Simpler, clearer, more stable: Making accountability work across health and social care

Accountability is not just of theoretical interest: it matters in the real world. The present arrangements for health and social care are complicated enough as it is, and the increasing trend towards integrating services runs the risk of making accountability more confusing and burdensome. So how can the framework be streamlined to give front-line services more time to get on with the job, while still answering the legitimate questions of a range of stakeholders?

This is the challenge addressed in the paper Simpler, clearer, more stable, published today, It reflects conversations with a range people: from central policymakers to front-line managers, in the NHS and local government, and also a few from outside the system altogether.  

The wider context changed over the course of the project. Of most direct relevance, NHS England announced the introduction of Sustainability and Transformation Plans (STPs). These epitomised the shift from the vision behind the 2010 reforms towards a more collaborative and place-based approach. The reasons for this are clear, but they pose questions for the accountability framework.

The paper identifies the principles that should underpin a sound accountability framework for health and social care, rather than one specific blueprint. I argue than an effective framework needs to be ‘Simpler, clearer, and more stable’, a slight play on the Olympic motto ‘Faster, Higher, Stronger’.

Simpler

An effective accountability framework should be comprehensive, and economical of time and money. So plans should cover both finance and quality, with one set of indicators – some  national and some local – and a co-ordinated approach to inspection and regulation. This will in itself reduce the time needed by front-line organisations to report to different masters. It would also make sense for the integration plans, required by the 2015 Spending Review, to be incorporated into the STP process, rather than prepared separately.

Clearer

An accountability framework should be transparent and rigorous where it matters, but encouraging towards innovation. Tensions are inevitable at present because the STP process, and other aspects of integrated working, were not envisaged when the legislative framework was put together. One of the best short-term routes through this is transparency about governance arrangements. Proper processes of risk assessment and impact assessment should guard against excessively risk-averse behaviour at various levels, and against the syndrome of adding indicators and rules here and there without ever taking any away.

More stable

Any accountability framework needs to be robust enough to work in the real world. The NHS Five Year Forward View says of the organisational structure that ‘there is no “right” answer… but there is a wrong answer, and that is to keep changing your mind’: the same applies to accountability. The overall framework of indicators and reporting structures should be set for a parliament, at national level, and then left in place for the rest of that five-year term. Local government inputs should similarly run for the life of a council. In both cases, people should resist the temptation to fiddle about in between. 

Challenges

If all this – indeed any of this – were easy, it would be in place in all countries. But I’m arguing that, with ambition and determination, quite a lot of the perceived problems with streamlining accountability can be overcome, so that the framework can be ‘simpler’, if not downright ‘simple’.

Some will no doubt be sceptical and world-weary about whether there is scope for much progress at all. I’ve reflected on a number of challenges.

Personalities

Some argue that any framework will always be trumped by personalities. But while it’s true that big personalities will always matter a lot, the point of a framework is to spread the good they can do, and limit the harm.

Relationships

A lot of conversations quickly turn to the importance of relationships in driving success. True again, but a good framework can help good relationships to form. Building relationships will take time, however, and one of the risks of the STP process is that it gives local people very little time not just to prepare the first iteration of their plans, but to forge the relationships needed to underpin real progress. That will be essential for the next phase.

The need for compromise

Integrated working (including around accountability) requires compromise and ceding some sovereignty, and many people don’t like this (for a mix of ‘good’ and ‘bad’ reasons). One of the aims of a well-designed framework should be to help them feel more comfortable about this ceding of sovereignty, by clarifying how their questions will be answered.

Implausibility

Finally, some argue that it’s unrealistic to expect stability: neither politicians nor managers will resist the various pressures to make changes. But the answer to that – and a theme running through this paper – is that this is up to them. Many of the key challenges in health and care are deep-lying and progress will take time – developing new drugs, tackling obesity, and some of the cultural changes required by integrated working. But the accountability framework is in the gift of policy-makers, and can be changed fairly quickly. This paper poses the challenge.

Andrew Hudson (@highburyrunner) is a non-executive director and consultant with wide experience of work in the public services