I sit on Bradford's Health and Wellbeing Board. This observation is pretty much spot on:
Dear NHS worshippers, sorry to be a killjoy, but look, the NHS is not ‘yours’, and never has been. You have no control over it. You feel like you are in control when you spin your little toy wheel, but try steering the car in any direction other than the one where it is already heading, and see what happens. The ones who really drive the car are the political class and the medical establishment. ‘Democratic accountability’ is a mirage. All it really means is that healthcare managers answer to bureaucrats, who answer to other bureaucrats, who also answer to other bureaucrats, who, after some more detours, answer to some politician. That’s democratic accountability. Feel powerful now?
The result is that healthcare delivery planning becomes an academic exercise. Nobody sat round the table in Bradford - yours truly included - feels remotely challenged, let alone worried about the decisions we might make (assuming we actually make any). We won't be held to account for those choices. The same is true for the boards of Clinical Commissioning Groups, the senior management of Hospital Trusts or any of the many other 'pseudo-business' structures and systems of accountability that litter the NHS landscape.
The result, of course, is that decisions are made very slowly. And when they are made the default is to indulge either the prejudice or the convenience of clinicians or managers. This doesn't mean every decision is wrong but it does mean that the organisation is deeply conservative preferring to sustain the structures, systems and operational principles developed for a paper-based (and smaller) 1950s NHS. It wouldn't surprise us if Sir Lancelott Spratt were to appear in the hospital corridor attended by clucking nurses and stressed looking junior doctors.
The problem isn't fat cat salaries or a glut of managers but rather than the managers getting those salaries aren't accountable for the decisions they make. So long, of course, as those decisions are made within the comfort zone of the NHS system. As a result, when really hard decisions have to be taken - closing a hospital, moving a specialist unit - they are made in a manner that absolves management from any negative consequences. Or not made at all.
Right now the NHS is busy talking up its financial problems. It has run a deficit (one that's slightly less than 1% of its budget but a deficit nonetheless). Senior managers and 'clinical leaders' are talking sternly about burning platforms, which apparently is jargon for a financially-mismanaged hospital rather than the consequence of an explosion at an off-shore oil well. And endless reams of unintelligible documentation clog up the in-boxes of those who perhaps have to make a decision at some point. These don't talk about what we actually need to have to deliver a great health system but instead consider "whole system thinking" and "effective governance". Then we're asked what a "remodelled system" would involve without having any coherent picture of the current system.
That the NHS delivers for most of us most of the time is a credit to the front line staff - those doctors, nurses and so forth that we think of as "Our NHS". But beyond this front there is an impenetrable jungle of non-accountability - that bureaucratic paperchase described in the quotation above. The primary purpose of that bureaucracy is to ensure that the 'whole system' is accountable meaning. of course, that no individual is accountable when things go badly wrong. In truth system accountability means there is no accountability.