Luxembourg Institute of Health, 1A-B, rue Thomas Edison, L-1445, Strassen, Luxembourg; Luxembourg Institute of Socio-Economic Research, 11 Porte des Sciences, L-4366, Esch-sur-Alzette, Luxembourg.
Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
Soc Sci Med. 2021 Jan;268:113512. doi: 10.1016/j.socscimed.2020.113512. Epub 2020 Nov 10.
The English National Health Service (NHS) constitutes a unique institutional context, which combines elements of hierarchy, markets and networks. This has always raised issues about competing forms of accountability. Recent policy has emphasised a move from quasi market competition towards collaboration in the form of new regional organisational arrangements known as Sustainability and Transformation Partnerships (STPs). We explore accountability relationships in STPs, focusing on the challenges of increasing horizontal accountability given existing vertical accountabilities, most notably to national regulators. We utilize a case study approach concentrated on three Clinical Commissioning Groups (CCGs) in urban and rural settings in England. We conducted in-person interviews with 22 managers from NHS organisations and local authorities and examined local documents to obtain information on governance and accountability structures. The fieldwork was undertaken between November 2017 and July 2018. We analysed results by considering which actors were accountable to what forums and the nature of the obligation (vertical or horizontal). We found that individual organisations still retained vertical accountabilities and were reluctant to be held accountable for the whole STP, given they were responsible for only part of the joint effort. Moreover, organisations did not feel accountable to STPs and instead highlighted vertical accountabilities upwards to their own boards and to national regulators; and downwards to the public. But while local commissioning organisations, CCGs engaged with their members and the public, STPs failed to engage adequately with the public. Nevertheless, there were indications that horizontal accountability was starting to develop. This could become complementary to vertical accountability by facilitating mutual learning and peer review to anticipate and defer regulatory intervention. While vertical accountability is necessary to provide oversight and apply sanctions, it is not sufficient and should be accompanied by horizontal accountability.
英国国民医疗服务体系（NHS）构成了一个独特的制度背景，其中结合了等级制度、市场和网络的元素。这一直引发了关于竞争形式的问责制的问题。最近的政策强调，从准市场竞争转向以新的区域组织安排（称为可持续发展和转型伙伴关系（STP））的形式进行合作。我们探讨了 STP 中的问责制关系，重点关注在存在垂直问责制（尤其是对国家监管机构的问责制）的情况下，增加横向问责制的挑战。我们利用案例研究方法，集中研究英格兰城乡地区的三个临床委托组（CCG）。我们对 NHS 组织和地方当局的 22 名管理人员进行了面对面访谈，并查阅了当地文件，以获取有关治理和问责制结构的信息。实地考察工作于 2017 年 11 月至 2018 年 7 月进行。我们通过考虑哪些行为者对哪些论坛负责以及义务的性质（垂直或水平）来分析结果。我们发现，个别组织仍然保留着垂直问责制，并且由于只负责联合努力的一部分，因此不愿意对整个 STP 负责。此外，组织并不认为对 STP 负责，而是向上级董事会和国家监管机构强调垂直问责制；并向下级公众强调垂直问责制。但是，虽然地方委托组织、CCG 与成员和公众互动，但 STP 未能与公众充分互动。尽管如此，有迹象表明横向问责制开始发展。这可以通过促进相互学习和同行审查来为监管干预提供预期和推迟，从而与垂直问责制互补。虽然垂直问责制是提供监督和实施制裁所必需的，但它是不够的，应该伴随着横向问责制。
