Doctors may have lost the chance to make a difference

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Former health secretary Andrew Lansley’s changes to the English NHS had at its heart a radical idea, derived (perhaps unconsciously) from philosophical discussions of the nature of trust. Who could best be relied on to put the interests of patients first? Where did trust reside?

In a mistrustful era dominated by ever rising levels of audit and scrutiny, the changes sought refuge in an older concept of accountability: that of professional standards. A system run by doctors would borrow some of the trust rightfully accorded them by their patients and use it to replenish trust in a system shaken by the revelations of poor care at Mid Staffordshire NHS Foundation Trust. The subtext of the reforms, never clearly articulated, was that regulation had failed—and was likely to fail again. At Morecambe Bay, it did.1

We have since heard the usual solemn undertakings that in future things would change: inspections would be tightened, transparency increased, a “duty of candour” imposed on managers, whistleblowers given access to free whistles, and the whole culture transformed into a vision of loveliness and light. This is claptrap, of course, and it misses the point. Once trust has been lost, it cannot be recreated by a few structural twitches and a ladleful of soft soap, because the current methods of achieving accountability damage trust rather than enhance it, as the philosopher Onora O’Neill argued powerfully and persuasively in her 2002 Reith lectures.

We already have a multitude of regulators stepping on each other’s toes or cunningly trying to shift responsibility over the fence when things go wrong. We don’t need more. Our only hope is a system run by conscientious professionals in whom we can repose trust. Sometimes they will let us down; but as Dr Johnson said in a remark quoted by O’Neill, it is happier to be sometimes cheated than not to trust.

This argument always made me more willing than most to see virtue in Lansley’s changes. I am surprised that doctors did not welcome them more, but the profession puts little trust in politicians so saw the changes as a way to make doctors carry the can. Their lack of enthusiasm, combined with the limpet-like reluctance of the centre to yield power, now seems likely to have neutered the reforms. Hardly a week passes without some new diktat from NHS England aimed at limiting the freedom of clinical commissioning groups to do the job the reforms gave them. Managers who presided over failure have miraculously clung to a power that has been enhanced and entrenched by the independence given to NHS England by the Health and Social Care Act, and they are laying down the law like Napoleon Bonaparte on a busy day.

This includes imposing quarterly ratings on the performance of the clinical commissioning groups (CCGs) and annual ones on organisational capability, with the cost of failure being a takeover by the centre. Traffic light ratings will be awarded against five “domains” on a “balanced scorecard.” Sound familiar? The deadly language is enough to tell us that this is regulation designed to stifle, though Barbara Hakin, interim deputy chief executive of NHS England, said brightly that “for the vast majority of CCGs this is about how we will support you.” Meanwhile, Bob Ricketts, director of commissioning support strategy at NHS England, said he doubted that any CCG had the competence to commission anything without using the services of the commissioning support units, which are essentially the recycled remains of the old apparatus that CCGs were intended to replace, not rely on.

Yet David Nicholson, chief executive of NHS England, celebrated his impending departure from that role with an interview in which he had the chutzpah to deny that the organisation was a regulator of commissioners, adding that “the idea you could have one model in a sort of Stalinist way driven from the centre seems out of kilter with the kind of NHS we want to create.” The only way to respond to that is with a deep indrawn breath and a quickly suppressed expletive. Let a thousand flowers bloom, so long as they all score the same for colour, scent, and vegetative vigour on five domains on a balanced scorecard!

Small wonder that the general practitioners who have put their trust in the intentions of the legislation are beginning to get restless. At a recent King’s Fund meeting Howard Stoate, chairman of Bexley Clinical Commissioning Group and a man who knows his way about (he’s a former Labour MP), bemoaned the constant meetings and the limitations being imposed on CCGs. “They let you do small things, not big ones,” he said. “They’re not letting go.” The challenge to save money under the quality, innovation, productivity, and prevention (QIPP) programme was far too modest, he said. “I’d love to have a 20% QIPP challenge. Nobody will let me. They don’t trust me.”

Michael Dixon, chairman of the NHS Alliance, the representative group for primary care providers, wrote recently that CCGs would need to prove that they wear the trousers and not NHS England, the regulator Monitor, or the Department of Health. “In short, do we now have a locally driven, primary care focused, and clinically led health service, or is it all a masquerade?” he asked.

It’s too soon to answer Dixon’s question, but it is hard to be optimistic. It’s a cliché to say that culture eats reform for breakfast, but that doesn’t make it untrue. Fear of failure, lack of innovation, and an outdated and—hard to admit, but true—contemptuous attitude towards its users have left the NHS beached. Doctors still have the public trust to have made a difference, but the opportunity may now have slipped through their fingers.