Cameron’s reforms risk being undone by weak accountability structures

ippr's Jonathon Clifton argues David Cameron’s reforms to public services risk being undone by the weak accountability structures he is putting in place.

Jonathan Clifton is a Research Fellow at the Institute for Public Policy Research (ippr)

David Cameron’s reforms to public services risk being undone by the weak accountability structures he is putting in place. Over the last few months, the government have made a bewildering array of announcements on health, education and criminal justice. Perhaps recognising the need to take stock of all these changes, the prime minister today set out his stall on public service reform more generally.


This wasn’t a policy speech – rather setting out the grand narrative from which individual policies flow. That narrative is an increasingly familiar one:

1. Letting people choose their services from a wider range of private, public and third sector providers gives citizens more power, and the resulting competition can drive up standards;

2. Freeing public service professionals from central government targets and bureaucracy will enable them to innovate and be responsive to people’s needs;

3. Services should be held to account by the people who use them, not central government – so there needs to be data transparency which citizens can use to make their choices and push for change.

Citing New Labour’s experience (he’s clearly read Blair’s memoir and taken it to heart), Cameron argued that Blair had been right on choice and competition but that he had failed to adequately hand power down to service professionals. His speech was peppered with personal references to teachers, doctors and nurses. If only professionals were free, he argued, we would have better public services and a big society.

While claiming to have learnt from Labour’s experience, Mr Cameron’s speech failed to take account of two lessons from the past.

First, while in a perfect world service professionals work entirely in the interest of service users, in reality this is not always the case. Tensions exist between patients and doctors (see how hard it has been to encourage GPs to open out of office hours); between schools and communities (it took the Extended Schools programme to ensure schools provided care and activities to enable parents to work); and between the police and residents (patrols that keep the public happy don’t necessarily cut crime).

Recent research from ippr revealed many professionals were resistant about the idea of engaging with service users to build a ‘big society’. Empowering professionals is not necessarily the same thing as empowering the service user, as Mr Cameron appears to claim.

Second, transparent information and the ability to switch to a different provider do not necessarily empower the public to hold their services to account. The volumes of data released by the government can be meaningless and taken out of context (see for example Perry Common School which was wrongly interpreted as spending vast amounts on back office functions in recently released school spending data).

What’s more, without intermediary bodies such as local authorities and the Audit Commission to hold services to account, citizens are left smaller and divided in their ability to challenge for improvement. And while the ability to choose a different provider might provide some impetus for change, the reality for most is that switching school or hospital is limited – driven by what is nearby and a known quantity. There are therefore limits to what choice and transparency can achieve.

These two lessons mean Mr Cameron should be wary of falling into the trap of devolving power to public services, but not putting in place clear mechanisms for holding them to account. Relying on choice and competition is not always an appropriate or effective way of holding services to account for how they perform.

Without clearer lines of accountability, supported by local democratic institutions and central government, there is a real risk that public services will not receive an impetus to improve.

13 Responses to “Cameron’s reforms risk being undone by weak accountability structures”

  1. DisabledPeople

    RT @leftfootfwd: Cameron's reforms risk being undone by weak accountability structures: //bit.ly/glP2af by @ippr's Jonathan Clifton

  2. Teresa

    RT @leftfootfwd: Cameron's reforms risk being undone by weak accountability structures //bit.ly/hTkO0r

  3. william

    ARe you telling me that the IPPR is a charity,which is its present tax status,or are you admitting it is a political organisation?You can have your views, but why should the taxpayer subsidise them?

  4. StephenHenderson

    I won’t pretend to fully understand the NHS health reforms- who can? Yet if devolving power to local practitioners is the way forward: how come dental services are so crap?

