A new report from health thinktank the King’s Fund has questioned the impact and value of NHS reforms bringing more local accountability.

Should Primary Care Trusts Be Made More Locally Accountable? asks what politicians mean by locally accountability, and suggests that the concept may be more rooted in political dogma than the actual wants and needs of local populations. Recent government reforms have devolved more power to local NHS bodies and front-line professionals, as with the semi-independent NHS foundation hospital and mental health trusts. Along with greater financial freedom and no direct Whitehall control, foundation trusts have a membership which elects the non-executive directors and the chair.

Legislation has imposed on primary care trusts (PCTs - the NHS local administrative unit) the duty to consult with their local population about significant service changes, and more recently, a duty to work in collaboration with social services in local government on the commissioning of services for children, the elderly and others in need of social care.

All three main Westminister political parties have commitments to tackle the ‘democratic deficit’ and let local people have more say over how their health care is delivered. This is expected to also be a principal theme of Professor Lord Darzi’s review of the NHS, expected in June.

How more localism might work
The report examines the various options for making PCTs more accountable to their local communities. It suggests that if the aim of involving the public is to give the NHS greater ‘democratic validity’, systematic changes such as giving local councillors control over PCT budgets, or electing PCT board members would be appropriate.

However, it suggests that if the goal is to improve quality of services, a more gradual approach would be likely to work better, with targeted initiatives such as citizens’ juries or enhanced Public Patient Involvement Forums focusing on specific PCT functions. Ruth Thorlby, King’s Fund Fellow and co-author of the report, said: “Governance of the NHS is highly centralised, and PCTs spend similar amounts of public money to local government without any of the democratic accountability that exists for councils. But while people have strong views about big, one-off changes to their local services – like the closure of a ward – there is little evidence of public demand for an active role in deciding how health service money is spent day to day.

“Until now, efforts to enhance public involvement have been patchy. Any new mechanisms for increasing local accountability must provide value for money. Part of the debate around local accountability in the NHS must be on what would be an acceptable price tag for involving the public more in decisions”.

The report also calls for a clearer definition of what is meant by calls for ‘accountability’. One interpretation would be that local people should be consulted ahead of changes in services, or that PCTs should provide more information on how decisions are made; alternatively, ‘accountability’ could mean the right to demand certain services and even the power to remove health bosses who do not meet their expectations.

Another of the co-authors, Richard Lewis, Director at Ernst & Young and King’s Fund Senior Associate, said, “Giving power to local people raises various questions, such as what happens when local people want to keep a service that national policy has deemed should close, or they want access to a treatment that NICE says, is not cost effective.

“There is variation in the system currently, some of it unexplained and unjustified, but more local decision-making will also inevitably mean more variation in services from place to place. That is not necessarily a bad thing but we need to be clear where variation is acceptable and where it is not. The public still regards the NHS as a national service and would resist anything that leads to the further development of a 'postcode lottery'. There will continue to be national responsibilities in a nationally funded service, the key is to work out ways of reconciling national and local accountability”.