No Authority? Then No Accountability – the Policy Governance® View on the NHS Constitution

The consultation on the proposed NHS Constitution closed last week. The UK Policy Governance Association (UKPGA) said it all for us in their submission.  M-A-C partners have been big fans of the “policy governance”® approach for public sector boards and Valerie Moore is an accredited PG practitioner. ( See our main website )

The UKPGA submission focused on two key aspects: accountability and local determination of needs. Those have to sorted out first before service users can be clear about what their entitlements to services are.  But the NHS Constitution lacks a statement of accountability – ie there is no answer to the question “to whom is it accountable and for what and how is that accountability to be exercised?”

M-A-C previously tried to interest our (then new) Prime Minister in this when we suggested to Mr Brown back in June 2007 that in his enthusiasm for the NHS, he needed to be clear about what the institution was for. We are glad to see that Ann Keen has assumed the mantel of “Minister for the NHS Constitution”, so we can address our views to her.

As we said to Mr Brown, so we say to Mrs Keen.  The end of the NHS in England – what it is for – should be understood as: “The health of all people in England is maintained as fully as possible for a sustainable tax burden”.

It should be that simple  – and it would be if we were clear that the owners of the NHS are the people who have paid and who do pay for it and who use it.  We also need to be clear that the “p word” we should use more of is “power” not “patients”.   If we were clear about those things, then getting the work done through good management would be a great deal easier.

So we were pleased that the UKPGA’s submission stressed the need for a statement of accountability as

“a central plank of the Constitution which should represent the terms on which the public’s authority is passed to the organisations that, together, comprise the NHS. “

The Statement of Accountability should

Give guidance to enable NHS boards to deal with the competing demands for accountability from:

  1. Parliament as representative of the national public interest
  2. Government as the executive of Parliament
  3. NHS regulators as monitors of compliance with parliamentary legislation and government policy
  4. Local communities as representative of the local public interest
  5. Patients as consumers of NHS services
  6. Staff as employees of NHS organisations
  7. Other stakeholders.

“Whilst it is perfectly right and proper for the NHS to be accountable to the public-as-consumers for any promises it makes to them, it is also vital that it is accountable to the public-as-owners for making only those promises that it can afford to keep if it is to remain a sustainable organisation.” As UKPGA further explained, “No person or institution can be held accountable for something over which they have no authority. Thus NHS organisations cannot be accountable to their local communities if they have no authority to vary their nationally prescribed responsibilities.

Access to healthcare services cannot be without reasonable limitation if the NHS is going to be accountable. The NHS Constitution should therefore be amended as suggested by the UKPGA: “You have the right to expect your local NHS to assess the health requirements of the local community and to put in place the services to meet those needs as considered necessary.”

The last three words are crucial to accountability because “local NHS boards [must] have the freedom to interpret the phrase “as considered necessary” and [be] able to prioritise and interpret nationally prescribed responsibilities in the light of local community needs.

The “planned differences” [discussed on our post of 14th October] that result would be evidence that the local NHS was simply doing its job.  Holding it to account for the promises that it could afford to keep would then be much more straightforward for us as the owners.

Contact Stuart Emslie at the UKPGA at either or 07932 376562.


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