  5. Democratic Society

    Noted: Cameron’s reforms risk being undone by weak accountability structures //bit.ly/hjErdu

  6. MikeyD

    RT @demsoc: Noted: Cameron’s reforms risk being undone by weak accountability structures //bit.ly/hjErdu

  7. Éoin Clarke

    So what has Andrew done? Lansley has done what all ministers aware that they are about to institute dodgy policy do, he has cloaked it. The consultation process into the NHS reforms has been flawed. The focus groups have exposed the participants to new language they do not understand. There are principally two main problems with Lansley’s reforms. By transferring budget control to GPs it opens up the potential of a lot of pork barrelling at local level. GPs will be able to refer complex operations, or treatments where there is a shortage of speciality, to private clinics. In many ways this is already happening since the outsourcing of work at the NHS has been growing for some time. But the process under which this referral takes place is going to be very worrying indeed. A broadsheet carried a report at the weekend that a GP had outsourced work to his own private company. So fraud and the misspending of tax payers money is a big risk.

  8. Dan J

    The Commonwealth Fund //www.commonwealthfund.org/ a respected private foundation set up in the US over 90 years ago which does research into health systems released a report in June 2010.

    What was the result?

    OVERALL HEALTH SYSTEM RANKING
    1. The Netherlands
    2. United Kingdom
    3. Australia
    4. Germany
    5. New Zealand
    6. Canada
    7. United States

    Yes the UK was number 2.

    And when it came to efficiency the UK was number 1.

    //www.bbc.co.uk/news/10375877

    Why are we radically changing a system that is working so well.

    Our health service is one of the cheapest of all rich countries.

    The UK spends 8.3% of GDP on health ($2.7k per person)
    = 100% coverage, life expectancy – 79

    US spends 15.3% of GDP on health ($6.4k per person)
    = only 82% coverage for under 65s, life expectancy – 78

    //www.npr.org/templates/story/story.php?storyId=110997469

    The US is an experiment in the free market for health – and it has failed!

    Why are the Conservatives not listening to the evidence.

    They say they want the clinicians to have more say – the clinicians are saying they don’t want these changes done so quickly in this way – why aren’t they practising what they preach and listening to the medical experts!

    PS Another example of decentralising, giving more local control (splitting up one body into 25) and increased market pressure?

    Privatisation of the railways.

    What happened?

    Costs went up!

    Now we now spend more on subsidising the railways than we did before privatisation.

    Ticket prices are also higher.

    Oh and not to forget Network Rail debt (which is government guaranteed) is £24bn. This didn’t exist preprivatisation.

    So was this decentralisation, localisation, marketisation a success?

    “We think that the separation has helped push up the cost of running the railways – and hence fares – and is now slowing decisions about capacity improvements. Too many people and organisations are now involved in getting things done – so nothing happens. As a result, the industry lacks clarity about who is in charge and accountable for decisions.”
    Chris Grayling, Conservative Party conference, 2006
    //news.bbc.co.uk/1/hi/uk_politics/5186196.stm

    Will the Conservatives be apologising in 2026 for wrecking the service and pushing costs up in the NHS?

  9. Matthew

    There is an easy way to increase patient choice, drive up standards, and increase accountability, without resorting to allowing a private sector free-for-all: mutualise the NHS.

    The mutual model would create democratic structures which called NHS staff to account, and where necessary take appropriate action. It would also allow for demand driven innovation. At the same time, the NHS would remain within the public sector – or, rather, the parts still in the public sector would.

    It’s actually a real shame that we missed our chance to carry out these types of reforms during our time in government.

  10. Mr. Sensible

    Jonathan I think you’ve hit the knale on the head with regard to accountability.

    Accountability and the ‘Big Society’ do not fit together.

    For example, It’s alright giving parents the chance to set up ‘Free Schools’, but to whom are they accountable? Not a locally elected authority, for certain.

    Similarly, with the NHS, it’s OK talking about patient choice, which I think is a good thing, but how is that to be acheaved when you getrid of the guarantees for patient care?

    This is just what the NHS, and other public services don’t need at a time when they are being squeezed financially.

  11. Miles Weaver

    RT @demsoc: Noted: Cameron’s reforms risk being undone by weak accountability structures //bit.ly/hjErdu

  12. RaidingTheParks

    RT @leftfootfwd: Cameron's reforms risk being undone by weak accountability structures: //bit.ly/glP2af by @ippr's Jonathan Clifton

  13. Daniel Pitt

    RT @leftfootfwd: Cameron's reforms risk being undone by weak accountability structures: //bit.ly/glP2af by @ippr's Jonathan Clifton

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