Self-examination rarely works...
…except, perhaps, in the case of one’s finding a change in the shape or feel of a breast or a testicle. But does it work when public service professionals – especially in healthcare – look at themselves as professional practitioners?
While I was a Fellow at the King’s Fund back in the late 1980s, one of the first pieces I wrote for the Health Service Journal after Margaret Thatcher introduced the internal market in the National Health Service was “Who is going to regulate this mess?”. My point being that without independent and impartial oversight, we have learned from many market experiences around the world that market interests are not necessarily public interest. And even back then and especially in private sector markets, the “gentlemen’s club” reputation of regulation in the UK (the “home of capitalism”) was not regarded as sublime.
A few years later, the newly formed Office for Public Management conducted the first NHS internal market behavioural simulation, “The Rubber Windmill”, with East Anglian Regional Health Authority. Thatcher glibly dismissed the simulation in Parliament as “war games in East Anglia”. The Times’ front page piece on that dismissal helped established OPM’s reputation for being challenging. But later the same market failures demonstrated by the Rubber Windmill were more soberly addressed by then Secretary of Health, Ken Clarke, who said it would all be OK “once we get the regulation into place”. Inevitably, he would be building on shaky foundations.
Indeed, public service regulation is shaky. Not least because good regulation – as my friend Professor Mark Moore at Harvard’s Kennedy School of Government, taught me: if a public service regulator is doing a good job, it appears to be doing nothing. “Doing nothing” because, in doing its job well, the regulator hardly ever needs to intervene; it’s “good job” has ensured public value delivery.
Today, in the UK, we argue a great deal about regulation – from the water industry to the media – largely because of the poor or dodgy performance of the regulated, and sometimes because of the seeming reluctance of the regulator to intervene. That said, while Ofwat and Ofcom continue to be the brunt of public criticisms, one often-proposed alternative to these government agencies – industry self-regulation - is dismissed by a cynical public who has experienced the self-interests of the self-examined.
Yet, despite the popular suspicions, we regularly see a form of self-regulation in healthcare. When mistakes or, tragically, unexplained deaths occur, Whitehall politicians, who might criticise the clinical professionals thought to be responsible, nonetheless frequently put these same clinical professionals in charge of official enquiries or reviews of the mistakes purportedly made by their own kind.
This doesn’t happen all the time, of course, the famous Mid-Staffordshire Foundation Trust Public Inquiry was led by an eminent QC, Robert Francis, not by a clinical professional (although Francis did specialise in medical law and he was advised by a panel of clinical professionals).
But shouldn’t all clinical reviews and, indeed, all more formal public inquiries be led by someone with no professional association with, or interest in, what is being investigated? If not, aren’t we placing the inquiry lead in a precarious position of being challenged by charges or suspicions of self-interest, whatever he or she says?
The recent publication of two overlapping clinical reviews of maternity services in the NHS has led me to wonder.
On the one hand, the review of Maternity Services at Nottingham University Hospital (NUH) NHS Trust was led by a distinguished former senior midwife. The other, nearly simultaneously released review, the National Maternity and Neonatal Investigation, was led, not by a maternity or neonatal professional, but by an ennobled diplomat and trained sociologist.
I have nothing to lead me to doubt the integrity of either report. Both are very well-written reports of much-needed reviews, coming after grave concerns about the quality of NHS maternity services. However, the differences in their findings are telling and that has led to my wondering.
The NUH review found that some clinicians had indeed failed to adhere to clinical guidance and it did cite some patient complaints of midwifery rudeness; the key findings, however, are inadequacies in workforce planning and staffing and a fear on the part of some midwives to speak up when they see things going wrong because of “bullying” by managers. The culprits of a “toxic culture” at the trust appear to have been non-clinical staff.
The National Investigation – albeit not focused on any particular institution – also raises several non-clinical inadequacies, including in NHS estates and digital infrastructure and a lack of integrated care. However, its findings are primarily challengingly about clinical staff learning, about professionals’ discriminatory behaviours and attitudes, and especially a penchant of those treating patients not to listen to them. So, needs for systems and managerial improvements, yes, but changes in clinical professional practice, as well. The glove – as they say - “fits both hands”. And it appears the chair saw that.
Of course, some clinical knowledge is needed if any review of clinical practice is to be undertaken properly. But the chair of a public service review - whose job is to ensure the full representation of interests, the widest contribution of insights and the broadest oversight - needs to be able to speak out in the interests, first, of the public, who pay for and use public services. Might that be constrained when the chair shares the same clinical training, affiliation and membership of those being examined? Again, I wonder.
And if the public wonders, as well, that does nothing to build public trust in public services, an essential for any of us wishing to improve social results. Regulation and examination of public services need to be above question, doubt or even wonder.