Final Report > Chapter 24: A Health Service which is Well Led > Recent changes

Recent changes

8 For a long time then, responsibility for clinical standards and for clinical performance was simply not thought to be a matter for government in its role of leading the NHS. This began to change when, in 1997, the Government started a programme of reform to bring matters concerning the quality of care into the mainstream of NHS management. We will examine in more detail the impact of these changes, but, briefly, we acknowledge here a significant change to the internal management of the NHS, namely the decision to place a legal duty on trusts and health authorities in relation to the quality of care. Whereas before 1999 a trust chief executive and trust board were not required to pay attention to the quality of healthcare, that has since changed. The 1999 Health Act states that each health authority, trust and primary care trust has a duty `... to put and keep in place arrangements for the purpose of monitoring and improving the quality of health care which it provides to individuals'. [4] This duty falls effectively on the chief executive. We also note the decision to create, for the first time, at some distance from government, institutions respectively to set and to monitor standards of care. These institutions, the National Institute for Clinical Excellence (NICE) and the Commission for Health Improvement (CHI) thus mark a further break with the past. The introduction of these changes is intended to have an impact on the role of government at the centre of the NHS. In `The NHS Plan', the role and responsibility of leadership from central government was spelled out in clear terms: `... the centre will: set standards, monitor performance, put in place a proper system of inspection, provide back up to assist modernisation of the service and, where necessary, correct failure.' [5] The DoH, it went on, will also have a role in championing the interests of patients by applying both pressure and support.

9 These developments contain an implicit recognition that government has two key roles in relation to the NHS. It has a role in terms of leading and managing the NHS to ensure that it delivers that which taxpayers and patients want: care of good quality. It also has another role, one which government quite properly holds in many areas of society where there is one or a few very large suppliers of a service, namely to establish a system to protect the interests of the people who receive that service. Such a system, in essence, is a system of regulation. In the past, in relation to the NHS, it was thought that a system of regulation aimed at healthcare professionals alone would be enough. Bristol has taught us that this is not enough. It is also necessary to have a system for regulating the institutions which provide healthcare.

10 Thus, the approach of government is changing, and changing, we believe, in the direction which the lessons of Bristol would suggest is necessary. We would argue however, that for the future the change must be clearly analysed and focused. What is required is much more explicit recognition on the part of government that, as regards quality of care, it has two separate but related roles: good management of the NHS, and the organisation of good, comprehensive regulation of the quality of healthcare. In the past, as the example of Bristol so clearly demonstrates, neither of these roles was properly understood or performed.

11 For the future, it is clearly the responsibility of government to establish the systems both for good management and for regulation. But it does not follow that government should do both of them. Indeed, there is a clear conflict of interest were government to perform both of these roles. As we shall see later, regulation of the NHS cannot be for government. It must be independent of government. It must involve and reflect the interests of all, patients, public and healthcare professionals, as well as the NHS and government.

12 This delineation in the roles that government should play is both simple and clear: serving through the DoH as the strategic headquarters of the NHS, and establishing the system of regulation, of both institutions and healthcare professionals, by independent bodies. We will set out the detailed implications of this approach in the pages and chapters which follow. We admit that to pursue this direction will take political nerve. But if trust in the proper regulation of the NHS is to be regained and then maintained, it is a step which government must take.

13 We turn now to examine as the two separate but related elements of a well-led NHS: (a) leadership and management of the service, and (b) regulation to ensure, on behalf of patients and the public, that standards for the quality of care are set and implemented.

Footnotes

[4] Health Act 1999 s18(1). London: The Stationery Office, 1999

[5] `The NHS Plan'. London: Department of Health, 2000. Para 6.6