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.

Shh! It’s a secret! The NHS involved us, the public, in its decisions – but they didn’t tell us how or when!

Well – NHS England has just re-written their guidance document saying how the public should be involved in decisions about the NHS. But – they kept this a SECRET! They only involved a few ‘select’ members of the public – in deciding how the NHS will involve ALL of us, the public, in NHS decisions in the future!


But – N NHS PV found out.  So we’re telling you.cropped-megaphone.jpg

(We were not included in the list of the ‘select’ few – who were invited to a workshop and sent some draft documents to comment on – but we have some new members who DID know – and they thought the Public SHOULD know!)

So – What is this all about?

In April 2013 the Health & Social Care Act became law.

This Act created both NHS England, the national organisation responsible for all NHS services in England, and Clinical Commissioning Groups, or CCGs, which are local organisations responsible for our local NHS services.

(There are 209 CCGs across England – Northern Ireland, Scotland & Wales are each responsible for their own NHS services).

The Act includes a legal duty for Public Involvement in the ‘commissioning arrangements’ of NHS services, (how they are planned and delivered) for both NHS England, in Section 23 13Q, and the CCGs, in Section 26 14Z2.

In September 2013 NHS England published a guidance document called ‘Transforming Participation in Health and Care for Clinical Commissioning Groups, CCGs.’

 This document has now been removed from the NHS website as it was replaced, on 6/4/17 by a new version , which is still the Statutory Guidance explaining the legal duty in the Act that CCGs MUST ‘have regard to’! 

This guidance shows CCGs how, and when, to involve both patients and the public in the decisions they make about how local NHS services are commissioned (planned and delivered).

The guidance is a legal document, intended to explain the wording of the Act.

It is the CCGs’ responsibility to make sure the NHS services local people need are made available to them, and they ‘must have regard to any guidance published‘ by NHS England about public involvement in decisions about these services. This requirement is also stated in Section 14Z2 of the Act.

In 2013, the original guidance explaining this legal duty was designed and written jointly, by NHS England working together with members of the public.  These were people who had used the NHS in England, and many gave their stories and described how they were often involved in improving the NHS services they relied on.

However in November 2016 Olivia Butterworth, who is the Head of Public Voice at NHS England, said she wanted people to help her make changes to the original guidance document.  She did this in a news blog, OB news blog 25.11.16, on the NHS England website News page, saying that this original guidance “has become outdated”  as “we’ve moved on” now.

Sincere apologies – the original link to her blog now takes the reader to another page on NHS England’s website as they have removed her blog from the website – completely!  

So we have inserted, instead, a copy we made and saved of her news blog – in case such a thing ever happened.

How were the public involved in ‘updating’ the guidance about involving them?

Olivia invited anyone to send in, by email to her, their ideas about how this guidance should be ‘updated’ before Friday 13th January 2017.  But this was a general invitation, for anyone, not just for the public.

And it only gave people seven weeks to respond, which included the Christmas and New Year holidays, so it was not likely to attract lots of responses.

She gave many reasons in her blog post for the urgent need to change this document.  But there were a number of people who wrote comments on her post and were not impressed.


You can see these comments by clicking on this link – comments-on-olivias-blog-post.  

They were at the bottom of her blog page, but have now been removed (in early March 2017).  

The blog post itself has also now been removed (mid-March 2017).

(They moved her blog post weeks ago from its original November position on the general News pages and put it on the Involvement Hub News pages. But there was NO information showing where it had been moved to –  in case anyone who had seen it originally wanted to revisit it.)

It makes you wonder – Did they want us to see it – or did they mean to hide it? 

We don’t know whether all these comments made on her blog post page were included, or taken account of, in the ‘updating’ of the original guidance.

This ‘send all your ideas to me’ method of ‘involving people’ meant that the ideas people sent in were only seen by her  – and those she chose to share them with.

That was not very ‘transparent‘!

There was no open discussion possible for people to share their ideas, and develop them together, other than all the blog post comments – which are no longer online for all to see!

We don’t know:

  • how many people sent ideas to her,
  • what they said, and
  • what was recorded,
  • which contributions were accepted, and
  • which were rejected
  • or why.

This is not an inclusive, meaningful or respectful way to involve the public.

It is certainly NOT ‘transparent’.

It shows a controlled, disempowering, tokenistic, and ‘managed’ approach to involving people in decisions.

What happened next?

We, the general public, haven’t heard anything since the general invitation to suggest ideas for ‘updating’ the guidance.  We haven’t been informed about what has happened.

But we now know that Olivia, on behalf of NHS England, had been busy in the meantime – behind closed doors!

Now – we can ‘show’ you the work that has been done – behind those closed doors.

Our new members include some on the list of the ‘select few’ who have been given ‘inside information’ and we thank them for sharing this with us.

We are able to reproduce it here for you, the general public, to make sure you are no longer completely ‘left out’ – not knowing what these draft plans are to involve us in decisions about our NHS.

Here is the ‘inside information’:

What happens now?

