Annex A > Chapter 4 - National Accountabilities and Roles > The National Framework: responsibilities for healthcare > Perceptions of responsibility
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Perceptions of responsibility
33 It was suggested to Sir Graham that it was the view of the DoH that the responsibility for the individual patient lay ultimately with the doctor. He responded:
`I think the truth is that there is a shared responsibility but a lot of people, organisations and people are involved in this. It is the Secretary of State's responsibility, with his Department, for example, to make sure that enough money is provided so that the Health Service can be run properly. That is his responsibility. It is the responsibility of every consultant or every consultant in the NHS to practise according to good standards of professional conduct and competence. It is the responsibility of the Trust or the Health Authority or whatever that employs that doctor to make sure that he is a suitably qualified person; that he or she has the necessary resources in order to carry out the work that he or she has to do; and at least to supervise in some way or other the quality of what is done.
`So I think it would be very simplistic, if I may say so, to suggest that there is one person or one organisation which is wholly responsible and has an undivided and total responsibility for this. But I think one can explain properly, and I hope I have done so but I may have failed to do so, pretty well precisely where the boundaries of responsibility are and how they fit together.
`One has to use words like - I do think, just again to say it, the primary responsibility, when you or I or any of us puts ourselves in the hands of a doctor or the Health Service, the primary responsibility for what takes place lies with the individual doctor. But it is a responsibility which inevitably he shares with his employer, if he is working in a hospital. And the Health Authority or the Trust itself obviously has also to share some of the responsibility higher up the line, because higher up the line also has a part to play. But the centre of gravity, so to speak, has to be at the level of the individual patients. It cannot be satisfactorily discharged from someone sitting in Westminster or Whitehall. We are talking about, you know, millions of events per year of an intensely personal kind involving individuals which they passionately care about, and it is quite wrong, really, I think, in any sense, to overplay the central responsibility. I hope, I sincerely hope, that is a realistic description and a proper description of how things are and how they should be, rather than simply seeking to step aside from responsibilities.' [37]
34 Sir Alan Langlands, Chief Executive of the NHS Executive 1994 to 2000, gave evidence to similar effect:
`Q. ... the Inquiry has heard two opinions about the responsibility or otherwise of the Department of Health, and by that I mean the Supra Regional Services Advisory Group and the Ministers to which it reported, for the quality of the paediatric cardiac services. One is that because it was the Department of Health which as it were provided the money, and which also had direct contractual relationships between the unit and itself, so that this service stood outside the normal purchaser/provider territory, it was the Department that was responsible for ensuring or monitoring and assessing the quality of the service that was being provided.
`The alternative view that has been expressed by officials within the Department of Health is that it was the health authorities - this is "health authorities" unspecified - that retained that role as part and parcel of their public health functions and that the funding mechanism that was represented by the Supra Regional Services Advisory Group did not alter that basic public health responsibility. Can you comment on that conflict of views?
