A New Deal on Autonomy and Accountability in Health and Care

UK Policy Public Services

A New Deal on Autonomy and Accountability in Health and Care

Posted on: 24th January 2022
Axel Heitmueller
Senior Associate Fellow

I look back at the early days of the pandemic with a mix of cold sweat and wonderment. Those early months in spring 2020 were filled with great anxieties about the ability of the NHS to cope with the rapidly rising numbers of hospitalizations. There was no cure, there was no vaccination, and there was a great sense of uncertainty. The spectre of people dying in corridors in Italian hospitals loomed large. No one knew when cases would peak.

At the same time, up and down the country, something extraordinary was happening. NHS organisations that had been in fierce competition for years found ways to collaborate. Innovation was adopted in days not years. Stifling bureaucracy was suspended. For the first time in my decade in the NHS, action preceded planning. There was no playbook, no business case template. A burning hot platform instilled purpose that couldn’t be served by postponing action to tomorrow.

Maybe naively many of us felt that this might be the beginning of a new chapter in the provision of health and care, allowing us to hang on to the momentum, the collaboration, and focus on transformation. A strong collective purpose, an existential threat leading to rapid change as opposed to plans for change.

That sentiment didn't last very long. Midway through April the Covid case numbers finally started to turn and with them the elastic band of change snapped back fast. On April the 29th 2020 the NHS London regional leadership issued a letter asking all London designated Integrated Care Systems (ICS) to produce a transformation plan within 10 days. This was to address 12 specific expectations including a high-level financial summary. To all intents and purposes, an impossible ask not least because everyone locally was exhausted, many were recovering from Covid themselves.

The muscle memory of NHSE kicked in with a vengeance.

By 10th May, we did submit a plan, the NHS always does. I’ve not counted the opportunity and real costs of those ten days and nights, but it will have been considerable.

It will come as no surprise to those who have gone through the motions many times before in the NHS that this plan was never delivered. It was never written to be deliverable. In the months that followed, it was simply superseded by new plans and instructions.

Schrödinger's NHS cat is the illusion of top-down change – always present, never to be seen. If half the plans for change published in the past decade had actually been implemented, the NHS would be a beacon of transformation. They weren’t and as a consequence it ranks towards the bottom of international league tables for health outcomes. This is increasingly impossible to sustain. Unprecedented sums of money are flowing towards health and with that come public and political expectations. At the same time, the first major health legislation in a decade is going through Parliament and Covid has demonstrated that accelerated change is possible.

Forthcoming White Papers, which will set out the detailed policy underpinning the legislative reforms in the coming weeks and months, are an opportunity to think harder about a change model that delivers on these expectations. There is much to learn from recent decades about the role of different policy levers.

The evidence is increasingly strong: healthcare as a complex eco-system can’t be meaningfully controlled top-down. A command-and-control style may provide the illusion of being in charge, but it most certainly does not foster innovation and change of the nature that is required. Market forces have also had limited impact. Reaching for structural change on its own also avoids the real work, form should follow function. Instead, implementable change requires local energy, aligned policy levers, collaboration, and a level of autonomy.

Less top-down and more local freedoms will run against the deep instincts of the Treasury which rightly seeks accountability for public spending. A central question for the reform agenda is therefore how to ensure accountability while moving towards greater local autonomy.

I see five potential areas worth considering for a progressive public management playbook to achieve meaningful change:

  1. Empower and trust citizens to hold local systems to account: local autonomy may come with local variation in care. Therefore, a necessary feature of a more devolved system should be a transfer of trust and power to citizens to hold their local healthcare system to account. Currently it is very hard for patients to understand what good care should look like. Addressing this will not only support direct accountability between a patient and care giver but also accelerate the adoption of best practice innovation.
  2. Rely on local democracy: the governance of Integrated Care Systems offers an opportunity to include local government. This opens the door to a progressive version of Local Area Agreements between different public sector organisations and citizens through their elected representatives. Regions differ in their health needs. Trading off resources and needs within local preferences and democratic structures will provide a different quality of legitimacy compared to traditional NHS plans.  
  3. Reward learning as part of accountability: making integrated care happen will require systems leadership. Compared to organisational leadership, this is a fundamentally different style. Part of systems leadership is acknowledging and becoming comfortable with not having all the answers. Systematic and continuous learning will be essential in driving change and should be explicitly rewarded and nurtured.
  4. Focus on fewer, essential measures: with more accountability concentrated locally, central control and regulation can retreat to functions that truly benefit from a national perspective and scale. This includes setting a small set of non-negotiable baseline safety and operational measures. Healthcare is evidence based and closing the gap between what we know and what we do is essential. Healthcare is also a high-risk business, and the NHS does not always get it right.
  5. Move towards dynamic, outcome focused measures: whether for national or local purposes, we should reduce the burden of data collection. Real World Evidence from electronic patient records and appenabled, patient-led data collection are increasingly routinely available. This offers opportunities to compare a broader and increasingly outcome-based set of measures across ICSs and providers in more timely and agile ways. It may also safeguard against the gaming of data collected specifically for performance management.

Sharing power with local organisations, citizens, and elected politicians requires a significant cultural and behavioural shift in NHS England and the centre of government. The pandemic offered us a glimpse of a much more innovative and dynamic health and care system, and the technological leap it created makes radical reform a realistic prospect. Seizing that opportunity will require political courage. But then, insanity is doing the same thing over and over and expecting a different result.


Over the coming months, Dr Heitmueller (Managing Director, Imperial College Health Partners) will work with TBI to develop the themes outlined in this blog and articulate a radical health and care reform agenda for the 2020s.

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