A new report from The King's Fund warns that the coalition government's reforms risk reducing accountability in the health system, potentially undermining the performance of key NHS organisations as a result.

The report looks at accountability for commissioners and providers of health care in the NHS currently and under the reforms set out in the Health and Social Care Bill. It concludes that the reforms are likely to meet the government's aim of reducing centralised control but fail to deliver on its commitment to improve local accountability, a key pledge in the coalition agreement.

The report finds a number of weaknesses in the accountability arrangements set out in the Bill including the following.

- Although GP consortia will be responsible for £60 billion of public money, their governance arrangements are weak, with only limited requirements for how they should be constituted and made accountable to the public.

- New health and wellbeing boards - which will bring together local authorities and GP consortia to join up health with other local services - have very limited powers to hold GP consortia to account.

- With mixed evidence so far about the performance of hospital boards, the scaling back of Monitor's oversight of foundation trusts could leave accountability in the hospital sector significantly weakened.

The report warns that the weakness of governance arrangements for GP consortia and health and wellbeing boards may result in the new NHS Commissioning Board intervening in the work of consortia to drive performance, undermining the government's aim of reducing top- down management. It welcomes moves to harmonise the accountability requirements for different types of providers in the hospital sector, but warns that reduced accountability and an over-reliance on meeting regulated minimum standards could lead to reductions in the quality and efficiency of hospital services.

On the basis of the report, which is published at the conclusion of the 'pause' in the passage of the Health and Social Care Bill, The King's Fund is calling for changes to improve accountability under the reformed health system including:

- more robust governance arrangements for GP consortia including a properly constituted board

- stronger powers for health and wellbeing boards, including a requirement that the NHS Commissioning Board should intervene if boards are not satisfied with the commissioning plans drawn up by consortia in their area

- measures to strengthen foundation trust boards and support governors in overseeing the performance of hospitals and holding senior staff to account.

The report concludes that, with the reforms introducing far-reaching changes to the health landscape, much will depend on how relationships develop between the various bodies in the system. It also suggests that it may be more difficult for parliament to hold different parts of the NHS to account in future. Ironically, this could lead to pressure for a return to greater political intervention in the future.

Anna Dixon, Director of Policy at The King's Fund and one of the report's authors said:

'This report highlights weaknesses in the accountability arrangements set out in the Health and Social Care Bill. The pause in the legislative process provides an opportunity to look again at these issues and strengthen accountability in the health system to drive improvements in performance and ensure that public money is well spent.'


Accountability in the NHS: Implications of the government's reform programme is published by The King's Fund on 1 June 2011.

The King's Fund