Standards in the NHS.

Abstract

Sixty years ago, the new National Health Service promised that a doctor would be assured ‘freedom... to pursue his professional methods in his own individual way, and not to be subject to outside clinical interference’.1 But after thirty years, the Chief Medical Officer, Sir George Godber, set out to define a ‘Cogwheel’ structure for the accountability and self-regulation of hospital doctors,2 and soon a non-governmental inquiry reported ‘It is a necessary part of a doctor's professional responsibility to assess his work regularly in association with his colleagues.’3 In evidence to the Royal Commission on the NHS in 1977, the British Medical Association was ‘not convinced of the need for further supervision of a qualified doctor's standard of care’. In its final report, the Commission responded, ‘We are not convinced that the professions regard the introduction of medical audit and peer review with a proper sense of urgency.’4 Thus, thirty years ago, standards in the NHS referred not to clinical practice or services but to buildings, equipment, capacity and allocation of resources.5 Any defects in the system were blamed on shortage of staff, money or facilities—after all, the NHS was then one of the cheapest comprehensive health systems in the world. There was little effort to examine how those resources were used or whether they could yield better clinical results. There had been several public scandals about the treatment of patients, the behaviour of doctors and the management of institutions, particularly in long-term care. But few people were keen for improvement, or even recognized a need for it. Tradition and the stout defence of clinical freedom made the management of doctors as easy as herding cats.