Prof Andy Brooks
NAPC Clinical Chair
Neighbourhood is the talk of the town. The ideas behind it are not new, but they have been given fresh impetus by the NHS 10-Year Health Plan and the national programmes now supporting implementation across England.
As neighbourhood working develops, one question is repeatedly asked:
Where will accountability sit?
It is a reasonable question. It can also bring conversations to an abrupt halt. People look around the room, hoping that someone will produce an organisational chart, a new committee structure or the name of the individual who will ultimately be held responsible. But perhaps the reason the question is so difficult to answer is that it is the wrong question, or at least not the first question we should be asking.
Our familiar model of accountability
The NHS is understandably keen on accountability, assurance and metrics. Its established governance arrangements are largely rooted in a top-down, hierarchical and transactional model. We are familiar with boards, committees, reporting lines, delegated authority, statutory duties, performance measures and named senior responsible officers. These arrangements have often served the NHS well, particularly when the task is clearly defined and sits largely within one organisation.
They make sense when responsibility can be traced through a recognisable chain of command. They are particularly suited to a system viewed through the lens of individual diseases, organisational services and episodes of treatment.
Neighbourhood health is different. It starts with the complexity of people’s lives. Health is affected not only by access to clinical care, but by housing, education, employment, income, relationships, transport, leisure, community connections and many other factors. If care needs to be delivered differently in response to that complexity, perhaps governance and accountability need to be approached differently too.
Who is accountable for Miss L?
Consider Miss L, a 42-year-old woman with moderate learning disabilities. She has recently moved into a flat closer to her parents. Her mother has significant mobility problems and her father is living with early-stage dementia. Miss L receives support from her parents, but she is also increasingly helping to care for them.
Living nearby has improved her mental wellbeing. She sees her parents more frequently and has become connected to a wider network of local support. At the same time, moving has taken her further away from some of the friendships she developed over the previous 20 years.
The flat itself presents another problem. The previous occupant kept cats, and the allergens left behind aggravate Miss L’s asthma and allergies. She has increased attendance at general practice and visited emergency departments several times and has occasionally required admission to hospital. Miss L has also discovered that she sometimes feels better after taking one of her mother’s ‘red tablets’, prescribed for a long-term inflammatory condition.
There are many factors affecting Miss L’s health and wellbeing: physical, psychological, social, environmental and relational. Her situation involves primary care, hospital services, social care, a housing association, learning disability support, her family and voluntary & community organisations.
So, who is accountable?
Is it her GP because of her asthma? The hospital because she has attended A&E? The housing provider because of the allergens? Social care because of her learning disability? The pharmacist because of the medication risk? Her mother’s clinical team because the tablets were prescribed to her? Or Miss L herself?
Clearly, no single organisation or individual can be held accountable for the whole of her situation. That is not evidence of governance failure. It is the reality of complexity.
Complicated is not the same as complex
A complicated problem may involve many different parts, but the relationships between them can usually be understood. With enough expertise, it is possible to design a process, allocate responsibilities and predict the likely result.
A complex problem behaves differently. The elements interact, circumstances change and an intervention in one part of the system may create consequences elsewhere. There may be several legitimate perspectives and no single organisation has enough knowledge, authority or capability to act alone.
Miss L’s move has simultaneously improved and worsened her health. Being closer to her parents gives her emotional support but also increases her caring responsibilities. The new flat offers independence and connection while aggravating her respiratory condition. Each individual decision may appear reasonable, yet the combined effect is difficult to predict.
Neighbourhood health is full of situations like this. Trying to force them into a model of single organisational accountability can result in each organisation protecting its own position rather than working collectively in the interests of the person. Under the banner of accountability, professional and organisational barriers can quickly be raised.
A different set of questions
This does not mean accountability is unimportant. Nor does it mean that everyone is responsible and therefore no oneThis does not mean accountability is unimportant. Nor does it mean that everyone is responsible and therefore no one is accountable. It means we need a more sophisticated approach. Instead of beginning with “Who can be held accountable?”, we might start by asking:
What are we collectively trying to achieve for this person and this community?
That creates the possibility of purpose-led rather than structure-led governance. From there, other questions follow.
- How can decisions be made as close as possible to the people with the relevant knowledge?
- Which decisions should sit with individuals, neighbourhood teams, organisations or system leaders?
- Where are individual accountabilities necessary, and where do several accountabilities need to work together?
- How will partners identify and manage risks that sit between organisations rather than neatly within them?
- How can governance remain proportionate, transparent and adaptable as local circumstances change?
- How will local people and communities participate not simply as recipients of services, but as partners in setting priorities, making decisions and assessing progress?
These questions are less likely to produce a tidy organisational diagram. They are, however, more likely to produce governance arrangements suited to the reality of neighbourhood working.
Accountability as a relationship
In neighbourhood health, accountability may need to be understood less as a reporting line and more as a set of relationships. Organisations will retain their statutory duties and professional responsibilities. Those cannot simply be wished away. But alongside them, neighbourhood partners will need to develop mutual accountability: being clear about the contribution each partner has agreed to make, being transparent when commitments are not met and responding collectively when circumstances change.
This requires trust, but it cannot rely on trust alone. Decision rights must be explicit. Information must be shared appropriately. Disagreements need a route to resolution. Local people need visibility of what is being promised and what is being achieved. The aim is not to remove accountability. It is to prevent narrow forms of accountability from undermining the shared purpose.
Avoiding the accountability trap
As neighbourhood health develops, there will be a natural desire to make it fit within the existing machinery of NHS governance. Some of that machinery will remain necessary. But if every new relationship must first be accommodated within existing organisational structures, neighbourhood working risks being stymied before it begins.
The danger is that accountability becomes a reason not to share information, not to pool resources, not to take a proportionate risk and not to act across organisational boundaries.
Miss L does not experience her life as a series of separate organisational responsibilities. She experiences one life. Our governance arrangements need to become better at seeing that whole life too. The question of accountability in neighbourhood health must be addressed. But it should be addressed in a way that recognises complexity rather than attempts to eliminate it.
Perhaps the question is not simply:
Who is accountable?
Perhaps it is:
How do we create a system in which everyone understands their particular accountability, while remaining collectively accountable for what matters to people and communities?
That question is harder to answer—but it may take us much closer to the neighbourhood health service we are trying to build. At NAPC we are working with local partners as they step through these questions. If you would like a conversation please get in touch.
