Sir Donald Irvine: Ministers should stop trying to manage the NHS

From an address delivered by the outgoing president of the General Medical Council at Northumbria University
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The Independent Online

The process of giving the public more power began with Mrs Thatcher's reforms – she really first signalled the change in direction, and this has been reinforced by the present government. It has become received wisdom. And we see the outward visible signs in the involvement of lay people in the governance of healthcare at all levels. This week in Parliament, the NHS Reform and Health Care Professions Bill sets out to broaden the base of public involvement even further.

The process of giving the public more power began with Mrs Thatcher's reforms – she really first signalled the change in direction, and this has been reinforced by the present government. It has become received wisdom. And we see the outward visible signs in the involvement of lay people in the governance of healthcare at all levels. This week in Parliament, the NHS Reform and Health Care Professions Bill sets out to broaden the base of public involvement even further.

These developments are welcome. But they do not go far enough. I have felt for some time that the power ought to lie as far as possible in the hands of individual patients. Who else but the individual receiving a service is best placed to decide whether it has been given in a manner acceptable to that person? The patient as consumer should be the ultimate arbiter of quality. That means giving people far more choice – choice of doctor, choice of hospital and so on.

The NHS is a huge business, too big to be run on a top-down basis from Whitehall. In their own way, both previous Conservative governments and the present government have appreciated the need for greater devolution, but success has so far eluded them.

A central, but usually unspoken part of the problem, is that since the day that the NHS began it has been in the operational charge of ministers of the day. We surely cannot continue with this much longer. Really strong diversity of provision, and the equally strong local management that is at a premium at the moment, will only come when there is more genuine local control and independence of action. Excellence flows when there is a real sense of local ownership. So some kind of real arms-length machinery for managing the health service is needed. There are various ways of doing this, and there should be full public discussion and debate on these options now.

Taking Ministers of the Crown out of their NHS management role would enable them to concentrate on what I think should be their real job. They need to make sure, through Parliament, that all citizens are provided with the range and quality of health care, tailored to local needs, that we all deem necessary and are prepared to pay for. Ministers should be concerned primarily with the state of the public health in all its many aspects, with standards and overall values, and not with distracting operational matters such as whether the menus in our hospitals are attractive enough. Ministerial effort and time should go into activities where they can and should be most effective.

If we could achieve an all-party consensus on this, we could make real progress on reform.

Lastly, I would simply return to the matter of morale. It is at an all-time low in our health service today, for reasons I have explained. Good morale is fundamental to good quality. Good morale is substantially a function of leadership, which, in the structure we have now, is in the hands of ministers.

In these demanding times the Government could helpfully reflect on its own ethical values and management style, because they have never been more important. Are they giving the right message? Matters would be helped if the Government would be upfront and completely honest with the public and the NHS staff on the realistic timetable of implementation.

It seems likely that when historians come to look back on the events of this last five years, they will see the turbulence and turmoil and the anxieties and distress as indicative of a seismic change, not only in the relationship between doctors and their patients but in how we see our health service in the 21st century.

The real debate now moves onto the future of the NHS itself, in particular to whether the Government's present plans are bold and radical enough to solve the twin issues of access and quality to a standard and within a timescale that we as citizens consider will meet our expectations.

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