Rebuilding accountability in the health service

Accountability in the NHS has always been a complex and evolving concept, but as the NHS attempts dramatic reform by "tilting to technology", the need for clarity at a local level has never been greater. As the Medical Technology Group's latest report, Rebuilding Accountability in the NHS, makes clear, this is the mechanism that will deliver the ambition of the 10-Year Plan while underpinning good governance and improved patient outcomes. Local leaders are, in theory, about to be granted greater autonomy, but without clear lines of responsibility and a robust oversight of this transformation, we risk widening the variation in care and outcomes across the country.

As Integrated Care Boards (ICBs) merge, NHS England is abolished, and the 10-Year Plan reshapes the operating model of the health service, understanding accountability at a local level is set to become a major priority for the system. But as our report shows, accountability remains fragmented and individualised, spread across the Department for Health and Social Care, legacy NHS England structures, regions, ICBs and providers, at exactly the time when patients and staff need a coherent, transparent system that supports improvement.

At its core, accountability is about clarity of responsibility, who is answerable for delivering services, how decisions are made, and what happens when performance falters. This is inherently challenging in a system with over 6,000 NHS bodies, where individuals are accountable from ministers down to ICBs. Lord Darzi's 2024 investigation underlines this difficulty, noting that tasks are distributed across such a large group of people, and that multiple layers of national leadership encourage local organisations to look upwards as much as outwards to the communities they serve.​