MPs have told the government that even though its NHS reforms are still at an early stage, they need certainty about who to hold accountable for health spending once they are complete.

"It is vital that the Department [of Health] creates robust accountability structures so that Parliament and the public can property follow the taxpayers' pound and hold those responsible to account," Margaret Hodge, chair of the Commons Committee of Public Accounts said yesterday, as the panel published its latest Landscape Review of the NHS.  "Key questions have yet to be addressed," added the Labour MP for Barking.

In particular, she said, the Committee is concerned that the Department has yet to develop a high-quality risk management protocol for either the commissioning or providing bodies. Health officials have told the MPs that certain health trusts and GP practices still have some way to go to achieving Foundation Trust status or becoming commissioning consortia, and the panel stresses that the Department must have effective systems in place to deal with failure so that, whatever happens, the interests of both patients and taxpayers are protected.

The Department has also acknowledged the risks associated with this "radical shake-up" of the NHS, and while the reforms could complement the need to make £20 billion in efficiency gains by 2014-15, they might also distract those responsible for making the savings while safeguarding standards of patient care, the MPs warn.

Furthermore, if the Department's estimate of the one-off costs associated with the reorganisation turns out to have been too low, it will make the challenge of achieving savings for reinvestment even tougher, they add.

In particular, the Committee report is asking the Department to provide detailed answers to the following questions: - who will be accountable to Parliament for protecting the interests of taxpayers in a devolved health system? - to what extent will health bodies having a "duty to engage" locally with, for example, Health and Wellbeing Boards and Local HealthWatch, lead to accountability? - what structures will link local GP consortia and the national NHS Commissioning Board, to which they are accountable? and - what information will be available to decision-makers, health regulators and the public on the cost and quality of services? 

The MPs' report also identifies a number of practical aspects of the proposed reforms where they require clarification in order to be able to identify and focus on the issues which present the greatest risks to value for money. 

In particular, they ask, how will: the treatment of patients with rare and expensive conditions will be funded; - continuity of services be safeguarded when a GP consortium or Foundation Trust hospital is failing or has failed; - commissioners and providers contract with each other to drive value for money in the system; - the NHS Commissioning Board work with GP consortia to redesign primary care services and also to ensure the proper configuration of acute services, so that value for money for the taxpayer and effective quality of healthcare for the patient is secured; - providers secure capital funding in future; - legacy debts from Primary Care Trusts (PCTs) be handled; and - the reforms affect existing health inequalities and performance variations for some NHS services.

The Committee acknowledges that it is unusual for it to examine the progress of reforms at such an early stage, but says that: "given the scale of the changes and our ongoing interest in health spending, we thought it important to gain a greater insight into the accountability and value-for-money issues raised by the reform proposals."

"We intend to review the progress of the reforms at regular intervals and this report signals the sorts of issues we will want to examine in future," the MPs add.