Accounts and accountability.

We have a publicly funded health service, so the money really matters.

(This post is really thanks to you dear readers. The report this post is drawn from was published last Friday 10/05 when the twitterati brought it to my attention).

The House of Commons has many roles. Most significantly they hold the Government to account – although a Government with a majority can use it to mitigate against that function getting in their way too much.

But the role of select committees is to hold a wide range of Government bodies to account, and often it does this quietly as a part of the background machinery of Government. The Public Accounts Committee plays an important role in publicly checking up on the important accountability for public money.

Those of us who spend our time thinking about the NHS know that the amount it spends (about £170 billions) is a very big number. Some may want more, but however you look at it, that amount is BIG. Friday’s publication holds the Department for Health and Social Care (DHSC) accountable for that spend.

This is not an arcane, back of the office, issue. As we shall see later in the week the failure, over years, to maintain budgetary accountability for NHS spend has repercussions. Even in May – so early in the financial year – having an impact on whether trusts can advertise for staff is significant.

For the last few years, DHSC has failed to get its accounts to the Public Accounts Committee on time. Their defence has been that it does not have a direct relationship with the organisations (NHS trusts and others) that spend the money. This is now the job of NHSE which, following the Lansley reforms, was separated from DHSC.

The Committee have little time for that explanation.

In the summary at the start of the report they say,

“For the last four years, the Department has not published its accounts until January, ten months after the end of the financial year. The Department has committed to advancing its timetable by one month each year. However, this unambitious plan would mean it would take a decade to return to timely accountability for one of the largest areas of public spending. The Department is still not working effectively with the organisations within its group to enable earlier publication and needs to work with other stakeholders to ensure the audit market for NHS providers and commissioners is more resilient..”

So, someone in DHSC obviously thought that saying they would improve their production of final accounts by a month a year would be a stretch.

This did not go down well.

Saying that we promise by the end of the decade to do what is expected of us, is seriously unambitious and as the House of Commons committee says this is for one of the largest areas of public spending.

Not producing timely accounts was sort of forgiven during the national crisis of Covid. Now the House of Commons really wants to know where the money has gone and is beginning to stamp its feet,

“We are not convinced by the Department’s assertion that it has little control over the issues relating to the audit of local NHS bodies that have repeatedly resulted in its accounts being delayed, nor that it does not have the levers needed to address them. We have previously recognised that over the last few years the Department has had to produce its accounts in exceptional circumstances, but these issues cannot be allowed to continue post-pandemic.” (Page 5)

What this is effectively saying is, “we know the Lansley system makes this a bit more difficult but £170 billion is a lot of money. And given the constitutional structure since the Treasury gives the money to you as the Department of State you are accountable to the public for that money.”

I love the phrase “we are not convinced by the Department’s assertion that it has little control..”. It is as if DHSC is reacting to the House of Commons by saying, in the parlance that I grew up with. “What me guv? Nothing to do with me.”

Of course, it is complex but saying to the public “we are a department of state, and we just can’t be held responsible” is, as far as the House of Commons Public Accounts Committee is concerned, just not good enough.

The report goes on to talk about some very specific issues of accountability. One that surfaces every now and again – and never gets dealt with – is the cost of clinical negligence litigation.

“We are concerned that the Department is spending £2.6 billion on clinical negligence payments without an effective plan to minimise future costs of the scheme. Incidences of clinical negligence continue to result in significant cost to the taxpayer, particularly in maternity settings. The Department has made provisions in its accounts worth over £21 billion to cover the potential costs of known clinical negligence events, one of the largest financial liabilities across government. The Department made cash payments relating to clinical negligence arising from maternity and neonatal services worth £1.1 billion in 2022–23, equivalent to an eye-watering one third of the NHS’ total maternity and neonatal services budget. Each claim is a tragedy for the people involved. Yet the Department does not know whether the number of clinical negligence claims across the NHS as a whole are increasing or decreasing. The NHS does not benchmark well on clinical negligence compared to many similar health systems, and the Department and the NHS recognise that huge improvements need to be made.” (Page 6).

This is poor on so many levels.

If we are really spending one third of the budget for maternity and neonatal services on the cost of a number of catastrophic failures of those services, it is shocking. We have known for some time that the maternity service in England is in trouble. Inquiry after inquiry has made important points about maternity services pointing to specific needs for improvement.

We see the human cost of this with the tears of grieving relatives on TV. Now we know that the financial cost is equivalent to one third of all of the money spent on the service!!

My conclusions are where I started this post.

It has taken the House of Commons Public Accounts Committee holding, as the name suggests, the DHSC and the NHS to account to inform us/me that public money is being spent on litigation – at a rate of one third of its total budget – for the failings of this service.

Thanks a lot to the select committee but how, HOW has a set of organisations committed to providing healthcare – free at the point of need and with equal access for all – come to such a position?