Control and accountability in the NHS market: a practical proposition or logical impossibility?
Within the NHS new quasi-market arrangements have divided management functions into three:
(1) a policy/strategy function (deciding overall policy and resource allocation);
2) a buyer/commissioning function (developing and managing contracts to purchase services to achieve this policy); and
(3) a contractor function (providing services to clients).
For background on the formation of the NHS quasi-market see Le Grand and Bartlett and Tilley. In this “managed” market the strategy process has been somewhat removed from operational management. Throughout the 1960s and 1970s the medical profession continually acted to preserve their professionalism/monopoly with regard to choices over care and treatment, justified by the sanctity of the doctor-patient relationship. Managers, then termed administrators, were not influential actors and health agendas were dominated by the need to react to problems rather than anticipate them. Accountability was fragmented, control took the form of feedback systems and a rolling plan delegated down to the professional care deliverers. Operational management is, in the 1990s, having to recast its information systems, finance and otherwise to accord with an environment that is focused on what might be termed “contract accountability”. It is contract accountability that is now required and being monitored by external agencies such as the National Audit Office and the Audit Commission. While there is now explicit monitoring of contract outputs and patient outcomes, the monitoring of more macro-related aspects of outcome and the impact of health-care programmes is still not adequately addressed. How can there continue to be any pretence to a national strategic focus to the development of health care in the UK?