`A. I do not think I am willing to choose either/or. I think I fall back on my point. What I want to avoid at all costs is any notion that somehow no-one is responsible, because I do not believe that to be the case, but I believe that the clinicians directly involved in provision of that service have some responsibility. Health authorities and the Trust which was the home to that service have some responsibilities, as we discussed earlier this morning, and the Department of Health clearly had some responsibilities, not just in relation to resource allocation in my view, back to this point about systemic failure, but to ensure that there was a system in place that ensured that these services were being properly provided. I think that the crucial thing would be to be absolutely sure in each of these cases that the roles and responsibilities, the distinctive roles and responsibilities of each of these players, was adequately defined.' [38]
35 In relation to supra regional services, Sir Graham Hart was later to say that the roles were not, in his view, adequately defined. [39]
36 The Inquiry was told that the DoH, under the direction of the Secretary of State, had responsibility for: (i) policy rather than operations [40] (thus the provision and the distribution of resources in the form of money, capital development and to an extent the workforce, and the determination of policy for and about the NHS was undoubtedly a responsibility that the department accepted); [41] (ii) `more problematically' [42] for ensuring the implementation of policy and a high standard of performance by the NHS. (`Performance' is to an extent an ambiguous word, the meaning of which has changed over time: it may have to be understood as referring to finance, rather than clinical outcome. Sir Alan Langlands emphasised the requirement upon the NHS Executive to `manage the performance of the NHS - including securing and allocating NHS resources ...' [43] and told the Inquiry that, in 1999, finance and performance were linked in one post within the NHS Executive HQ; [44] Dr Peter Doyle, Senior Medical Officer, DoH, told the Inquiry that when the Performance Management Directorate was set up at the DoH, the performance with which it was concerned was `primarily' to be understood in the financial sense. [45])
37 This range of responsibilities was reflected in the formal accountability of local administration. After 1991, local administration was increasingly carried out by trusts. Sir Alan told the Inquiry:
`... all Chief Executives of NHS Trusts and Health Authorities have, since 1995, been designated as "accountable officers". This will be extended to Chief Executives of Primary Care Trusts. This means that they are answerable to Parliament through me for the efficient and proper use of the resources in their charge. In case of serious management failure they would be expected to accompany me to answer personally before the Parliamentary Public Accounts Committee'. [46]
The legal accountabilities of a trust to the Secretary of State (and hence those matters over which the DoH would have immediate control) were predominantly concerned with financial performance and management. [47]
38 Further, following the introduction of hospital trusts, the NHSME set up regional `outposts' to monitor the financial performance of trusts. [48] The function of these was described as:
`... very much based on the financial arrangements of the trust; they were there - not I think exclusively, but certainly one of their main functions was to monitor the financial health, to handle capital allocation, that kind of thing.' [49]
39 In reviewing the evidence as to the extent to which (and the sense in which) the DoH and the NHSME accepted responsibility for the care of patients, a distinction has to be made between non-clinical and clinical care. To the extent that the DoH and the NHSME were concerned with `quality', it was defined until recently by reference to non-clinical care: the Patient's Charter, when introduced in October 1991, focused on non-clinical standards. The purchaser-provider contracts tended to focus on cost, volume and other non-clinical measures. [50]
40 When looking, on the other hand, at responsibility for the quality of clinical care, the DoH (including the NHSME) appeared to some observers to regard itself as having very little responsibility. According to Dr Phillip Hammond, a local GP and journalist:
`... the DoH seems to show little appetite to have a "controlling mind" and appears unable to act to protect patients without the full agreement of the relevant professional bodies who are, by their nature, self-protective'. [51]
41 The evidence given on behalf of the DoH was, indeed, that it adopted a `hands-off' approach so far as individual clinical care was concerned (this approach was said to be changing during the period with which the Inquiry is concerned). [52] Thus, Sir Alan Langlands said, in relation to the early 1990s, when asked about interventions by the Department in response to a trust's apparent failure to provide a proper quality of care (at least in relation to failure to meet numerical targets in respect of finance or waiting lists):
`... mixed messages emerged from the Department of Health. On the one hand there was a clear signal that we should, from a regional perspective, have a definite hands-off approach in relation to trusts. On the other hand, we would be expected from a regional level to pick up the pieces if something was going wrong. So that was a time of rather confused accountabilities in that regard.' [53]
42 A number of reasons for such a hands-off approach were advanced by those from the DoH who gave evidence. First was clinical freedom. Sir Graham Hart recalled:
`... if you go back to my early days, so to speak, of involvement in all this, which would be in the 1960s, and even roll it forward to the early 1980s, really, there was a feeling around - this can be oversimplified - that clinical freedom meant that the centre - Ministers, in effect - should keep out of anything to do with the practice of medicine ...'. [54]
`There was a deeply-rooted reserve on the part of the Department - shared by the professions - about Departmental involvement in clinical performance. This was in general seen as the preserve of clinicians, individually and to some extent collectively.' [55]
44 This view was echoed by clinicians themselves, with an emphasis on individual rather than collective responsibility. Indeed, the latter was discounted. For instance, Professor Leo Strunin, President of the Royal College of Anaesthetists (RCA), told the Inquiry that:
`... it was fairly common back ten years when people thought, "Well, as long as I am doing a good job it is not actually my problem what is occurring around me"'. [56]
45 Such a view was emphatically expressed by Dr John Roylance, Chief Executive of the UBHT 1991-1995, from the perspective even of local management:
`Q. Can we have your statement, WIT 108, page 20. I am going to ask you in a moment about the paragraph beginning: "In respect of senior medical staff ... ." Did you regard medical staff as professionals?
