One consistent thread running through the Government’s proposed NHS reorganisation is a reduction in local accountability to the communities served by NHS bodies.
The cutbacks in Integrated Care Board (ICB) running costs involve a wholesale process of ICB mergers that in many cases result in even larger geographical areas being run by a single body, with fewer staff, and even less local engagement than before.
Expanding ICBs
The NHS Confed has explained how 34 ICBs in the Midlands, East of England, London, South East, South West are to be reduced to just 19 “clusters” with the intention that clusters will merge into single enlarged ICBs.
Only the North West and the giant North East and Yorkshire regions are left unaffected, because their ICBs are already so large and cover such large populations.
The new cluster of Derbyshire, Nottinghamshire and Lincolnshire will create a single enormous authority reaching from Skegness on the North Sea coast to Glossop on the outer edges of Greater Manchester; the cluster linking Coventry and Warwickshire with Herefordshire and Worcestershire spans from Nuneaton in the East through to the Welsh border. Of course, the enormous unmerged North East and North Cumbria Integrated Care Board already covers coast to coast across the northernmost part of England.
The decision to reduce ICB staffing costs is leading to a diminished core administrative presence across a broader geographical area. This change will limit the opportunity for community concerns to be adequately heard and further hinder any meaningful public involvement.
Shrinking accountability
The range of issues for which the ICBs are responsible is also being cut down. However, the NHS England document on implementing the mergers and changes does not mention accountability even once in 14 pages.
There is no indication to suggest anyone drawing up the proposals has spent even a minute considering how the changes might impact on the millions of local people involved in each case.
Add to this the proposed abolition of local Healthwatch, the withered remnants of the once potentially powerful Community Health Councils (CHCs), which were established in 1974, and funded by government and given statutory powers to act as the voice of the patient and the local community. CHCs for 30 years had powers to make unannounced inspection visits, to attend all health authority meetings, and to freeze the status quo on a contested change while the issue was referred to the Secretary of State.
While many CHCs failed lamentably to make best use of their powers and lacked the courage to challenge the prevailing wishes of the health authorities (and, later, NHS trusts) a good number of them did fight hard, stand their ground, reach out and work with communities, in some cases building big campaigns in defence of local hospitals and services. It was these strong and independent CHCs (notably Barnet CHC which stood at the centre of the long fight to save Edgware Hospital) that drew the anger of Alan Milburn, to the point where he incorporated abolition of CHCs in his legislation to establish foundation trusts.
Healthwatch was a creature of Andrew Lansley’s appalling 2012 Health and Social Care Act. Local Healthwatch was only given much reduced powers compared with CHCs, and there are too few examples of them standing up at all for the rights and needs of local patients – but their abolition will leave no community voice at all to raise local concerns.
Public involvement through an app?
Labour’s 10-year Plan for the NHS in England proposes to use “direct patient feedback” from the App (aka “patient voice”), rather than empower organisations to speak up for people. It explains:
“Since their inception in 2012, Healthwatch England, working with local Healthwatch organisations, has gathered detailed patient feedback and used this to influence debate around local service delivery. While this has been valuable, we need to go much further. We will bring patient voice ‘in house’ – to give it a greater profile within a reformed Department of Health and Social Care.” (p91)
Another take on this might be that any form of organised independent representation would seem to get in the way. The 10-Year Plan, which requires health and care providers to have “patient voice” arrangements in place by 2026, but aims to shut down any other avenue for public accountability. And, as Ken Jarrold and Nick Spears have pointed out in a recent HSJ article:
“[The 10-Year Plan] proposes to give power to the patient through transparency, voice, and choice. The public and patients will be so busy managing their own care through the NHS App they will not have time to worry about trivial matters such as the governance and management of the NHS. That can be safely left to the managers.”
