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Does Hewitt believe in local public accountability?

Patricia Hewitt’s terms of reference were to “consider how the oversight and governance of integrated care systems (ICSs) can best enable them to succeed, balancing greater autonomy and robust accountability”. But, despite the reference to accountability, perhaps I should have reined in my optimism that there would be something for primary (and secondary) care patients and the public in any of the 36 recommendations.

Mike Etkind
Mike Etkind

I was aware the context of the review was to look at ways of addressing top-down oversight of ICSs. However, in proposing that ICSs have more delegated responsibility via less detailed oversight, I did hope that ‘accountability’ would be framed not just in terms of upwards. Simplistically, the more the buck stops with ICS/integrated care boards (ICBs) rather than at national level, the greater need for openness and accountability to the local recipients of their services: eg to users of primary care they commission.

The positive stuff

I found some positive words in the report about public engagement.

There’s a great line in the narrative: “local communities must be involved through a continual process of engagement, consultation and co-production in design and decision-making about local services. Strong and visible local accountability, recognising the principle of subsidiarity, also plays an important role in promoting legitimacy with the local population through empowering, accountable and transparent decision-making” (3.27). For me a ‘local community’ includes the patient body at neighbourhood/primary care network (PCN) level and patient participation groups (PPGs).

There’s a nod to public involvement by reference to the Wigan deal. And then paragraph 5.7 says “the aim should be for an ICS to show its residents, local Health and Wellbeing Boards, oversight committees and Healthwatch, as well as national bodies, how much it is collectively spending” – albeit with the qualification that it should happen “as the financial framework for ICSs develops”.

The report also says: “For every ICS, increased transparency is vital to enabling local autonomy” (exec summary). As part of the narrow recommendation for a national partnership group to develop a new framework for GP primary care contracts, there is text saying that the group’s membership should include “crucially – a number of patient and public advocates” (4.15).

And, scraping the barrel of the text, there’s the sketchy assertion: “As every system establishes its place governance and leadership, taking into account relationships with different providers, this information should be transparent and accessible for their communities”.

But fine words butter no parsnips

It transpires that the report’s reference to increased transparency is just in the context of data sharing amongst NHS organisations: NHS England (NHSE) and the Department of Health and Social Care “should incentivise the flow and quality of data between providers and systems” (3.132).

References to local communities are made essentially in the context of NHS organisational relationships: “empowering local leaders to work with and through their partners and local communities…can only happen at scale if the broader environment in which they operate is aligned to enable them to do so” (2.11). So does this mean Hewitt thinks ICBs can currently ignore the NHSE’s guidance on Joint Forward Plans (which specifies working with “people and communities that will be affected by specific parts of the proposed plan, or are likely to have a significant interest in any of its objectives”), and neither inform, co-produce with, or consult PPGs or others on primary care aspects?

And there are no recommendations referencing local public/patient transparency and accountability. The focus is all on ‘internal’ NHS, local government and central government structures and systems.

Analysis

If Hewitt genuinely believes that “In many ways, local accountability is hard-wired into ICSs” (3.28), I very much question how much she and her team understand the reality on the ground. For me, as a PPG chair, it has always been a matter of having to bang on clinical commissioning group (CCG)/ICB doors to attempt to find out what’s going on and to get any sort of hearing.

With my ICB, I regret I’ve found that transparency and accountability have reduced since it took over from our CCG, and was never good in pre-ICB days. I’ve seen little sign of compliance with the NHSE’s Integrated care system implementation guidance on working with people and communities. Principle 1 in that guidance, for example, is to “put the voices of people and communities at the centre of decision-making and governance, at every level of the ICS”, but the patient participation group at my GP surgery has not been directly informed or consulted on any of the big decisions being made by my local ICB. Perhaps others have been more fortunate, but I’ve not heard so on the PPG grapevine.

For example, can I expect, as a patient, member of the public, or PPG chair, to be engaged in Hewitt’s encouragement to ICS to “support the joining up of different elements of urgent care, including 111, community pharmacies and walk-in centres and ensure the most effective provision of services to meet population need without focusing solely on one area of primary care when commissioning those services” (4.7)? Or to “play a greater role in driving primary care transformation” (4.8)? It may come as a surprise to some health administrators, but the public has some experience that could be brought to bear. On the former, I, myself, have recently had the chance to compare the options of self-care, AskFirst, 111 online, my local urgent treatment centre, my community pharmacist, and my GP for a twisted knee!

I’ve heard too many times already that it’s early days for ICSs when it comes to public engagement and transparency. My rejoinder is that local public accountability seems to have been low on the priority list pretty much for ever in the health service, so the latest reorganisation is no excuse.

I would put substantial money on less than 1% of the public being able to explain what an ICB is, what area their local one covers, or what it does – despite NHSE’s own website stressing the importance of ICBs. It says: “Integrated care systems (ICSs) are partnerships of organisations that come together to plan and deliver joined up health and care services, and to improve the lives of people who live and work in their area”.*

I was also struck by the recent King’s Fund blog* which demonstrates how accountability is in the opposite direction to the people who are affected by ICB decisions. An ICB chair describes it as “quite egregious the extent to which relatively junior people at a regional level have acted and used the authority of their regional position to completely undermine more senior people working within their systems”**.

And I can’t help harping back to the NHS Constitution. If it means anything, then what happened to “The NHS is accountable to the public, communities and patients that it serves”? But maybe it would have more traction to move away from a legalistic mandate and view transparency and engagement from the lens of the benefits to systems and places that can accrue from telling customers and consumers what is going on, and genuinely hearing and listening to what they have to say – some of which I set out in my article for the April 2019 edition of Insight PCNs: When are we going to tell the patients?.

Conclusion

I understand that the overarching view is that there is no accountability deficit because the NHS is ultimately beholden to government, and the Government is accountable to Parliament. But if the principle of subsidiarity is genuinely to hold sway, and if more and more responsibility is to be given locally to system, place and neighbourhood, we the public and patients have a right to know about, and to be able to scrutinise, what is being done on our behalf.

The report is, in a way, summed up for me by the recommendation that the proposed reform of Control of Patient Information regulations should be implemented to allow local authorities and the local NHS to access our information. This may or may not be sensible. But what about us having sight of their information?

Mike Etkind is among other things chair of a PPG, a volunteer with his local Healthwatch, a Mind befriender, and a representative on NHSE’s PPG Champions group on NHSE’s Primary Care Community Engagement Strategy Group. All views are his own.

*https://www.england.nhs.uk/integratedcare/what-is-integrated-care/
** https://www.kingsfund.org.uk/blog/2023/04/hewitt-turning-tide-performance-management-or-swimming-against-it

Last Updated on 1 June 2023