The NHS in England in 2012

Three issues have dominated debate about health policy in England during 2011. The first has been the Health and Social Care Bill currently before parliament, which seems likely to pass into law in the spring. Amendments made after the report of the Future Forum have done little to appease critics, who continue to worry that the bill marks a major step towards privatising aspects of NHS provision and commissioning.

The second issue is the performance of the NHS. With funding unlikely to increase by more than a fraction of 1% in real terms over the next six years, there are widespread concerns that patient care will be affected as financial deficits increase. At a time when several NHS organisations are struggling to balance their budgets and even more are not meeting targets on waiting times and other key priorities, the auguries are not promising.

The third concern is the quality of patient care. Here, there is an apparent contradiction between reports from the Commonwealth Fund and the Organisation for Economic Co-operation and Development,1 2 which show the NHS in a positive light, and evidence from the Care Quality Commission of the inability of some organisations to treat older patients with dignity and respect.3 The Francis Inquiry into the Mid Staffordshire NHS Foundation Trust has trained the spotlight on failures of quality in one hospital, and the inquiry’s report—expected during the first half of 2012—is likely to contain wide ranging recommendations designed to prevent these failures being repeated.

The Francis Inquiry has focused on how the commissioning, supervisory, and regulatory bodies detect and correct deficiencies in service provision. In the course of taking evidence, the inquiry heard about the part played by professional regulators, the Department of Health, the strategic health authority, the primary care trust, the Healthcare Commission, Monitor, and the leadership of the Mid Staffordshire NHS Foundation Trust itself. One of the recurring themes has been the complexity of relationships between these bodies and the challenges they face in identifying and preventing quality failures in hospitals.

In his summing up at the end of the inquiry’s hearings, Robert Francis listed 20 areas on which he expects to come to conclusions and make recommendations.4 These areas include the interface between the regulation of governance, finance, and quality and safety standards; the use of commissioning to require and monitor safety and quality standards; and the means of embedding the patient voice throughout the system. Particular emphasis was placed on recruitment, training, and regulation of staff, including the senior managers of NHS organisations, and the exercise of the fitness to practise functions of professional regulatory bodies.

All three of the issues that have dominated debate in 2011 will remain important in 2012, although the performance of the NHS and the quality of patient care will become more prominent. This is because the funding pressures facing NHS organisations are bound to increase, which will make it difficult to sustain the improvements in performance seen in the past decade, and also because the inquiry’s report will be a big event. The failure to provide an acceptable standard of care to patients will rightly attract a great deal of interest, and it may well lead to the government introducing legislation to deal with weaknesses in the current regulatory framework.

Yet if the report of the Francis Inquiry makes uncomfortable reading for regulators, managers, and non-executive board members, it will throw down serious challenges to doctors and other clinicians. However well designed the arrangements for regulating performance and managing services may be, the quality and safety of patient care depend first and foremost on the skills of the clinical teams delivering that care. Failures such as those that tragically occurred at Mid Staffordshire raise fundamental questions about the doctors, nurses, and other front line staff working at the hospital, and why they did not act sooner or more decisively to prevent quality failures happening.

Bruce Keogh, medical director for the NHS in England, emphasised this point in his evidence to the Francis Inquiry, arguing that the first area on which to focus is the quality of individual clinicians and their professionalism.4 He went on to contend that this needed to be supplemented by peer surveillance within clinical teams and a willingness to challenge poor practice and performance. Also important was the support available to teams and the role of senior leaders within hospitals in enabling clinicians to deliver the best possible care. It might be added that doctors also have a responsibility to challenge failures in care by their peers and other clinicians—even when they may be subject to so called gagging clauses—as do nurses, midwives, and other regulated professionals.

All of this suggests that the royal colleges, the General Medical Council, and other institutions with a role in ensuring high standards of clinical practice will find themselves under scrutiny as the role of professionalism returns centre stage. As a consequence, renewed attention will be given to revalidation and appraisal and to ways in which clinical leadership in hospitals and other organisations providing care can be strengthened. The caution here is that the failures in paediatric heart surgery at Bristol Royal Infirmary in the 1990s occurred in a hospital led by a medical chief executive, suggesting that simply putting doctors in charge is unlikely to be sufficient.

The opportunity for the medical profession in this context is to demonstrate a degree of collective leadership that in the past has been difficult to mobilise. If part of the solution to the problems of Mid Staffordshire is to develop a new professionalism, then it behoves the institutions with an interest in this area to overcome their differences and show the public and government that they are willing to take a lead on patient quality and safety. If they are able to rise to this challenge, the leaders of the profession can become players on the pitch rather than remaining, as so often, spectators and commentators on the sidelines.