`Q. In effect, once appointed, was it part of the consequence of clinical freedom that they were self-teaching and self-correcting?
`Q. Did you take the view, therefore, that it was not for managers to interfere?
`A. I recognised that it was impossible for managers to interfere.
`Q. So essentially, the clinician at the bedside made the decision which he or she thought was in the best interests of the patient?
`Q. And management felt that it could not, and should not, interfere?
`A. And does not, in any part of the Health Service.' [57]
46 A second reason for not accepting responsibility for individual clinical outcomes was that national responsibility for local activity would be impracticable. A third was that there was no effective power in central management to intervene. A fourth was that in any event the responsibility for the individual patient's care lay elsewhere, principally with the hospital doctor (or at least the consultant).
47 The first of these reasons has already been outlined. Part of it was a view as to the proper role of central government in creating (in respect of services such as paediatric cardiac surgical services) the `... right kind of environment in which the tendency would be towards limitation and specialisation' as opposed to `... putting down an absolutely rigid framework within which there was no room for movement at all.' [58] Part of it was a view (held by the profession itself), that the DoH should not get `involved with anything to do with the clinical treatment of patients' [59] since this was the proper preserve of the individual clinician.
48 The second reason, the impracticability of taking responsibility at national level for local operations, was described as follows by Sir Alan Langlands:
`... it is impossible, and certainly undesirable, for the NHS Executive to monitor the treatment of individual patients or patient groups'; [60]
`It is simply impracticable for the Secretary of State to be in any detailed sense responsible for what goes on every day in every hospital ... it is quite impractical, and I think wrong, for the Secretary of State or the Department on his behalf to try to superintend or supervise or be involved in routinely what is going on in each and every hospital, health centre and so on. It is just not practicable.' [61]
49 The third reason, the lack of powers, was expressed in the following terms in relation to hospitals before trust status was introduced:
`... if the Secretary of State had tried to, as it were, put on his hobnailed boots and go down to a particular place and say, "Stop doing that". You could have done it, but it might not have been very wise and I think you would have had to have had some very good specific reasons, not just general reasons.' [62]
50 Sir Alan Langlands said (in respect of the time after trust status was introduced) that the Secretary of State for Health could not tell trusts what to do:
`The NHS (Management) Executive was to manage the NHS primarily through Health Authorities. NHS Trusts were given greater freedom to manage more of their own affairs. They were accountable to the NHS Executive for meeting their financial targets and to Health Authorities through the contracting process for the volume and quality of services they provided. The Secretary of State had no power to direct NHS Trusts in respect of the services they provided.' [63]
`Q. ... the members of the Trust Board, and in particular the Chairman, were appointed, were they not, by the Secretary of State?
`A. That is correct, and the Secretary of State, while having no powers to direct Trusts in the way at that time that he would direct health authorities, and that would be the contrast I would make, did, however, have powers to remove the Trust Chairman or the Trust Chairperson and members of the Trust Board.
`Q. Were those grounds linked to the financial performance of the Trust or were they more widely framed?
`A. I could not remember offhand what the legislation says, but certainly the interpretation on the rare occasions when this in my experience happened was drawn more widely than just financial failure.
`Q. More widely so as to encompass what factors?
