Final Report > Chapter 21: Introduction > The structure of the NHS: understanding management and regulation

The structure of the NHS: understanding management and regulation

25 We have said that our approach is patient-centred. The future of the NHS lies in a realignment of services so that they are organised around the patient. And it lies more fundamentally in an understanding of the distinct roles of regulation and of management. Regulation must ensure that the NHS works in patients' interests. Once it is grasped that it is the interests of patients which should determine the future form of the NHS, what we say here acquires its context. In approaching our task we have found it essential to address what may be described as the architecture of the NHS. In particular, we have asked ourselves what should be the role of government, principally through the Department of Health, and how should systems concerned with the safety and quality of healthcare be organised. We recognise that the NHS is a state-run organisation with a virtual monopoly in the provision of healthcare. As such, responsibility for the NHS can and will always be traced back to the Secretary of State for Health as the person responsible to Parliament. It is right that the Department of Health should be the headquarters for the NHS, at the apex of a hierarchical system of management. But management of the service is quite distinct from regulation. By regulation, we do not refer to the various economic approaches, such as through the market. Instead, we mean the totality of the processes and systems for assuring and improving the safety and quality of healthcare, including the regulation of healthcare professionals and the regulation of the institutions in which they work.

26 The regulation of the NHS in this broad sense must not, in our view, be in the day-to-day control of the Department of Health. While it is the proper role of government to establish the regulatory framework, to ensure safety and promote quality, that framework must be as independent as possible of the Department of Health. This is quite simply because it is not in the interests of the public or of patients that the monopoly provider should also set and monitor the standards of care. Instead, these functions must be carried out by independent bodies within a statutory regulatory framework. The regulatory bodies, embracing, as we have said, matters to do with safety, quality and standards as well as the competence of healthcare professionals, must themselves be co-ordinated and their efforts aligned by some overarching system. Duplication must be reduced. Equally, holes in the system must be stopped. Only in this way will the fragmentation and lack of clarity about responsibility for regulating the quality of healthcare, which was such a feature of Bristol, be addressed. And by insisting on independence from government, the systems to ensure safety and promote the quality of healthcare will be made secure from the vagaries of passing political pressures.

27 Let it be clear what we are saying. We are not saying: management bad; regulation good. We are saying that each has its role. Management must be for the Department of Health and exercised in every trust but, from the perspective of patients, regulation is a different enterprise. It is there to protect them against all political weathers. We admit that one way forward is to proceed as in the past through a subtle blend of regulation and management. This distinction could remain blurred as could the precise identification of who is responsible for what. The difficulty lies in the fact that this is the traditional `insiders' fix. Those running things know what's what. Everyone else remains unsure and unclear and thus excluded. Only by making explicit that which has been implicit, will the interest of the patient and public be served, because they will then know what's what. This is the process which government has already begun. It should go further, towards a gradual realignment of management and regulation.