Healthwatch North Yorkshire argues this is far from satisfactory:
“Ratings-based tools like the NHS App don’t reach everyone: people without smartphones, with limited digital literacy, non-English speakers, or those recovering from trauma. Healthwatch provides depth, not just scores. We explore issues like access to NHS dentistry, rural healthcare, maternity care, and mental health services through real conversations — not just surveys. We provide real stories, real experiences, not isolated data and statistics. We understand people’s experiences and make practical, informed recommendations for change.
“… the public could soon be asked to give feedback mainly through the NHS App. That might sound convenient, but it’s no replacement for meaningful, human conversations. Star ratings are subjective — and often only used when something’s gone wrong. Tying hospital funding to these ratings, as proposed, risks punishing services for things beyond their control: a missed call, a delayed appointment, or even poor parking.
“And what about those who can’t use the app? People without smartphones? People with disabilities? Non-English speakers? Or people who’ve experienced trauma and don’t want to reduce their experience to a score out of five?”
A response to the abolition from Healthwatch North Yorkshire also points out that the proposals go even wider: “The entire Healthwatch network … is set to close under the Government’s new 10-year health plan.”
This network includes the National Guardian’s Office (which was supposed to “Make Speaking Up Business As Usual,”) and the Health Services Safety Investigations Body (which only came into operation on 1 October 2023 as “a fully independent arm’s length body of the Department of Health and Social Care,” and investigates “patient safety concerns across the NHS in England and in independent healthcare settings where safety learning could also help to improve NHS care.”)
Foundation trust scrutiny
Another dog that only rarely exercised its right to bark has been governors of foundation trusts, who in theory have extensive powers. The Plan wants to scrap them, even as it offers greater “freedoms” to the best performing FTs. Jarrold and Spears point out that the likely alternatives are far from ideal:
“Councils of governors are the supreme body of FTs with the power and responsibility to appoint the chair of the council and board of directors, the non-executive members of the board, and approve the appointment of the chief executive. They are supposed to be consulted on all major issues.
“It seems such matters will now be subject to a tidy managerial process, no doubt run by regions. There will be little non-executive scrutiny, and FTs will celebrate their new strategic autonomy by being presented with their chairs. Alternatively they will be led by a self-perpetuating oligarchy in which boards have the freedom to determine their own composition without any messy involvement of the public, patients, carers, local authorities and staff.”
But that’s not all. The loss of FT governors would run alongside other erosions of public accountability by foundation and NHS trusts: the ongoing rounds of mergers, often between trusts tens of miles apart, are also creating giant provider organisations that are now increasingly detached from any genuine local accountability.
Lack of accountability is a threat
As Lowdown has been warning for some time, many trust boards (and even larger-scale ‘provider collaboratives’ that may span a whole ICB area) have for some time been taking controversial discussions and decisions on cutbacks and job losses in closed session, rather than in public, adds to the veil of secrecy and the problems for local communities or specific groups of staff and their unions seeking ways to raise their concerns.
To complete the picture of reduced public access and accountability, the abolition of NHS England, too, and the merging of its many responsibilities into the Department of Health and Social Care, means even the limited level of information that has been published alongside the live-streamed and recorded NHSE Board meetings will come to an end. The DHSC Board, such as it is, has always functioned behind firmly locked doors with public and press excluded. This provides the kind of secrecy within which Mr Milburn feels most free to act on his agenda without any public scrutiny at all.
These erosions of what was already limited levels of accountability are barely being discussed. Many campaigners have been entirely unaware of the openings that still existed, and many more have been frustrated at the lack of action or any signs of life from Healthwatch at local level.
But surely nobody can believe that the feedback from individual patients via the NHS App can give a louder or firmer voice than a body set up to reflect, raise, and follow through local concerns.
Nor can it substitute for the opportunity at least to gain up-to-date information from open sessions of key bodies and keep up to date with events and decisions, giving at least an outside chance of challenging when things seem to be going wrong.
Labour is proving itself to be the party that cuts off the last remnants of local NHS accountability, and tries to fob off patients and the public with the kind of tokenistic automated “feedback” nonsense that now annoys us all as customers after we make any online purchase.
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