`A. In my experience of this, to encompass factors like the breakdown of the relationship between the non-executive group, the managers and sometimes the clinical staff in the hospital. In other words, where relationships became dysfunctional to the point at which they impeded the proper work of the Board.' [64]
51 The DoH's apparent position, therefore, was that the best that could be done from the centre was to exercise persuasion to influence local units. Thus Sir Graham Hart said:
`I think it is very questionable what, as it were legal powers the Secretary of State would actually have had to stop a unit from carrying out ... procedures'; [65]
and Sir Alan Langlands noted that:
`The Secretary of State, in legislation, had no power to direct Trusts [which may have been in difficulty because of the quality of service they were providing], but would seek to influence these Trusts and would use the team that supported him or her, the management team, to exert that influence. So whilst there was no direct power, there was very strong central influence where things were going wrong ... .' [66]
52 One means of persuasion was the use of CMO's letters issued to publicise good practice. [67] However, there was no mechanism to monitor compliance with the advice and guidance in relation to clinical issues which was seen to be the prime concern of others, such as the Royal Colleges. Thus former CMO, Professor Sir Kenneth Calman said:
`The Department of Health from time to time issues guidance on management, but not generally in relation to clinical practice unless based on professional views from outside the Department.' [68]
53 The perceived lack of power, the need for persuasion rather than coercion, and the view as to the proper role of central Government, were reflected in a reluctance to become involved in controversy:
`... if Ministers might be tempted to tread down that path of involvement and intervention, then they could be pretty sure that there would be a tremendous row about it with the profession, and that is something which you certainly do not want to do without forethought'; [69]
`... a Minister would always think twice or three times about, as it were, entering into a controversy with a particular unit or series of units by saying, "I want you to stop doing this", unless, as I say, there was some really good evidence'; [70]
and (with specific reference to the de-designation of a particular unit as a supra regional centre):
`... if [the Minister's] only ground for doing it was, "We have this general policy which is in favour of these procedures being done in a few centres and that is why we have supra regional services and you are not one of the chosen few, so to speak, so I want you to stop for that reason", I think that would be [a] very difficult argument to carry off in a situation of public controversy.' [71]
54 The fourth reason, that the responsibility for the quality of clinical care lay elsewhere, was stated by witnesses who gave evidence on behalf of the DoH. Sir Graham Hart said that the mainstay of quality was in the hands of healthcare professionals themselves and the trusts who selected and employed them:
`A. ... the mainstay of quality, as I have tried to say throughout, the main safeguard as far as patients and the public are concerned, should lie in the qualifications and the professional conduct and whatever of the people who are chosen very carefully to carry out this work - the consultants.
`A. The doctors, and the other professional staff who work with them. And in the hands of the people who employ them, the trusts and so on and so forth. That is the main safeguard.' [72]
55 Doctors themselves did not easily acknowledge this notion of collective responsibility, even that of clinical teams:
`... [the concept in] most doctors' minds [was that] ... of accountability primarily to the patient and peers.' [73]
56 Sir Graham Hart thought that:
`It must be the case that the primary responsibility for clinical practice, wherever it is, lies with the doctors actually carrying it out. They do not get a very good airing on this, but actually that is the foundation of this whole system.' [74]
57 Professor Sir Kenneth Calman's view was that the immediate treating clinician would `probably' have responsibility for the delivery of care, adding:
`I say that because it would be the consultant who would have the overall responsibility, rather than the doctor in training themselves.' [75]
58 Sir Graham echoed Sir Kenneth's view as to the role of the consultant, but expanded on the context:
`It is the personal responsibility of the consultant to carry out their work conscientiously and competently, and on the people who employ them, which in this case is the Trust or before that the Health Authority. So of course they have a primary responsibility.' [76]
59 A clinician taking responsibility for his own practice may not secure good clinical care for an individual where he may lack the insight, skills, knowledge or perspective to appreciate what constitutes proper care in the context, even though his complete integrity is in no doubt. The Inquiry sought evidence, therefore, as to the level at which (and by whom, apart from the individual clinician) responsibilities for the competence of a clinician were discharged.
