Feature

Let us get on with it

Increased surveillance and regulation has marked Labour’s approach to improving NHS standards – but now the regulators must be allowed to do the job, says Linda Patterson

When New Labour was elected in 1997 there was widespread dissatisfaction with the performance of the NHS. A rise in consumerist attitudes and a plethora of medical scandals, like the Bristol heart surgery case, had dented public confidence. New Labour inherited the purchaser-provider split and the internal market from the previous government. GP fundholding had resulted in some innovative practice but also an increase in inequity, with patients from non-fundholding practices having to wait longer for specialist treatment. Local trusts with increased autonomy were meant to be competing for contracts from health authorities or fundholders. This internal market was partial, but had resulted in some destabilisation of the hospital service which was widely perceived as damaging. Although trusts had some autonomy, the Department of Health centrally set specific targets for NHS activity, such as number of people on the waiting lists or numbers of patients treated and this was linked to the release of money from purchasers. There was also an acceptance of commercial medicine, with some tax incentives for private health care insurance for older people and a reliance on private sector funds for capital projects.

During the 1980s and early 1990s the drive to improve quality in the health service relied on a number of initiatives, both statutory and non-statutory. Broad quality standards were written into the contracts placed between purchasers and providers. External statutory regulators, such as the Audit Commission, reported on quality issues. Non-statutory regulation, such as accreditation of medical training and requirements for ongoing education, was administered through the medical royal colleges. A number of institutions undertook voluntary accreditation schemes, such as the King’s Fund Accreditation and Investors in People, and clinical audit programmes were encouraged, although there have been doubts about the efficacy of this approach.

A first class service?

In the 1997 NHS white paper, The NHS Modern and Dependable, and the subsequent document A First Class Service, attention to the quality of the service provided was made a statutory duty for all NHS organisations, for the first time since the creation of the health service. Quality became an explicit duty of care alongside financial probity. Quality improvement now relies on all the mechanisms described above but in addition a new ‘quality framework’ has been promoted, containing clear standards for the service. National service frameworks have been published for mental health, coronary heart disease and older people, which set standards for the performance of primary and community care services, hospitals and social services. The National Institute for Clinical Excellence (NICE) reviews health technology and medicines and draws up clinical guidelines. It seeks to ensure that the NHS uses treatments supported by evidence, and that those not supported by evidence are not used. It was also established to stop ‘postcode prescribing’ whereby some health authorities would allow some drugs to be prescribed while others would not. Now, if NICE issues a report supporting particular medication in particular conditions, local health authorities are expected to implement these recommendations. But this is only being done within existing resources and there are already some problems in implementing NICE guidance.

Dependable local delivery of services is to be achieved by improved professional self-regulation, and changes in the General Medical Council and other professional regulatory bodies are currently in process. A commitment to lifelong learning and ongoing professional development for all members of NHS staff is seen as a key plank. The central framework of clinical governance brings together the strands of quality improvement within the health service. The definition of clinical governance is ‘the framework through which NHS organisations are their staff are accountable for the quality of patient care’. It covers the organisation, systems and processes for monitoring and improving services.

These standards are to be monitored through the normal performance management of the NHS, by eliciting patient and carer views of the service through the National Patient and User Survey, and by the work of the Commission for Health Improvement (CHI), which has a duty to monitor the quality of care in NHS organisations in England and Wales.

Re-organisation, again

Since 1997 much has been done to emphasise quality of care. NICE has begun its work, clinical governance is being developed and supported by education programmes in the NHS, professional self regulation is being modernised and CHI has become active. However, these new bodies have only just come into existence and it is not yet possible to see demonstrable change. The government has become impatient with the pace of change and so has introduced more pressure for change into the system, under the heading of ‘modernisation’. This is intended to challenge both NHS bureaucracy and professional vested interests, and to achieve change by increased regulation of the service. Extra resources are targeted at specific programmes in order to achieve desired changes. In 2000, the Department of Health brought together managers and clinicians from the front line of the service, along with patient representatives and civil servants to work on the NHS Plan, published in July 2000. This increases resources for the NHS and promises more front line staff but introduces the concept of ‘earned autonomy’. Institutions which meet their performance targets (‘green traffic light’ organisations) will be allowed more freedom but those that do not (‘red traffic lights’ organisations) will be strongly managed from the centre. There is a concordat with private medicine so that patient care may be contracted to the private sector if the capacity of the NHS is not great enough. In April 2001, the Modernisation Agency was launched to carry out this agenda. This is a collection of experts on waiting lists, clinical governance, cancer care and so on charged with supporting change within the NHS. The Modernisation Agency will work outside the line management structures of the NHS with an emphasis on changing organisational culture and redesigning work processes. When the Modernisation Agency was launched, the secretary of state also announced a move towards devolved management of the health service, after having taken a lot of central control in the first few years of the government. Re-organisation of the NHS management structure is to happen once again. The regional offices will be downgraded and there will be 30 strategic health authorities. Primary care groups will merge into larger primary care trusts, and professionals and managers will supposedly become more involved in the local management and delivery of services.

So the work of CHI is being carried out against a background of a great deal of structural change within the NHS. Many NHS managers will currently be thinking about organisational change and will be worried about their own employment and security. It might be argued that instability is the time when change for the better can occur, but for such change a high level of staff commitment and motivation is needed, so that the purpose of the health service (to provide good patient care) is not lost from sight.

The work of CHI

CHI is a non-departmental public body independent of direct government or NHS control. Its principles are to be patient centred, putting the patient’s experience at the heart of its work, to be independent and fair, and to promote developmental while remaining rigorous and evidence based. All reports will be published and accessible through local libraries as well as on the Internet. CHI’s approach is not to have inspection for its own sake. CHI’s functions are to undertake clinical governance reviews in all NHS organisations in a rolling programme in England and Wales. This will include primary care, mental health, acute trust and also patients cared for in the private sector under NHS contracts. CHI also undertakes investigations where there have been serious service failures, but it does not undertake inspections for their own sake. CHI will in future be reviewing the national service framework for coronary heart disease. Finally, as more data is gained, CHI will be in a position to offer leadership and guidance about what does actually improve quality in the health service. Good practice will be celebrated, as well as poor performance highlighted.

CHI is only one of the regulatory bodies established by this government. They have been established in response to the politics of service failures, the most recent example being the Organ Donation Agency. As a result we face the paradox that politicians may expect that regulatory bodies will ‘name and shame’ – rather than adopt the kind of developmental approach which has been shown to improve the quality of care in the longer term. There is also a paradox that independent bodies have been set up, outside direct central control, by a government which has strong centralising instincts. The question for us is whether politicians really will be able to let the regulatory bodies they have created get on with the work and allow a ‘light touch’ management approach, as proclaimed by the rhetoric of modernisation.

Looking ahead

There are a lot of levers for change in the NHS at present. More resources are going into the health service, there is much more emphasis on patient experience, there is increased regulation of professions and there is an attack on the bureaucracy of the NHS. However, the premise that regulation does improve quality is not well tested. Regulation only works if changes are made and sustained. CHI will expect all NHS organisations to produce an action plan, which will be monitored through the performance management of the health service. The question which must be asked is whether health service has the capacity to really monitor its activity and the quality of the care that it provides, for the current performance management arrangements emphasise activity and costs but not the quality of care.

As the work of CHI proceeds with the publication of the clinical governance reviews and Investigation reports, we will need to measure the impact of this effort on the health service. We will only know in a number of years time whether CHI, alongside the other regulatory initiatives, has really improved the quality of the health service. If it has not had a measurable effect another approach to improving quality will be sought, and then the agenda may well shift in favour of more commercial solutions.