Feature

New signs of accountable healthcare

Despite the rhetoric of quality, it’s getting harder to hold health care providers to account, warns Gillian Dalley

Since the introduction of the Patient’s Charter, it has become commonplace to argue that people’s expectation of what they can legitimately expect from the health service have grown proportionately. The numbers of complaints have risen along with a concern for seeking redress under the terms of the Charter. There is now greater public debate about accountability in public services, with reports from the Cadbury and Nolan committees fuelling this concern. Questions are increasingly being asked about how public money should be spent, by whose authority and to whom should decision-makers be accountable.

In spite of this apparent climate of concern about quality and accountability, it could be argued that it has become more difficult to be confident that health services are up to standard and open to scrutiny. In theory, there are various bodies charged with checking on the quality of services offered. Broadly speaking, there are four processes which should guarantee service quality: lay assessment (via community health councils); regulation and inspection (through inspection units); complaints procedures (in-house, but ultimately up to the ombudsman); and contract compliance. CHCs have a general responsibility to act as watchdogs on behalf of their local populations and a right to visit NHS premises to inspect services. Residential and nursing homes are inspected regularly by local authority and health authority inspection units. In addition, service providers are required to have in-house complaints procedures which are readily accessible to the public should they have a complaint. Within the purchasing/providing relationship, purchasers are able to lay down quality standards which providers are expected to meet within the terms of the contract.

This looks relatively straightforward, even watertight. But since the 1990 reforms, being assured about quality and seeking redress when there are failures often seems far more difficult than before. This is largely due to the fact that the structural relationship between the patient and the service has become fractured. Before the reforms, the patient was in a direct relationship to the NHS (and the local authority if social services were involved in providing domiciliary services). The health services that the patient received were NHS services planned, managed and provided by the local health authority. Since the reforms, the relationship is much more complex. While health authorities purchase services, the services themselves may be provided by a variety of trusts (not always local to the patient) and, increasingly, by a series of private providers. The question of who is responsible for what, and to whom the patient should go to seek redress is often unclear.

Take the typical case of an older woman who receives a community care package of domiciliary services (district nursing, home help, meals on wheels) but becomes ill and goes into hospital. Once there it becomes clear that she cannot be discharged home because she is too frail. Arrangements are made for her to be discharged into a private nursing home. Although she lives in London she has to go to a home on the south coast because there is not enough nursing home provision in London to meet demand. The number of agencies involved in the provision of her care over this period is extensive. Before going into hospital she received district nursing from the local community trust, but home care from a private domiciliary agency (but paid for by the local authority who also provided meals on wheels). She went into hospital which was part of the local acute provider trust. Both the trusts which provided her care were commissioned by the health authority. When she was discharged into a private nursing home, both the local authority and the health service were involved in the placement. The local authority as community care lead authority was responsible for means-testing her for financial support. She is now expected to pay her nursing home fees through selling her house and only once her own resources are exhausted will she receive full state support.

Throughout this complex set of arrangements, the patient and her family have felt helpless. At many points they have been dissatisfied but do not understand their position and do not know how to seek redress. How far is the local authority accountable for the service provided by private domiciliary care agencies or private sector residential and nursing home providers (even though they may be paying for it)? What is the relationship between the health authority and the trusts it commissions services from in individual cases? How can the monitoring of block contracts safeguard the interests of individual patients? Are in-house trust complaints procedures sufficient or should the purchasing authority play a part in following up complaints? CHCs have access to NHS premises but they do not have parallel rights to enter non-NHS premises. While the patient is partly funded by her authority in London, the nursing home in which she is based is inspected by the health authority inspection unit local to the home. There are few direct links between the home and the London authority.

The administrative arrangements governing health and social care are complex enough for the agencies and organisations directly involved. But for patients and their families, they are dangerously bewildering. The spirit of the Patient’s Charter which suggests that power is being transferred to the patient is entirely misplaced