Final Report > Chapter 24: A Health Service which is Well Led > The future framework for the regulation of the quality of healthcare > The regulation of healthcare institutions

The regulation of healthcare institutions

38 We turn now to consider in greater detail the co-ordination of the regulation of healthcare standards and of the standards of healthcare institutions. We will deal in the next chapter with the regulation of healthcare professionals. Our starting point is to repeat that currently the state is virtually the monopoly provider of health services in this country. The public and patients are entitled, therefore, to expect that (a) there are systems in place to ensure that this monopoly is able to achieve its prime objective, healthcare of high quality for patients, and that (b) there are systems in place to ensure that this state monopoly is publicly accountable in this regard. Furthermore, such systems, if they are properly to do their job on behalf of patients, must be trusted both by the public and by healthcare professionals. This means, in our view, that they must be independent. They must be at one remove from party political debate. They must be seen to have a life and status of their own, free from changes in political fashion. Standards and quality in healthcare must be the sole priority of the body responsible for them, not one of a number of competing priorities. The NHS is quintessentially a statement of political values. Thus, it is inevitable and right that central government should seek to lay down the parameters of the NHS's activities, particularly in the realm of finance and priorities. But, once this is done, the systems for monitoring the extent to which it is meeting its stated aims must, in our view, be de-politicised, so as thereby to rekindle and maintain public confidence in the NHS. We believe that the framework which is gradually emerging could and should be made stronger and more independent in a number of respects.

39 To illustrate our point that there is some way to go, we refer to the system so far developed for the setting of standards in healthcare. The DoH remains very closely involved in the process, despite having set up an organisation, NICE, to carry out this task. [14] Sir Donald Irvine, Chairman of the GMC, recently asked, `Can a centralised bureaucracy, led by a Minister of the Crown, be both standard setter and near monopoly provider?' [15] The tension between being a monopoly provider and setting standards needs careful analysis. On one view (Sir Donald's) there is a conflict of interest. The monopoly provider will always be tempted to interfere to make the standards match the needs of the day, or, more worryingly, the political priorities of the day. But, at the level of abstract analysis, it is perfectly plausible to take the opposite view from Sir Donald. Who better than the monopoly provider to set the standards? The monopoly provider knows what resources are available and can seek to tailor standards to resources. The same arguments could also be applied elsewhere: to the conduct of national audits of performance and to the publication of information about healthcare performance on a national scale. Who better than the monopoly provider to report on its own progress? It has access to all the data and can analyse and present it.

40 But we are not engaging in some abstract analysis of how best to organise the NHS. We are talking about how best to persuade those affected by it and those working in it to rebuild and retain their trust in the NHS. In our view that trust can best be rebuilt and sustained by central government continuing the process it has already begun of establishing an independent framework for quality assurance. This means in practice that the organisations which have been set up to support, sets standards for, and monitor the NHS must be given greater authority and independence. It also means that the organisation and funding of these organisations may have to be revisited to ensure that they are able to fulfil their respective roles. It means that in the regulation of healthcare institutions, the Department's role should be increasingly strategic: to establish `offshore', as it were, a system of regulation; to support its authority; and to review its functioning over time with a view to improving it. This is a crucial lesson from Bristol. As we have said, adopting this role will take nerve and political courage. But it is the right way to secure the future of the public's trust in a national health service.

41 How should government go about this task? Our vision of the DoH's role in the future, in relation to regulation rather than to the management of the NHS, is that its responsibility lies in ensuring that a proper system is in place and that the various bodies are able to make their contributions to the overall framework of improving the safety and quality of healthcare. This is the extent and limit of the Department's responsibility. The issue here, and it is a complex and demanding issue, is how to set the proper bounds of the political on the one hand and the expert and the public on the other in a national health service. We take the view that the only system which will enjoy public trust and confidence is one in which the political responsibility is limited to creating the overall framework and monitoring it thereafter.

42 There are already organisations charged with bringing about improvements (CHI and NICE). These are not new bodies. We would incorporate them into the framework we propose. But they would have to be differently constituted. They should be made fully independent of the DoH. Indeed, that CHI and NICE are not sufficiently independent, is already creating a sense that both are limited in their powers to act. Neither body, for example, has the powers to enforce compliance with its reports, and both bodies look primarily to the DoH (the monopoly provider) for their membership, their resources, and to set their detailed agenda. By way of illustration, CHI's independence cannot be manifested or enjoyed as long as it is the Department rather than CHI itself which sets the targets for the number of trusts which must be inspected each year.

43 The type of model which we favour for CHI, NICE and the proposed National Patient Safety Agency is that of a body such as the Foods Standards Agency. The FSA is at arm's-length from government and while its overall general objectives and practices must be approved by government, the government's power to direct its activities is otherwise limited. Moreover, it has an explicit duty to ensure that members of the public are kept adequately informed about and advised in respect of matters which the FSA considers significantly affect their (i.e. the public's) capacity to make informed decisions. [16]

44 But, as we have made clear, we do not stop there. A plethora of organisations, all with their own ambitions and anxious to defend their `territories', was one of the defining features of what happened in Bristol. To bring together the various activities of these agencies, to ensure that issues are not missed, and to give some kind of strategic direction, some further mechanism is needed.

45 Such a mechanism would ensure that the activities of the various parts are co-ordinated and integrated. This is the role central government currently presumes to play, but it does so unconvincingly. In particular, it tends to an extent to see the creation of the agency or organisation as a solution in itself, while retaining real control at the centre. Furthermore, as we have said, one of the principal lessons of Bristol is how various organisations can become blind to the activities of each other.

46 Thus, as mentioned earlier, we see the need for an overarching body to monitor and co-ordinate the activities of all the various agencies concerned with standards and quality. The Council for the Quality of Healthcare would have an independent status, once established by government. The various agencies would be required to report to it and would derive their authority from it. Its terms of reference would be laid down by statute and it would report both to the DoH and to Parliament. It would provide the much-needed leadership to ensure that patients receive care of a proper standard and quality. While the Secretary of State for Health would be responsible to Parliament for its activities, it would be understood that the Department's role was one of establishing and funding the Council, and setting and periodically reviewing its strategic framework, rather than being involved in its operational activities.

Footnotes

[14] The DoH sets standards in `priority' areas of healthcare through National Service Frameworks; it also determines annually the list of conditions in relation to which NICE should develop standards

[15] Sir Donald Irvine. `The changing relationship between the public and the medical profession'. Lloyd Roberts Memorial Lecture. Royal Society of Medicine, 16 January 2001. www.gmc-uk.org

[16] Section 7 Food Standards Agency Act, 1999