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The 2020 Public Services Trust Blog

Tuesday, October 19, 2010

Two missing links – accountability and information

By Charlotte Alldritt

Until this morning I had thought I’d understood the general gist of the Government’s White Paper, ‘Liberating the NHS’.  Even if, as Sir David Nicholson admitted, the Department is still “working on the detail” I thought I had a fairly firm idea of the direction of travel. 

But now – after four of the most senior managers of the NHS tried to explain it to the Health Select Committee inquiry on commissioning – I’m more confused than ever.  While the devil will indeed be in the detail, it is not clear how the whole system will align the incentives and levers of finance, clinical expertise and commissioning for quality care.  Add the need for £20 billion in productivity savings and a 30% cut in management costs, and it’s a significant mountain to climb.

A first step will be in making clear the relationships between the Department, local authorities, GP consortia, the NHS National Commissioning Board, primary care inside and out of the remit of GP commissioners, social care, Health and Wellbeing Boards, individual patients, GPs disengaged or disinterested with the new system architecture, and the whole range of other stakeholders.  Without clarity on these relationships, as Rosie Cooper, Labour MP for West Lancashire asked repeatedly “Where is the accountability”?

Accountability is one of my two prime concerns for the new system of commissioning for healthcare.  How will providers be held to account for the quality of their outcomes for individual patients in the new system?  How will commissioners be held to account for the outcomes they achieve for their communities?  To what extent are local authorities to take the rap?   Where will discussions on competing ideas of ‘appropriate’ resource allocation take place? 

We know that the NHS National Commissioning Board will have ultimate authority.  But, as each of the four witnesses this morning (Sir David Nicholson, Dame Barbara Hakin, Dr. David Colin-Thome, and Ben Dyson) intimated, the local dynamics of the system will be key to delivering efficient and effective healthcare.  Appropriate accountability structures and incentives need to be in place to engage both clinicians and patients to achieve this.

The second of my prime concerns underpins the first; information and data quality.  For providers, commissioners and individual GPs to be held to account there needs to be a body of credible information on comparative outcomes, inputs and transaction costs.  ‘How much would the new Commissioning management system cost per head?’ asked Chris Skidmore, Conservative MP for Kingswood.  The Department does not know yet, but is determined to see it “significantly below 5%” of total costs.  Who will be monitoring those costs and outcome measurements?  David Nicholson says that the NHS Information Centre will – for the first time – be a hub collection point for Commissioning Boards to submit their standardized data.

However, it is not yet clear the extent to which the Information Centre will prescribe data standards or data requirements (e.g. and especially in primary care where it is almost entirely lacking).  As Dame Hakin and Dr Colin-Thome suggested, peer-based scrutiny and competition on outcomes can be a powerful lever for improving quality amongst clinicians.  But will this data be collected and made available for comparison?  Furthermore, in the new age of transparent government, will this data be openly available to the public?

The 2020 PST Information and Technology Group have submitted a formal response to the Health Select Committee on the role of information for commissioning.  We believe that that the White Paper does indeed hinge upon the ‘information revolution’ that the Secretary of State speaks of. 

The absence of accurate data on performance, spending and costs leaves commissioners and the public blind when crucial decisions have to be made about investment in, or closure of, services.   When the DH refers to high levels of patient satisfaction with their health professionals, to what extent do patients know how their GP compares with others?  Since patients and the public cannot get the answers to simple questions like, ‘How good or bad is my local GP?’ or ‘Which local provider organisations provide the best care?’ they can’t make informed choices about where to get care.  And they can’t make an informed contribution to local health discussions such as the merger or closure of services. 

We therefore recommend, for example:

  1. Standardised national data sets need to be developed urgently for episodes in primary care and community services, similar to the routine data set on episodes of hospital activity.  These should be done incrementally so that that striving for ‘perfect’ does not extend the existing delay of many years.
  2. It should become a legal duty of all providers who are funded by the NHS – including individual clinicians – to collect standardised, high quality data on their individual patient activity and outcomes to meet the national standards
  3. Commissioners should have the power to require addition local data access and suspend providers’ NHS funding or referral of patients for failure to comply.

 To be a truly devolved system as the Government envisages for the NHS, requires publicly available, high quality data across the full range of health services.  Only then will we be able to build a system which engages clinicians and citizens to work together, and so delivers quality care for patients at lower cost.


The 2020 Information and Technology Group submission has been lodged with the Health Select Committee, which will report later in the autumn.  For all enquiries on our recommendations and other work, please contact Charlotte Alldritt ( 


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