Citizen accountability in the "New NHS' in England

The NHS is facing a combination of lower spending and increasing demand. In response, NHS England is requiring local areas to substantially rethink and reshape services through Sustainability and Transformation Plans. These have been devised largely without the involvement of patients and citizens, giving rise to widespread concerns about service loss. Other structural changes are also taking place that have no obvious place for citizen engagement. All of this is highlighting the problem of a lack of local accountability and legitimacy for decision-making in healthcare. This commentary describes the changes, identifies the accountability gap and suggests a framework for future development.