We haven’t been informed.

But the workshop slides suggest that a final version of both the Draft Guidance documents, above, will be published at the end of March 2017.  It is not clear if this will be after being approved by the the NHS England Board, or not!

We think that you, the public, should know about a decision soon to be made by NHS England about how you, the public, are to be involved in NHS decisions!

Unfortunately the deadline for comments was 23rd February 2017.  So we have all missed the deadline.  We sincerely apologise for not being able to share this with you earlier.

We can only hope that when the final version of the Statutory Guidance for Public Involvement is published, maybe at the end of March, NHS England will decide to formally consult us all before the new guidance is set in stone.

What N-NHS-PV thinks!

That NHS England is proposing to move far away from its original declared promise, and legal duty, of ‘transparency‘ and ‘participation‘:

This promise was clearly stated on P2 of the minutes of the inaugural meeting of the NHS Commissioning Board, later called NHS England, in October 2012 in the description of the role of the NHS Commissioning Board, which is now called NHS England.

But NHS England demonstrates this move away from the original promise:

  • in the content of their new draft Guidance document for involving the public
  • and in the way they seemed to rule out actually involving the public in ‘updating’ the one that was published in 2013 – about how to involve the public

NHS England has ignored ‘transparency’ in developing the draft guidance for Public Involvement which has been:

  • changed in a way that was developed and written in secret
  • changed by involving very few ‘selected’ people in its development
  • controlled by NOT ensuring these people actually ‘represented’ the wider public view
  • developed with the timescales for feedback too short to involve the wider public

We respect our new members who actually shared the drafts with lots of people.

NHS England’s new guidance gives no recognition of the tradition of user-led, inclusive Patient & Public Participation in the NHS:

  • This was still practiced when the minutes of the first meeting of the organisation later called NHS England, were written in October 2012
  • Public involvement was then still ‘facilitated’ (supported and enabled)
  • Rather than being ‘managed’ and ‘controlled’ as it is now, and as the draft guidance document suggests it should be in the future

NHS England’s new guidance does a U turn on the time when people:

  • were ‘supported’ and ‘enabled’ to be involved in decisions about the NHS
  • had individual differences recognised and any barriers to being involved removed or addressed to allow everyone an equal voice
  • had experience and understanding respected and valued
  • were treated with respect and offered an inclusive and equal model of involvement
  • were NOT segregated into ‘silos’ based on ‘need’ in a way that masquerades as equality

But that’s not the end of this down-sizing of the Public’s role in the future of Our=NHS – GONE is the accountability of:

  • NHS service planners to the Public for their decisions about the NHS
  • NHS commissioners to the Public for their Public Involvement arrangements
  • NHS-chosen ‘patient representatives’ to the Public for all they say & do ‘on our behalf’

In fact we, the public, won’t be told who these Patient representatives are, how they act and what they say as they ‘represent’ us, or even how they ‘consult’ us.

NHS England are making decisions  FOR us – the people who use, and pay for, Our=NHS

The guidance does NOT describe how to meet the actual wording of the relevant parts of the Health & Social Care Act 2012, which is its purpose: 

  • The actual wording of the Act, in both Section 23 13Q, (for NHS England) and Section 26,14Z2, (for CCGs) states clearly the legal duty to involve the public requires them to involve ‘individuals to whom the services are being or may be provided
  • The draft guidance promotes a ‘top down’, management-led approach to Public Involvement through NHS managers selecting a few people to involve in the decisions about service planning and delivery
  • It introduces a targeted approach to equality, making assumptions about people, even suggesting that voluntary organsations can speak for the people they provide services for

Individuals should decide who they want to speak, or advocate, for them:

  • The draft guidance is NOT describing the involvement of the ‘individuals to whom services are being or may be provided
  • To do this the NHS should be aiming to involve all the individuals within the general public, to hear all their views, and allow them to choose their own representatives

The new document gives Statutory Guidance and should match the requirements in the Act, which refers to ‘individuals‘:  

It should NOT substitute the people that the NHS chooses to act as ‘patient representatives’ for The Real Thing, members of the Public:

  • Members of the public mean just that – individuals
  • Individual members of the public should all select the individuals to represent US
  • We should all be informed and involved in decisions about Our=NHS


We will look at how the NHS England officers are advising CCGs to involve us, the public , in future decisions in a new post:

  • WHEN the new Statutory Guidance is published – end of March 2017 (maybe)
  • As a NEW document ABOUT INVOLVING US – that DIDN’T INVOLVE US in writing it!

Please tell us what YOU think – about this undermining of the role that the Public used to have in decisions about the future of Our=NHS.

Why not look at a ‘Ladder of Participation’ to see what level of influence you are being allowed?

Sherry Arnstein created a Ladder of Participation in America in 1969 describing the different levels of control over their lives that those who hold the power allow ‘citizens’ to have.

