Healthcare delivery
Rebuilding accountability in the health service
The Medical Technology Group’s latest report outlines how we can rebuild accountability in the NHS, while improving patient outcomes. Barbara Harpham, Chair of the Medical Technology Group, provides an insight into the report findings and looks at how local leadership can deliver NHS reform.
Accountability in the NHS has always been a complex and evolving concept, but as the NHS attempts dramatic reform by “tilting to technology”, the need for clarity at a local level has never been greater. As the Medical Technology Group’s latest report, Rebuilding Accountability in the NHS, makes clear, this is the mechanism that will deliver the ambition of the 10-Year Plan while underpinning good governance and improved patient outcomes. Local leaders are, in theory, about to be granted greater autonomy, but without clear lines of responsibility and a robust oversight of this transformation, we risk widening the variation in care and outcomes across the country. As Integrated Care Boards (ICBs) merge,
NHS England is abolished, and the 10-Year Plan reshapes the operating model of the health service, understanding accountability at a local level is set to become a major priority for the system. But as our report shows, accountability remains fragmented and individualised, spread across the Department for Health and Social Care, legacy NHS England structures, regions, ICBs and providers, at exactly the time when patients and staff need a coherent, transparent system that supports improvement.
Defining accountability in a period of reform At its core, accountability is about clarity of responsibility, who is answerable for delivering services, how decisions are made, and what happens when performance falters. This is inherently challenging in a system with over 6,000 NHS bodies, where individuals are accountable from ministers down to ICBs. Lord Darzi’s 2024 investigation underlines this difficulty, noting that tasks are distributed across such a large group of people, and that multiple layers of national leadership encourage local organisations to look upwards as much as outwards to the communities they serve. These problems are also not new. Sir Alec Merrison’s 1979 Royal Commission described a
system burdened by an “extra and unnecessary tier” of management, leading to delays in decision making, duplication, too many meetings and a lack of effective accountability at local level – symptoms that can feel uncomfortably familiar in today’s NHS. Patricia Hewitt’s Independent Review of Integrated Care Systems recognised the need for clarity, but our report found this complex accountability framework can remain difficult to navigate in practice, something compounded by the latest period of restructuring that is reshaping roles and responsibilities. Just over 10 years after the last major
structural charts were drawn, many of the organisations they depicted no longer exist and new ones have been created, with functions and responsibilities still in flux. The lines of accountability have, in theory, been reduced, but the report’s interviews with ICB leaders reveal that clarity on how those lines work in practice has not yet “landed”, and leaders are often unsure what, precisely, the centre is holding them to account for. The MTG therefore
set out to shine a light on where accountability is working well and where it needs to be strengthened, using Freedom of Information requests, public documents and NHS England’s annual ICB assessments to assess leadership, innovation and outcomes.
Where accountability breaks down The report paints a picture of accountability mechanisms that are frequently fragmented, dependent on individuals and too often burdened by processes that are out of date. Accountability continues to be spread across DHSC, NHS England, regions, ICBs and Trusts, and although the 10-Year Plan and the new operating model aim to strengthen the line of sight from national to local level, this has not yet translated into a single, clear framework for Boards and leaders. In interviews, leaders spoke of a “cottage industry of process” and of being pulled between productivity, waiting lists, national metrics and broader population health aims. Leadership variation emerged as a critical
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