Patients' champion the NHS should fear

John Spiers is the man the medical establishment loves to hate. He is about to get his revenge

The Department of Health must be ruing the day they selected a "safe" right-wing Tory multi-millionaire to chair the Brighton Healthcare NHS Trust. If they thought they had got themselves just another political yes man, like so many others appointed at the start of the health reforms, they know now they were wrong. But if it is bad news for the NHS bureaucracy, it is likely to be very good news indeed for patients.

John Spiers has just been appointed chairman of the Patients Association. What's that? Barely heard of it? You will. This quiet, respectable charity founded in 1963, part-financed by the Department of Health, has hardly been a player in the past few years of radical NHS change. Preferring to operate through nods and whispers in the corridors of power, enjoying an intimate if unhealthy relationship with the mighty Royal Colleges of the medical profession, its voice has been muted.

No longer. Nothing John Spiers does is muted. He is the megaphone without the diplomacy. He makes Mike Tyson seem uncombative. "The NHS belongs to patients, not to the medical establishment" is his motto. Oh, how the Department of Health will rue the day!

The story so far. Spiers, aged 53, made his fortune in publishing. A right-wing Tory in Brighton, a JP, on countless boards and charities, he was appointed to the Brighton Healthcare chairmanship in 1991. To the disgust of the doctors, he was famous for hymning the praises of Virginia Bottomley in honeyed, cooing tones. When I first met him, he was sitting in his office at the hospital, his feet up on his desk, dressed in a bright white suit, surrounded by dazzling modern paintings (he is a collector), with a photo of Bottomley taking pride of place on his wall.

From the start, he called himself "the voice of Joe Public". He outraged hospital staff by getting into a wheelchair incognito, in his own accident and emergency department, pretending to have lost all feeling in his legs. He was told to wait five hours; a porter swore at him; a nurse told him he'd have to wait 20 minutes to be taken to a disabled toilet on another floor. This, he said, was the "invisible hospital" that NHS managers never saw.

He regards the Patients' Charter as nothing of the kind and intends to campaign for the real thing - what he calls a Patient's Patients' Charter. Instead of measuring the hotel services and the waiting times in the NHS, it will test the things people most want and need to know: how good is the treatment? How good is the doctor? What are the outcomes for this procedure under this consultant?

In Brighton, Spiers set up a clinical performance unit to measure the quality of his own doctors, designed to link the results eventually to doctors' pay. No other manager anywhere had gone as far as this, and the doctors rebelled. The British Medical Association declared war. The standing consultants' committee passed a near-unanimous vote of no confidence in him.

Expecting support, he found his friends in the Health Department, even his Blessed Virginia, looking the other way in embarrassment. So he resigned, the first NHS trust chairman to be ousted by doctors.

The department's formal statement noted only that he was "lively" and this was an internal affair for the trust. In their treachery, they may have unloosed an unguided missile.

The glee I detected in Spiers's eye as he bounded out of his first Patients Association council meeting to meet me betokens his determination to set about the medical establishment with renewed vim. The timid old Patients Association may have little idea what a hand grenade they have unpinned. His ideas aren't radical, they are revolutionary.

First, he wants league tables of all doctors' results collected and published. The BMA throws its hands up in horror. How can you compare a doctor doing routine work with a doctor who takes on risky cases? Jim Johnson, head of the BMA Consultants Committee, says: "I could cut my death rate by 10 per cent, no problem. I'd just refuse the iffy ones." He adds: "If you collect the figures, they should only be given to managers, never to patients." Another doctors' spokesman concurs: "We wouldn't want to frighten the patients."

These are the attitudes that Spiers intends to demolish. Publish and be damned, he says, since only by publishing will the tables be refined to take subtleties into account. The Government was tempted but has backed off providing these tables in England and Wales, unwilling to stir up doctors before an election.

Such figures as there are (all preserve doctors' anonymity) show that the specialist teams of doctors which treat the most cases do best, while the "dabblers" in general surgery are the most dangerous. The BMA retorts that general surgeons are the back-bone of the NHS, staffing the district general hospitals where it would be impossible to have surgeons in every specialism. But Spiers is always one jump ahead: "Just so. That is why district general hospitals have to go. People will have to travel further to very large regional centres, for cancer or anything serious, where there is round-the-clock coverage by consultants on duty in every field. You need properly staffed specialist ambulances to transport people farther to get better care."

All the recent major reports into various aspects of the NHS back him up. Specialism is best and worth travelling for. The trouble is, patients don't want it. They cling to every killer cottage hospital or dearly loved local crumbling Victorian pile, where too many exhausted junior doctors carry out complex emergency operations unsupervised. Small and local may be popular, but except for minor treatments it is neither safe nor economic. Yet how are patients to know that, unless the figures are published? Spiers sees it as his job to educate patients better to demand the things that really matter. To do that, he needs the figures.

He also wants public assessments of GPs, and is demanding that GPs open their clinics at times people can use them, between 6pm and 9pm, and at weekends. He wants to remove GPs' right to dump troublesome or unprofitable patients.

The Patients Association has a large corporate membership of NHS trusts, and a very small individual patient membership of well below a thousand. The trouble with patient power is that it has no democratic basis and so is not a legitimate estate within the NHS. Spiers intends to conduct six major opinion polls a year to sound out patient opinion far and wide. He needs to prove that he has popular patient support if he is going to carry real authority.

John Spiers is an extremist. Almost all his criticisms of the way the NHS is run are absolutely right but lacking finesse. As a manager, he tried to do too much too soon and offended too many potential allies among the good doctors. But as a professional protester and patients' advocate, he has found his metier. If he can establish the reputation of the Patients Association as a bona fide popular group, he may at last provide the missing genuine voice of the consumer within the NHS.