Final Report > Chapter 6: Quality, Standards and Information > Monitoring
<< previous | next >>
Monitoring
The role of the Department of Health
29 Priorities and funding were set nationally, but it was then for each RHA to translate these into a local health service. Guidance on planning and priorities was issued by the DoH to regions each year. The Chair of each RHA annually met the Secretary of State to review priorities and to take a view of the health service in the region. Miss Hawkins told us about the focus of the reviews: `Frequently it would be against things like health promotion and disease prevention: whether you were closing the large mental handicap hospitals and creating community care ... were your services like cardiac patients getting enough cases through units ... very wide ranging items at times.' [12]
30 The Chair of the relevant RHA then in turn met each of the Chair of the DHAs within the region to ensure that national priorities, and the region's interpretation of them, would be followed in the year ahead.
31 The meetings between the Secretary of State and the Chair of the RHA were supplemented by contact between officials. It was reported that Miss Hawkins told a BBC Television `Newsnight' interviewer that in 1988: `Civil servants were hell bent on the numbers game. They were not bothered about the outcome of the operations; they just wanted to be able to quote a big increase in the number of operations being undertaken.' In her evidence to us she gave the same impression. [13]
32 Professor Sir George Alberti, President of the Royal College of Physicians since 1997, told the Inquiry that the DoH's focus appeared to be more on throughput and waiting lists than on outcome or quality of care and that the lack of guidance given in the area of audit was a reflection of this: `They were not interested in results; they were interested in as many people passing through the system as possible for as low a cost as possible ... commercial considerations did seem to enter into it rather strongly. [14]
33 In 1991, however, there was a development in approach. The Performance Management Directorate (PMD) was established within the DoH with the aim of improving NHS performance both through planning and continuous review. We were told that: `Using taskforces PMD sought to bring together colleagues from across the Department and the NHS to tackle development and other high-priority issues. PMD consisted of multi-disciplinary teams containing administrators, doctors, nurses and economists.' Its fundamental role was to improve `the quality, quantity and effectiveness of services of the NHS by liaising strategically with the Regions.' [15]
34 The idea at the time was that regions, in turn, would apply the same approach of `performance management' to their relationships with DHAs which, by 1991, were `purchasing' health services, rather than directly providing them. Throughout the period, however, assessing and assuring the quality and performance of clinical services in particular hospitals were regarded by the DoH as being matters for the hospital, or for the health service in that locality.
35 Until 1991, the DoH relied upon the regions as the main means of access to the districts which managed acute healthcare services. Thereafter, with the creation of trusts, a new system was put in place, that of the regional outposts (also known as trust outposts of the NHS Management Executive). There was no longer a direct managerial link between hospitals which became trusts and regions. Instead, a deliberately unobtrusive system (called at the time a `light touch' approach) was adopted.
36 The trust outposts reported to officials concerned with finance in the DoH and were responsible for ensuring that trusts met their statutory financial duties, and for approving capital schemes. The outposts were not required to pay attention to clinical matters, nor to other areas of performance, although by default they could become involved in issues relating to the provision of services if, for example, a trust had a serious financial problem or a capital scheme was proposed. The Secretary of State had no power to direct trusts in respect of the quality of care that they provided.
37 Sir Alan Langlands, Chief Executive, NHS Executive from 1994 to 2000, summed up the state of affairs. He described the situation after the establishment of trusts as one which relied on professional self-regulation, the development of processes of audit, a rudimentary internal market where purchasers held providers to standards set out in contracts, and a hierarchical relationship between the DoH, DHAs and trusts. Even if these were all perfectly aligned, he said, there was no certainty that any of the parties would be in a position to identify or respond to issues of clinical performance. [16]
<< previous | next >> | back to top
Footnotes
[14] T9 p.44 Professor Sir George Alberti
[15] WIT 0482 0220 Dr Roger Moore