters that affect more than one local authority area
  • requiring to be consulted by the relevant NHS body on any proposal for substantial change in health service provision in their area
  • reporting to the Secretary of State if they are not satisfied that the consultation was adequate in content or in time allowed

A local authority also has a statutory duty to scrutinise any particular matters about the planning, provision or operation of health services in their area that has been referred to them by the local Healthwatch.

Unfortunately the scrutiny functions of local authorities are not always carried out very rigorously having become a bureaucratic exercise rather that an exercise in meaningful public accountability.

What about Healthwatch?

In 2013 there was a local Healthwatch created in each local authority area, with the local authority responsible for the contract and its establishment.  There are 152 of these with each being required to:

  • Gather the views of local people about local health and care services, where these need improving and where any gaps are
  • Build a picture of how the local health and care services are performing and collect evidence to clarify specific concerns
  • Attend the local Health & Wellbeing Board to feed in the local overview of local health and social care services which is based on the views of local people
  • Carry out ‘Enter and View’ visits to inspect services giving concern and send a report to the service provider which may include recommendations for improvement
  • Alert local commissioners, Healthwatch England and/or the Care Quality Commission of any particular concerns about local health and care services
  • Signpost local people to information about local health and care services and how
    to access them
  • Provide people with information about their choices and what to do when things
    go wrong, such as how to get support from the Independent Advocacy Service
  • Act as an independent social enterprise with the power to recruit its own staff and to make its own workplans
  • Produce an annual report  demonstrating it is inclusive and enables the local population to lead in its work and are directly involved in its governance

However Healthwatch nationally only works with about 6,000 volunteers and about 300,000 individual views.  But there are at least 55,000,000 people in England, so only a few were actually involved with Healthwatch, with on average:

  • 0.01% of local people as Healthwatch volunteers
  • 0.5% of local people with their views about services gathered by Healthwatch

Many Healthwatch representatives on their local Health & Wellbeing Board say little or nothing at all, certainly not having a local overview of local health and care services to feed into discussions.

 Healthwatch cannot be said to represent the public and are only accountable to a very small percentage of their local population


What about the Seven Nolan Principles of Public Life?

All elected representatives in local and national government, and all the senior managers, directors and board members of ‘public bodies’, including Councils and the NHS, have to act within the Seven Nolan Principles of Public Life.

These are listed in full on the last page of the Nolan Report – The First Report of the Committee for Standards in Public Life, that was Chaired by Lord Nolan and presented to the UK Parliament in 1995.

These Seven Principles expect all those in public service to behave in a way that shows:

  • selflessness – not acting for personal or financial benefit
  • integrity – not being beholden to outside influence
  • objectivity – making any choices their role requires on merit
  • accountability – answering to the public for their decisions and actions
  • openness – being open and transparent in their decisions and actions
  • honesty – declaring and addressing any conflicts of interest
  • leadership – leading and promoting the principles by example

But – as none of these people acting as public servants are directly answerable to us – for either how they behave – or for their decisions and actions they take – how can they be considered be directly accountable to the public?

How can we trust that they always act in the public interest when we don’t know what they do – in our name – as they are not directly accountable to us?

How can we trust that what they do with our public money is always carried out according to the seven Nolan Principles of Public Life when they are not directly accountable to us?

Well then – Is there any Public Accountability in OUR NHS?

At the beginning of this post a definition described accountability in public services, including in the NHS, being all about:

  • decision-makers being answerable to us for the decisions they make – they are not!
  • the public trusting the decision-makers are acting in our interest – well we don’t!


When trust becomes broken it is time to CHALLENGE!



The NHS belongs to the PEOPLE!

What do you think?

We will look at the new, and very secretive, ACCOUNTABLE CARE SYSTEMS next – are these partnerships to integrate services accountable to the public?

We will also look at the ACCOUNTABLE CARE ORGANISATIONS too – supposed to manage the budgets and contracts for integrated services in each local area – do they serve the people and give us safe and effective services – or do they just save money, and take decisionb-making further away from public, and political, accountability?

There are two legal challenges already to the content of the Accountable Care Organisation version of the NHS Standard Contract.

Please share your thoughts about all this with us.

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