Accountability in the NHS – The pursuit of a false God? by Jack Evershed

Introduction by Professor Marcus Longley, Director of WIHSC and Professor of Applied Health Policy

What’s the most interesting job in NHS Wales?  One of the contenders for the title must be a job thats so big it takes two people to fill it!  This week’s blog in our ’20 blogs for 20 years’ series is by Jack Evershed, the joint Chair of the Mid Wales Healthcare Collaborative.  Jack – along with his co-Chair, Dr Ruth Hall, who will be writing next week’s blog – leads a unique collaboration of three Health Boards and the Ambulance Trust.  Recommended in the WIHSC review of healthcare in Mid Wales,  it is forging a new pattern of services, and a new way of working, for the people who live in a band across the middle of Wales from Ceredigion and south Gwynedd to the English border.  

Jack’s background confirms the uniqueness of this new force in healthcare.  Like Britain’s political elite, he read PPE at Oxford, but then ran the family farm, while finding time to lead the Community Health Councils in Wales, and campaigning on local health issues.  His blog reflects on how NHS Wales should make difficult decisions, which has particular resonance in the context of the Welsh Government’s current Green Paper on NHS governance.

Accountability in the NHS- The pursuit of a false God?

Ballot Box? Courts? Governance structures?

During the lifetime of WIHSC the pursuit of accountability within the NHS has led to an almost bewildering array of structural changes. Often the judicial process has been the last resort provider of accountability (eg Francis report, judicial reviews, compensation cases). This is a negative accountability, not the positive accountability that everyone is seeking – an NHS that takes account of and acts on the hopes, fears and aspirations of its population.

Welsh Health Ministers have tried various governance arrangements to provide a Health Service that is responsive to the local population. Small local boards, commissioner provider splits, larger regional boards, patient bodies, all have been tried but have not consistently provided the answers. Often these organisations have been unable to meet the aspirations of their populations or meet their statutory requirements or targets. Perhaps it is the pursuit of accountability that has led to this unsatisfactory situation. In the same way that allowing farmers with their diverse needs to dictate the weather would lead to climate chaos, trying to formulate an NHS governance structure that promises local accountability may be intrinsically flawed.

The Westminster Government has retained accountability for the Economy but has delegated the operation of the main levers of the Economy to an independent apolitical committee, the Monetary Policy Committee (MPC). The Government sets the framework (growth, inflation etc) and leaves the decisions on the operation of monetary policy to the MPC. This averts short term political necessities interfering with what needs to be long term strategic management.

Perhaps this provides a model for the Welsh NHS. The democratic process can lead to a set of principles within which a Health Services Committee should operate*. These would be high level principles about equality of access, quality of outcomes, promotion of health and well being. The long term strategic decisions would be taken by this body, rather than the various local bodies with their diverse pressures. The local bodies can then concentrate on the delivery of services. This way the positive accountability (responsiveness to people’s needs and aspirations) remains with the Welsh Government, and the negative accountability (duty of care) is shared with the local bodies delivering the service.

There are many grey areas in this model about some of the commissioning decisions. In the same way that the MPC sets the base rate and the banks, building societies and other financial institution deliver a variety of loan packages and deposit accounts, so the local bodies could deliver services in various ways. Perhaps this model could deliver high quality services that are fair, sustainable, and adapted to local need.

Jack Evershed, the joint Chair of the Mid Wales Healthcare Collaborative

*Similar arrangement to the All Wales Medicines Strategy Group.


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