ABSTRACT
In the early 1990s the NHS reforms introduced markedly new forms of governance structure into the NHS. These were criticised by the then Labour opposition and many academics as critical issues relating to public accountability were being disregarded in favour of a ‘private sector’ model of governance (Ashburner, 1997). How effective private sector boards are in their governance role and how appropriate this model is for the public sector raises further important issues about board role and performance. This chapter reviews the process of change that occurred in the health sector in the 1990s and discusses its significance in terms of its impact upon governance structures in the NHS. The extent to which changes have been introduced to counter critics and to strengthen the NHS board model has been limited. The subsequent election of a Labour government was potentially an opportunity for the issue of public accountability to come to the fore and to be addressed within the large new policy initiatives which focused on the ‘modernisation’ process for the NHS. In the White Paper The NHS – Modern and Dependable (DoH, 1997), one of the six key principles is to ‘rebuild public confidence in the NHS as a public service accountable to patients, open to the public and shaped by their views’ (ibid.: 11), while at the same time ensuring that ‘financial confidence and probity are maintained’ (ibid.: 39). The expansion of the ‘board’ model into the primary health care sector with the creation of primary care groups, which eventually became primary care trusts, offered an opportunity to develop and evaluate new forms of governance structure. Given the role of primary care boards in the choice and purchasing of care across the health sector, greater accountability here could be argued to be of particular relevance. While some small changes of emphasis are evident in the creation of primary care groups, there has been no attempt to introduce local, democratic decision-making in any formal sense. Primary care groups are only required to have ‘accountability agreements and have a named Accountability Officer’ (ibid.: 49). This chapter assesses the implications of this inertia and maintains that further
changes are still possible and desirable if the government is truly committed to greater levels of ‘participation’ and to ensuring the probity and effectiveness of boards in the management of the NHS.
