Scholars have suggested that reforms associated with a shift from government to governance have fundamentally altered the accountability landscapes of modern welfare states. The promotion of policies in favour of organisational autonomy, coupled with the rise of New Public Management Practices (NPM), have been correlated with the proliferation of innovative, and increasingly hybrid accountability arrangements, which have supplanted, or at the very least, supplemented traditional vertical forms of political accountability. In some contexts, the policies have promoted the role of organisational mechanisms that encourage the public to be involved and to hold their public services to account. While some scholars have emphasised the possibilities, as well as the limitations, associated with the new forms of public accountability, further research is required to critically explore the realities of the processes and the outcomes of such mechanisms. The contribution of this thesis is intended to provide insights into the themes, key issues and tensions which relate to the functioning of direct forms of public accountability in practice. Through drawing on the in-depth case of the NHS Foundation Trust policy, that was passed into law in 2003, and which introduced an innovative direct form of public accountability, this study examines the perspectives and experiences of the directors, the governors, the policy makers and the regulators concerning the implementation of this new mechanism, in one NHS Foundation Trust, in order to analyse the factors which shape the practices of public accountability. The analysis also considers the identified outcomes of the mechanism and it addresses the implications for the conceptualised possibilities and limitations of public accountability. While the approach adopted is, in part, exploratory, the analysis is guided by close reference to current theoretical understandings, drawn from accountability theory, new institutional theory, and organisational and management studies. Through an in-depth analysis the NHS Foundation Trust policy reform, this thesis is intended to make an important contribution to the central debates and to the existing body of knowledge that is defined as accountability scholarship.