Comment Blog 21 February, 2024

Accountable to whom?

Rosie Beacon
Research Manager and Head of Health

In the world of public service reform and devolution, the word ‘accountability’ is bandied around a lot. Who has it, where it sits, how it changes outcomes. Generally, international evidence indicates that if you want effective devolution, then both accountability and budgets must be devolved to a more local level. And yet while the definition of budgets is obvious, what is meant by ‘accountability’ is more ambiguous.  

Three questions must be answered: what is accountability, and how is it different to say, responsibility? If creating more accountability is so important, then how does more accountability change decision making behaviours and ultimately improve outcomes? And how are decision makers actually held accountable?  

The fundamental difference between responsibility and accountability is that responsibility is about fulfilling obligations set by someone else, while accountability is about taking personal answerability for results.  

The defining feature of accountability is that it involves mechanisms that allow the users of that service to express their judgements on the providers. In a market, this would mean payers can choose which providers they use. Or in the public sector, democratic processes in which the public pass electoral judgement.  

There are several different ways in which localised accountability can change the behaviour of decision makers. If a policymaker has a substantial budget for healthcare and the political accountability for it, they are strongly incentivised to identify the biggest cost drivers and design services that address the issues behind them – for example obesity, elderly citizens, or homelessness.  

Their incentive here is partially electoral and partially financial. If they fully own and are accountable for the budget, then targeting root causes effectively should lead to cost reductions, and those savings can then be channelled into another area of health (or indeed another public service).  

In the counterfactual, where they have the budget but little accountability, they will be required to allocate budget to a particular problem identified by those who are politically accountable, whose political incentives may demand different interventions.  

If democratic accountability is based on national rather than local data, interventions are likely to be based on national level trends that do not easily translate in every locality. For citizens, this can leave locally specific problems unsolved, and undermines allocative efficiency as well as trust in government.  

Take, for example, Newham, who identified smoking reduction as a priority, given how much it increases the likelihood of a litany of long term conditions. The council started doing outreach by going out to construction sites, including the local Tate and Lyle sugar factory and the council’s depot where refuse workers and other teams work. The take up and effectiveness of the stop smoking service has been impressive, and smoking prevalence in Newham has dropped 9.9%, lower than the London and England averages.  

The point being, the local government were close enough to the local population to identify this as an issue and to make precise, targeted interventions. They are accountable for the improvement in outcomes for these people and the budget savings this intervention could provide. And ultimately, if people thought these interventions were ineffective or misguided, they could vote them out! 

Genuine devolution to local political leaders, who have a closer proximity to constituents, means the information gap is much smaller, and they can therefore make much more tailored and rapid interventions than at a national level. Key to responsive accountability. 

The different mechanisms of accountability – how local decision makers would be made to answer for their decisions and performance – is crucial. These can range from the grassroots to the centre. The ideal mix is a combination of the democratic and the technocratic.  

The typical mechanism of accountability for citizens is via the formal electoral process. But while electoral success is a powerful incentive to provide a service aligned to the specific needs of the public, a technocratic model is also needed.  

Technocratic accountability is provided through formal regulatory processes applied via the centre, with the ability to take punitive action if necessary. This enables a level of technical scrutiny that is not usually achieved through elections. An effective system of top-down accountability would allow for some consistency in standards across the country while enabling sufficient local autonomy in decision making.  

In summary, there is no blanket definition for accountability – how it changes decision making, and therefore outcomes, is contingent on a number of variables that will vary from place to place. But there is a lot to be said for shortening the chain of accountability closer to the citizen – it’s not merely a matter of democratic principle, but one of better policymaking.