This will be my last column as editor. I want to wish my successor Professor Niro Siriwardena every success in the next phase of developing the journal. It has been a privilege to have been the editor of this journal and to have had the chance to work with the staff of the journal, both at the University of Leicester and Radcliffe Publishing, editorial board, readers and authors. The journal continues to go from strength to strength and we can look forward to a further period of growth.
For this, my final editorial, I have been reflecting on the future direction of the NHS quality system. Three current developments have major implications for the future of the NHS quality system. First Secretary of State for Health, Patricia Hewitt, has announced plans for a major public engagement exercise to help shape the future of care outside of hospitals. A White Paper will be produced towards the end of 2005 on Health outside of hospital. This has the potential to make ground-breaking policy. Second, widespread change is also expected in the systems for regulating healthcare professionals as a result of the Donaldson review of medical revalidation and Foster review of healthcare regulators in the light of the fifth Shipman inquiry report by Dame Janet Smith.[2–3]
The White Paper on Health outside of hospitals is expected to focus on primary care development by introducing patient choice, ‘contestability’ and plurality of providers. We are likely to see an emphasis on a greater range of services in the community from an increased range of providers, increased responsiveness of primary care to patient needs and the public health agenda. The Chief Medical Officer (CMO) advisory group is looking at the future of medical revalidation, the structure and function of the General Medical Council and the future development of clinical governance. The Foster review has been set as a parallel group to review all other UK health regulators. It will also examine procedures for ensuring that the performance or conduct of non-medical healthcare professionals does not pose a threat to patient safety and to ensure the operation of an effective system of continuing professional development and appraisal for non-medical healthcare staff. With the advent of several new roles in the health service such as care practitioners, the Foster review will also produce policy to ensure the effective regulation of healthcare staff working in new roles.
What should the strategic response be to these current problems with NHS quality and professional regulation? The development of the NHS quality systems has been a welcome and much needed development. Impressive progress has been made in improving standards and in setting up processes for standard setting and monitoring. The key issue now is: how does it all fit together? What is the relationship between the different parts of the NHS quality system, with each other and with the schemes run by professional organisations and regulators? And some elements – such as the NHS complaints system are experiencing difficulties. In my experience as a practising general practitioner (GP), a common complaint frompatients is of fragmentation of care across the multiple interfaces that now exist in health care. Patients also want greater responsiveness and accountability. It is right that systems for quality evolve as the structure and function of the NHS itself changes.
The strategic future direction of clinical governance has become an issue. It was introduced as a system for improving quality and accountability by promoting a culture of excellence. Now there are increasing expectations on employers to quality assure individual healthcare professionals and services. This ‘policing role’ in clinical governance is something that many clinical governance leads are uncomfortable with. And clinical governance itself will need to evolve particularly to see how it operates across interfaces. These ambiguities need to be resolved so that we have a clear answer to the question: What is clinical governance for?
It is time to take stock of the big picture. What is needed is clarity of purpose of the different aspects of the NHS quality and safety system and to define the inter-relationships. The links with royal college and regulatory quality systems also need to be clarified. I hope that what will emerge from these and other reviews is an overarching vision of an integrated, comprehensive and patient-centred system for quality and safety of health care in the NHS.