The long-awaited NHS 10-Year Plan sets out an ambitious agenda to address the defining health challenges of our time, including digitisation, prevention, workforce reform as well as service redesign. On paper, it may appear comprehensive. However, for all its scale and ambition, it avoids one fundamental question of who holds the system to account?
Across more than 170 pages, democratic accountability is barely mentioned. Healthwatch England has been abolished. The National Guardian’s Office and other safety bodies have been absorbed or sidelined. NHS England, once the focal point for operational responsibility, no longer exists as a distinct entity. Yet nowhere in the Plan is there a clear answer to a basic democratic question: who is actually in charge, and who do they answer to?
This is not a technical oversight. It is a structural failure. Without clear, visible and accessible mechanisms for public scrutiny and influence, strategy documents like this do not deliver on promises of reform. In reality, they amount to aspiration masquerading as policy with little substance on how success will be achieved or measured, or failure held to account.
Accountability isn’t a side issue, it’s the infrastructure for trust
Just days after the Plan was published, Dr Penny Dash’s independent review into patient safety across the NHS was released. It presented a stark picture: six national bodies duplicating work, £60 million a year spent on safety with fragmented oversight, and hundreds of unnecessary deaths each year compared to OECD peers. The UK still records around 82,000 avoidable deathsannually from treatable conditions. As a result, it is clear that while the system attempts to monitor itself extensively, it does so ineffectively and at a considerable cost to the taxpayer.
Meanwhile, NHS Resolution paid out £3.1 billion in clinical negligence compensation last year. That is not just a figure on a balance sheet. It reflects lives disrupted, families failed, and a system that often defaults to legal redress in the absence of visible accountability.
This trajectory is neither sustainable nor inevitable. Other countries spend far less, deliver safer care, and manage safety through coherent and accountable oversight structures. Crucially, they also embed the public in how those systems are governed, not only through formal consultation, but through visible structures of democratic input and oversight.
Other countries do it better and more democratically
England’s system is unusually centralised and lacks the direct democratic input found in many of its peers. By contrast, several comparable countries take a more decentralised approach, where they combine lower spending with stronger safety performance and clearer lines of public accountability.
For example, in the Netherlands, patient councils are embedded in provider governance by law. In Sweden, regional health boardsare directly elected and hold responsibility for healthcare delivery. In Estonia, digital tools allow citizens to access their health data, provide service feedback, and view aspects of how decisions are made.
These examples are not flawless nor wholly and directly applicable to the NHS, but they show what is possible when systems are built around public engagement rather than political control or managerial discretion. They clearly demonstrate robust models for a different kind of NHS, one that treats accountability not as a reputational risk but as a democratic obligation.
What the public thinks: confused, shut out, and disengaged
In my recently published report for The Constitution Society, I found a striking disconnect between public expectations and how the NHS actually functions:
- 92% of the public have never interacted with any NHS accountability mechanism
- 85% hold NHS managers responsible for system performance, but 69% also blame elected politicians
It was equally clear that most people could not identify how decisions are made, how feedback is used, or where to turn with serious concerns. A 2025 YouGov survey for Healthwatch England (now being abolished) reinforces this pattern: 24% of adults reported receiving poor NHS care in the past year, but only 9% submitted a formal complaint. Of those who did, 56% were dissatisfied with the outcome. Furthermore, one in five feared that complaining would affect their future treatment, and a third said they did not believe their complaint would lead to any improvement in services.
This is not simply a disengaged public. It is a public kept at arm’s length from the very system it funds and relies upon, increasingly convinced that speaking up will make no difference and might even carry risk.
If accountability is not designed in, it will be left out
The 10-Year Plan offers a blueprint for change; however, unless accountability is built into that blueprint, the reforms will lack legitimacy and may ultimately backfire.
There is a better path available, and my research proposes several practical, evidence-based interventions:
- Publish regional accountability maps, so the public knows who is responsible, and for what
- Establish local patient assemblies with budgetary and strategic influence over ICS priorities
- Mandate digital feedback loops, showing not only what people say, but what changes as a result
- Pair safety regulation with democratic oversight, not just structural consolidation
These are not radical ideas as they are tried and tested elsewhere. The real question is: why has England not followed suit?
This is a political choice, not a policy oversight
Ministers and NHS leaders often cite ICSs, Trust Boards or even the Patient Advice and Liaison Service (PALS) as proof that the public has a voice in how the system is run, but this may be misleading. What passes for engagement is typically a form of managed consultation – tightly controlled, procedurally neat, and offering little room for genuine learning, influence or dissent.
Without structures like elected oversight, independent scrutiny, or transparent decision-making, the public is expected to participate without any power. That may suit those designing the system as it keeps control tidy and avoids awkward questions, but the consequences are increasingly hard to ignore. Public trust is slipping, legal claims are rising, and more and more people feel like the NHS is no longer something they shape or share in – it is something that happens to them.
A call to action: publish an accountability annex
If the government is serious about restoring public trust, it should publish an accountability annex to accompany the 10-Year Plan, ideally before the next general election. This annex should set out, in clear terms:
- Who is accountable for what
- How the public can engage and what influence they will have
- How performance, safety, and spending decisions will be opened to scrutiny
Without such an annex, the Plan risks becoming just another ambitious strategy, disconnected from the people it is meant to serve. Its credibility will depend not only on what is promised, but on whether the public can see how those promises will be delivered, and by whom.
Dr Keegan Clay Shepard.
Keegan Clay Shepard is a research fellow at the Constitution Society where he recently published his report: Exploring Democratic Accountability Structures and Pathways in the NHS.
The Constitution Society is committed to the promotion of informed debate and is politically impartial. Any views expressed in this article are the personal views of the author and not those of The Constitution Society.