 The original Ladder of Participation devised by Sherry Arnstein in 1969

Some of you may know that, in 1969, Sherry Arnstein looked at citizen control and how citizen participation helps people achieve it.  As she worked in America she used the word ‘citizen’ – an American term for our ‘general public’ or ‘people’. The word ‘citizen’ has now been adopted in the NHS.

Sherry studied different citizen campaigns in different parts of the USA and published her conclusions in an academic paper.  Her work shook up both the political thinking of the time and its comfortable democratic principles.

She talked about the ‘have nots’, as citizens/people without power, and about how citizen participation was a means for them to gain some influence over the affluent society they lived in, and a share in some of its benefits.  Her Ladder shows the different levels of citizen participation that measure how much control people are allowed to have over aspects of their lives.

She also described how, the closer the ‘have nots’ got to achieving full citizen control, the more barriers and excuses were introduced by those holding the power to make the decisions that affected their lives.  And, how these barriers and excuses showed the discrimination that existed at the time.

Sherry was working on this at the end of the ’60s, a time when there was the American civil rights movement, the anti-Vietnam War movement and student unrest everywhere. screen-shot-2013-10-11-at-12-13-29-amA poster she saw created by French students in the 1968 Paris uprising particularly inspired her.

‘I participate, You participate, He participates, We participate, You participate, They Profit’

It’s uncanny how relevant the words from her paper are today – nearly half a century later.

“The heated controversy over “citizen participation”, “citizen control”, and “maximum feasible involvement of the poor”, has been waged largely in terms of exacerbated rhetoric and misleading euphemisms.”

 “The idea of citizen participation is a little like eating spinach: no one is against it in principle because it is good for you. Participation of the governed in their government is, in theory, the cornerstone of democracy-a revered idea that is vigorously applauded by virtually everyone.”

“And when the have-nots define participation as redistribution of power, the American consensus on the fundamental principle explodes into many shades of outright racial, ethnic, ideological, and political opposition.”

This version of her Ladder of Participation clearly summarises her analysis: slide_6

Only a decade ago people in many places across the country experienced participation in the NHS at rungs 6 and 7 of the Ladder of Participation which Arnstein describes as Citizen Power.

Whereas in today’s NHS in England ‘citizens’ are allowed no more than rungs 3, 4 and 5 of the Ladder of Participation, which Arnstein describes as Tokenism.

But the NHS, in England, is now introducing the two lowest levels of Arnstein’s Ladder of Participation (1 ‘manipulation’ &  2 ‘therapy’) by encouraging people to manage their own health.  As part of the Sustainability and Transformation Plans and New Models of Care we are now expected to change our lifestyles and to ‘self-manage’ any long term conditions we may live with.  The NHS describes this new expectation as ‘patient involvement, or participation, in their care’ but Arnstein describes it very clearly as Nonparticipation.

Even worse – only a few weeks ago – NHS England’s Patient and Public Participation Team introduced their new, supposedly improved, ‘Citizen’ Participation programme.  But this will only work at levels 1 – 5 of the Ladder – which is ‘Nonparticipation‘ and ‘Tokenism‘.

The people’s voice in the NHS has been taken away – why?

 A decade ago the NHS was proud of working with patients, and the public, to improve services which then began to work better than they had for a long time.  Why are the ideas and suggestions of the people using the NHS now considered so dangerous that they need to be silenced? It is really disappointing that the level of Participation in the NHS has sunk so low in such a relatively short time.

Why is this necessary – why is the public voice so dangerous?  

The Ladder below describes a modern version of Arnstein’s Ladder of Participation created by a French student in 2009 showing how ‘citizen control’ is seen as dangerous by those holding the power and control. The 1968 Paris student slogan is included (top right), and the spelling is interesting but the message is perfectly clear.


Arnstein’s Ladder, created to describe how people could gain power and control over their lives, has been ‘diluted’ over the years by those holding the power.

downloadEach time her Ladder is simplified its meaning is diluted as there is no reference to her clear analysis.  The very simplified version shown here is often used to show Arnstein’s Ladder.

But when compared to the detailed one shown earlier it tells us very little.

The one the right is a New Economics Foundation version, many ‘co-‘ words, but no clear escreen-shot-2014-03-10-at-5-12-46-pm-278x300xplanation or analysis!

N.B. It was included, on P20, in the Northern Ireland Health Minister’s 10 year plan to save their health service ‘Health & Wellbeing 2026, Delivering Together’ that was published last Tuesday (25/10/16).

coproduction-tree-660This is produced  by Governance International, a consultancy set up in the ’00s, one of the new Involvement Industry.  They help public services to ‘focus on smart savings and innovations to achieve better citizen outcomes‘!

Well they have a tree surrounded by all the ‘co-‘ words – so they must be good!

Finally – Arnstein’s Ladder of Participation, created to describe how people could gain power and control over their lives, has now been adopted by big business.

There is now a Ladder of Participation for On-line Customers.


Another about Loyalty to a Brand, for the marketing department.crm-strategy-20-638

There is even a ‘success’ Ladder for all those ambitious middle managers!!