60 Sir Alan Langlands thought that guarantees of good clinical performance (at least between 1989 and 1999) derived from:
`... the practice of individual clinicians and clinicians working in teams. The commitment of these individuals and teams to agree the standards of practice that they are trying to achieve, to audit and compare progress against these ... .' [77]
61 Above the clinical team, Sir Kenneth regarded responsibility as lying with the employing trust [78] and then the Regional Director of Public Health or the GMC:
`A. If you are working in a team or a group of individuals, if there is a competence issue, then that might be picked up and be dealt with at that level, for example. Beyond that, it would be the Trust through the Medical Director or in pre-1989 terms, Medical Superintendent. Beyond that, it would be the governing body or Trust Board, and beyond that, to the Regional Director of Public Health.
`Q. And beyond the Regional Director of Public Health?
`A. It would depend on the issue, but if this was an issue of competence, it would go to the General Medical Council.' [79]
62 Both Sir Alan and Sir Kenneth explained further the role and responsibilities of the Regional Director of Public Health. Sir Alan said:
`Within the NHS Executive we have alerted staff to the procedures they should follow if they are approached with informal reports of poor clinical performance. In all cases the information should be passed to the Regional Director of Public Health who takes responsibility for ensuring that adequate investigation and follow-up actions are taken.' [80]
63 Sir Kenneth told the Inquiry:
`Q. Is it the case that the Director of Public Health at the Regional Health Authority would be regarded within the Department of Health as being part of the Department of Health, albeit at a lower level than the central level?
`A. Yes, and in fact over the period of time as part of this Inquiry, it would be seen very much as part of it, and indeed, nowadays the regional office is part of the enquiry.
`Q. So it is a false distinction to talk of the Department of Health and then the Director of Public Health; the distinction would be between central and regional aspects of the Department; is that accurate?
`A. That is a very neat way of producing it. I saw Dr Scally [Regional Director of Public Health] as very much part of us, if you like.
`Q. Does the same apply to the Regional Medical Officer?
`A. Exactly the same. I mean, some of the relationships, going back a little bit further, are slightly different, but in general, that would be the same principle, yes.' [81]
64 Central responsibility for individual clinical outcomes was therefore not accepted, for the four broad reasons identified in evidence and examined in paras 42-63 above. Acceptance of responsibility for the provision of services of a particular type was also limited.
65 As to the provision of services, the view from the centre was that:
`By 1984 this responsibility [for providing hospital services] fell for the most part on about 200 District Health Authorities [DHAs], which were accountable to 14 Regional Health Authorities (RHAs) which in turn were accountable to the Secretary of State.' [82]
66 Sir Graham told the Inquiry:
`A. Back in the 1980s Districts were, as you know, responsible for the management of the individual hospitals, yes.
`Q. And the District responsible to the Region?
`Q. And the Region to the centre?
`A. Correct.' [83]
67 Central power was, however, diluted by the structure. Sir Graham Hart told the Inquiry:
`... there are a whole series, many hundreds of statutory bodies set up by Parliament, who are responsible for running the services locally, and who have a responsibility to decide what goes on in those hospitals. That is bound, and very properly, to dilute the power which lies at the centre.' [84]
68 In addition to issues of responsibility and influence, there were practical difficulties that hindered the development of methods for the measurement and assessment of the quality of clinical performance. Sir Graham told the Inquiry:
`Q. ... [quoting the Griffiths Report] "Surprisingly, however, it [the NHS] still lacks a real continuous evaluation of its performance against criteria such as those set out above ... . Rarely are precise management objectives set. There is little measurement of health output. Clinical evaluation of particular practices is by no means common and economic [evaluation] of those practices extremely rare." Leaving aside the economic evaluation and leaving aside the question of output, the number of operations done, clinical evaluation of particular practices is by no means common. In this paragraph as a whole, what Griffiths appears to be observing and, the implication is, complaining about, is that the NHS had no proper measurement of the quality of the care it was providing in general terms. First of all, from your own perspective, was he probably right about that, at the time?
