Health and Social Care Bill

Baroness O'Neill of Bengarve Excerpts

Tuesday 11th October 2011 Lords Chamber

[Baroness O'Neill of Bengarve]

My Lords, like other noble Lords, I return to the theme of accountability and the approach taken in the Bill. However, I am going to say only a very little about accountability to the Secretary of State. I fully agree with the Government that that accountability should not be managerial or executive. There is something absurd about the locution that has it that the Secretary of State delivers services. We have many organisations in which accountability to the top does not rest on the top having executive power. Charities and schools, corporations and universities do not hold to account by using managerial or executive powers. They hold managerial and executive powers, and those who exercise them, to account. In these types of institutions, accountability, as we know, is variously to trustees, governors, boards, councils and so on. Accountability in the NHS will be distinctive, and it needs to be clear that the Secretary of State is not on the hook for every failure of delivery. However, he or she needs well-defined powers for dealing with a range of contingencies, of which the noble Baroness, Lady Williams, and the noble Lord, Lord Marks of Henley-on-Thames, reminded us.

Getting this right will not be easy, but I hope that we can achieve acceptable clarification within the timetable of the Bill. I hope that this might be done by allocating additional time on the Floor of the House in Committee, even at the expense of other legislation, and that the usual channels will look on the necessary adjustments sympathetically. I am privy to nothing and I may be mistaken in that hope.

The forms of accountability to which I mainly want to draw your Lordships’ attention and about which I want to talk at greater length are much less exalted. Many noble Lords have emphasised the importance of cultural change if the new structures are to achieve what the Government hope they will. However, we all also know that demands for detailed accountability come trooping in the wake of legislation. They accumulate in regulations, codes of practice, guidelines and guidance, and all of these can militate against cultural change by requiring NHS staff to follow time-consuming procedures that are often perceived as tedious and bureaucratic, and that may even damage the very services to patients for which staff are being held to account. Over the years as we have gone through one piece of legislation or another, noble Lords have often heard Ministers reassure the House that some lacuna or difficulty in a Bill will be dealt with later by adding regulation, guidance or codes of practice. I fear that the record of mopping up the difficulties of an Act by such add-ons is not very encouraging—and can be extremely discouraging to those so held to account.

Excessive and ill-designed forms of accountability for front-line staff may not only demoralise but have detrimental effects on the very services for which they are held to account. Where health professionals are distracted or harassed by ill-designed forms of accountability that they perceive as destructive, wasteful or unproductive, or simply as excessively bureaucratic, cultural change will be undermined, and productive and co-operative working relations will be made harder and may indeed be prevented. Unfortunately, examples of destructive, wasteful and unproductive accountability requirements are not uncommon.

As an example of destructive forms of accountability we need only consider those cases where accountability creates perverse incentives to act in ways that undermine or damage the very activities for which people are held to account. To take an example that is, I hope, out of date, some interpretations of accountability for achieving targets for waiting times incentivised the diversion of effort into, let us say, imaginative ways of logging the “beginnings” of waiting times. As I said, I hope that this example is out of date, but it would be naive to imagine that perverse incentives will never be introduced —always with the best of intentions—and the Bill needs to incorporate measures to provide for realistic challenges to proposals for additional forms of micro-accountability.

As regards wasteful forms of accountability, I offer an example that I met a few years ago when chairing an inquiry into the safety of maternity services in England for the King’s Fund. A midwife told us in evidence, “It takes longer to do the paperwork than to deliver the baby”. I have no doubt that that was a bit pithy and exaggerated but her words have stayed with me. While I have no reason to think that a consequence was that the women in labour received inadequate care—although it is possible that this happened—or that the requirement to complete this paperwork actually destroyed good clinical care, this was surely a waste of the midwife’s skills and of NHS resources.

With regard to unproductive forms of accountability, I offer the example of requirements for NHS staff to log data that do not provide useful feedback for them. While accurate statistics matter for many purposes, the provision of formative feedback to those who compile the information can matter most, and it can change a mindlessly boring clerical task into one that has a point and can even be motivating. An NHS that prioritised formative uses of information would enable healthcare staff to find out more about their own unit’s performance and its strengths and weaknesses.

I recognise that Ministers would never intend to introduce destructive, wasteful or unproductive forms of accountability, but I fear that, because accountability creeps in the wake of legislation, it often turns out to be unintelligent or defective in more than one way. The demands for better regulation that have been extolled, and indeed encouraged, for so many years have often proved ineffective. Therefore, if we want intelligent accountability we shall, I think, all need to take a very active view of how this can be achieved, and accept that with accountability more is not always better; indeed, it can paralyse.

That control of the proliferation of damaging requirements for accountability also affects medical research. For example—the noble Lord, Lord Willis of Knaresborough, and the noble Baroness, Lady Morgan of Drefelin, referred to this—current interpretations of the Data Protection Act 1998 impose an extraordinary and, in my view, unnecessary burden of complexity on clinical research in this country.

Therefore, I should like to ask the Minister what steps he proposes to take to prevent and deter the creation of reams of additional, time-consuming, excessive and even destructive forms of micro-accountability in the NHS as it emerges from these changes. Could he perhaps consider a Churchillian move by assigning to the new institutions a duty to penalise the promulgation of excessive forms of micro-accountability, perhaps by insisting that such documentation be written in plain English and be no longer than a single side of A4? Oh that he could, but I doubt that that is possible. Or are we to believe that the intentions of the Bill will magically stem existing predilections for excessive and sometimes stupid forms of accountability?