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To whom will GP commissioners answer?

Simple questions do not always have simple answers.  Consider the question: to whom will GP commissioners and clinical commissioning groups be accountable?  It sounds simple enough.  Yet at a recent summer school workshop on social values and clinical commissioning, the participants were quickly able to identify some 15 bodies, groups or agencies to whom those in CCGs might be accountable. There will almost certainly turn out to be more.

You cannot answer this question without first considering for what they will be accountable.  For the spending of their money, they will be formally accountable to the NHS National Commissioning Board, but the National Audit Office and Parliament will want to know whether money is being spent to good effect.  Ultimately, tax-payers will want to know whether commissioners are delivering what they are expected to.  And although the system has been set up on the assumption that the secretary of state will not interfere, there is no doubt that at the first sign of trouble, the Department of Health will want to know what is going on.

Commissioners will be making difficult decisions about health care priorities.  They will have to decide eligibility thresholds for IVF treatment, determine the conditions under which to fund bariatric surgery, balance the claims for preventive outreach work for those using drugs with expensive pharmaceutical interventions.  In other words, they will have to make all the priority judgments that the old Primary Care Trusts had to.

HealthWatch has been set up to represent local populations and commissioners will have to account to local committees on how they are making decisions on priorities.  But they will also confront the Clinical Senates, local Health and Wellbeing Boards and patient groups.  They ought to provide an account to those denied treatment by their decisions, but how this can be done and indeed whether it can be done at all, has still to be worked out.

And then there is the question of accountability to providers.  The system has been established on market principles.  Commissioners are supposed to shop around for the best buy.  But relationships with long-term suppliers where quality of service is important are not like choosing to go to Sainsbury’s rather than Tesco for your weekly shop.  When contracts are discontinued or not granted, suppliers are going to want to know why.

If  quality seems to be compromised , then HealthWatch will be able to involve the Care Quality Commission, of which it is formally a part.  But commissioners are also professionals.  If things go wrong, they may find themselves accountable to the GMC, and they will certainly feel a professional duty to explain to their peers how they are making their decisions.

Most of these accountability relations are formal.  But there is one informal source of accountability that all participants in the summer school thought would be important: the press.  Local health service decisions affect individual patients and the local and national press will surely be following the difficult decisions.

The setting up of the new NHS is a formidable case of ‘learning by doing’.  Commissioners will want to build up their own accountability matrix as they go along.1

Professor Albert Weale is Professor of Political Theory and Public Policy at University College London, and is one of the directors of a joint research project on social values and health priority setting.


1 A version of this accountability matrix can be downloaded at


The  ‘accountability matrix

For What? To Whom?
The spending of money NHS National Commissioning Board
  National Audit Office
  Department of Health
Choice of priorities HealthWatch
  Clinical Senates
  Health and Wellbeing Boards
  Patient groups
  Those denied treatment
  Provider organisations
Quality Issues Care Quality Commission
  General Medical Council
Informal accountability The press

Professor Albert Weale is ESRC Professorial Fellow and Professor of Political Theory and Public Policy at UCL