Intended for healthcare professionals


Over-regulation is eroding trust in doctors, NHS England warns

BMJ 2014; 349 doi: (Published 20 November 2014) Cite this as: BMJ 2014;349:g7076
  1. Matthew Limb, freelance journalist, London, UK

Over-regulation in the NHS may erode people’s trust in doctors and clinical teams “to do the right thing,” attendees at the King’s Fund’s annual conference have been told. Speakers at the conference said that an unforgiving industry climate driven by rules and sanctions had left many frontline NHS staff fearful of making honest mistakes in the pursuit of improving care.

Ed Smith, NHS England’s deputy chair who also chairs its audit committee, said, “I think over-regulating professionals can erode the foundation of their work, and people switch off. If trust exists solely because there are sanctions against those individuals we don’t actually trust people at all.” He added, “The more we rely on rule following to shore up trust, I would argue the less likely [it is that] trust will be based on assumed integrity.”

Smith spoke at the conference in London on Thursday 13 November and took part in a panel discussion on the topic of engaging staff to improve care quality and transform the NHS “from within.” He said that the state seemed to resort to regulation as a “reflex” and that rules had become the “dominant axis” for the way organisations were run. Good leadership meant treating people as “inherently trustworthy,” and the development of instincts and behaviours in the NHS was vital in improving organisational performance, he said.

Chris Ham, chief executive of the King’s Fund, said that he was encouraged to see more being done to improve cultures and leadership in the NHS from the “bottom up.” He said that culture change and quality improvement required a “long march over time” rather than “a quick fix.” This meant being “realistic” about what the Care Quality Commission could and could not do, he said, adding, “We shouldn’t expect to find salvation through a single national inspector of quality and a regulator of that kind.”

Ham said that NHS boards and clinical teams should provide the “first and second lines of defence” against poor standards of patient care and that they should only look to the CQC as a “backstop.” He emphasised the need to improve leadership at all levels, saying that clinical leadership should be given much more attention.

“Much of it comes down to what has to be done and can best be done within individual NHS organisations or increasingly local systems of care and in those frontline clinical teams—the microsystems where good patient care happens or doesn’t,” said Ham. “We ignore the importance of teams and microsystems at our peril.”

Jennifer Dixon, chief executive of the Health Foundation and a board member of the Care Quality Commission, said that regulators such as the Care Quality Commission and Monitor might have the confidence to “back off” more if a new model were found to help NHS providers with self assessment and self improvement.

Andrew Chilton, medical director at Kettering General Hospital NHS Foundation Trust, spoke about insufficient evidence of trust within the NHS. “On a daily basis I see, in our region and around the country, more fear, more pressure, more regulation being injected. I’m not seeing the development of trust and people working together,” he said.

Tracey Batten, chief executive of Imperial College Healthcare NHS Trust, said that labelling trusts as “failing” even though many were still doing excellent work would not help them to improve. “To be a staff member working in an organisation that is termed failing is something that is very disheartening,” she said.

Julia Cumberlege, who chairs the all party parliamentary health group, said that little “forgiveness” existed in state regulation. Cynics would say that the regulators “go in when the battle’s been fought and bayonet the survivors,” she said. “We don’t exactly have an environment in this country where people recognise that mistakes are made, not wilfully. I don’t think our media friends always recognise that in all walks of life things do go wrong.”

Maureen Baker, chair of the Royal College of General Practitioners, said that she would like to see a reduction in the burden of regulation in primary care. She said that such regulation was having a “very significant” effect on small practices.

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