`A. Yes. I mean, I would say, I think, what he was saying was that there was no system, if you like. Some of these things happened, but they did not happen in an organised and systematic way. I think that is true. He was spot-on, there. [85]
`The 1983 report to the Secretary of State by the late Sir Roy Griffiths recommended not only the introduction of general management in the NHS, but also the reform and strengthening of the Department's internal organisation and mechanisms for discharging its responsibilities in respect of the NHS. ... there was to be a particular emphasis on policy implementation and performance management in respect of the NHS. This was an area of activity in which the Department had already begun to recognise the need for improvement. ... [86]
`Although much data on clinical outcomes and performances was available [in the 1980s], it was not used systematically, except in limited contexts, and then by professional organisations. National systems such as the Confidential Enquiry into Maternal Deaths were very much the exception. [87]
`As I have said I think later on in the statement, the Department's responsibilities - functions, at any rate - tend to be very much of a kind of strategic and general kind related to policy, to the provision and distribution of resources, and at a high level, I suppose, the implementation of policy and performance, although, as I say in my statement, I think these are rather more problematical areas and ones where, over the years, I think probably the position has changed somewhat.' [88]
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Footnotes
[37] T52 p.107-8 Sir Graham Hart
[38] T65 p.61-2 Sir Alan Langlands in the context of questions about responsibility for supra regional services
[39] WIT 0040 0001 Sir Graham Hart
[40] WIT 0335 0008 Sir Alan Langlands
[41] WIT 0040 0001 Sir Graham Hart
[42] WIT 0040 0001 Sir Graham Hart
[43] WIT 0335 0008 Sir Alan Langlands
[44] NHS Executive HQ, as at September 1999; the post holder had responsibility for `monitoring and analysis of NHS performance'
[45] T67 p.50 Dr Doyle. It should be noted that the Performance Assessment Framework introduced in 1999 now has responsibilities which specifically include assessment of `health outcomes of NHS care'
[46] WIT 0335 0009 - 0010 Sir Alan Langlands
[47] HOME 0002 0202; `Managing the New NHS'
[48] T52 p.85-6 Sir Graham Hart
[50] T65 p.51 Sir Alan Langlands
[51] WIT 0283 0043 Dr Hammond
[52] T65 p.13 Sir Alan Langlands
[53] T65 p.13 Sir Alan Langlands
[55] WIT 0040 0002 Sir Graham Hart
[56] T14 p.4-5 Professor Strunin
[58] T52 p.25-6 Sir Graham Hart
[60] WIT 0335 0002 Sir Alan Langlands
[61] T52 p.3-4 Sir Graham Hart
[63] WIT 0335 0004 - 0005 Sir Alan Langlands
[64] T65 p.7-8 Sir Alan Langlands
[65] T52 p.21-2 Sir Graham Hart
[66] T65 p.11 Sir Alan Langlands
[67] T66 p.18 Professor Sir Kenneth Calman
[68] WIT 0336 0003 Professor Sir Kenneth Calman
[72] T52 p.103-4 Sir Graham Hart
[73] WIT 0051 0003 Sir Donald Irvine
[74] T52 p.101 Sir Graham Hart
[75] T66 p.20 Professor Sir Kenneth Calman
[76] T52 p.101-2 Sir Graham Hart
[77] T65 p.56 Sir Alan Langlands
[78] The composition of the Trust Board is outlined in Chapter 8
[79] T66 p.21 Professor Sir Kenneth Calman
[80] WIT 0335 0017 Sir Alan Langlands
[81] T66 p.91-2 Professor Sir Kenneth Calman
[82] WIT 0040 0001 Sir Graham Hart. The statutory responsibilities of the RHAs and DHAs are dealt with in Chapter 5
[83] T52 p.73-4 Sir Graham Hart
[85] T52 p.35-6 Sir Graham Hart
[86] WIT 0040 0001 Sir Graham Hart
[87] WIT 0040 0002 Sir Graham Hart