http://bmj.com/cgi/content/full/324/7334/378

 

BMJ 2002;324:378-379 ( 16 February )

Editorials

Regulating the regulators

The "overarching council" does not have an overarching vision

The British government has plans for a new council to oversee the eight statutory regulators of health professionals (see box). The plans went out for consultation in the summer¹ and are included in a bill currently before parliament.² Proposals for the new overarching council were mooted in the NHS plan and backed by the recent Kennedy report into children's heart surgery at the Bristol Royal Infirmary. ^{3 4}

Under the proposals the new Council for the Regulation of Health Care Professionals will "build and manage" a coordinated and consistent framework for regulation across health professions. It will put patients first and ensure open, transparent, and consistent procedures within each regulatory body. The council will comprise representatives of the public, the professional regulatory bodies, and government appointees (to be in a majority of one) including members of the public, and health service managers. It will be led by a chairperson appointed, for the first term, by the secretary of state. The council will be able to require regulators to change their procedures; refer their decisions on individual cases to the high court when it judges such an appeal to be in the public interest; and investigate claims of maladministration.

The council is a welcome, if overdue, attempt to address how the regulators of health professionals could work more closely together. However, the bill and the consultation document lack clarity in four areasthe council's vision, purpose, accountability, and place in the wider system for public protection and redress. This makes it difficult to envisage exactly how it might reshape regulation, redefine professionalism, and enable changes in clinical practice.

Firstly, there is lack of clarity over the council's vision. Will it simply regulate the old order of separate professional regulatory bodies for each profession, or will it create a more radical future? The council confirms a permanent and welcome shift in power to a partnership of public, professions, and health service, all working under political scrutiny. But there is room for a more radical intent. The council could mark the beginning of the end of single profession regulation. It could be the progenitor of a new type of interprofessional regulation which encompasses the reality of team based healthcare and the more flexible workforce needed to deliver it.

Secondly, in the absence of a clear future there is an unsurprising lack of clarity over the council's core purpose. Under existing proposals it would be a hybrid organisation with regulatory functions (holding the professional regulators to account), responsibility for developing and coordinating regulatory policy, and the requirement to act on complaints of maladministration or refer "unduly lenient" decisions to the high court. This is an uncomfortable and unconvincing combination of roles. A developmental policy making body requires a different type of organisational composition from a tough independent watchdog.

Thirdly, the proposed arrangements for accountability lack thoughtfulness. The suggestion that the professional regulators should be accountable to the new council and through the council to parliament raises more questions than answers. This may be better than the current anachronistic accountability of all but the pharmacist and nursing regulators to the privy council, but it is an unsatisfactory fudge. Unsurprisingly this is one area that has elicited strong opposition from the existing bodies.⁵ How the council can formally hold the regulators to account when those same regulators will be members of the council is hard to see.

Fourthly, it is not clear how the council could work with the wider system of public protection, redress, and organisational learning, including the Commission for Health Improvement, the National Patient Safety Agency, and the NHS complaints procedure. Surprisingly, the consultation acknowledged but did not respond to the suggestion of the Kennedy report that such a council should be involved in coordinating the education, training, and development of healthcare professionals.

This lack of clarity leaves a large space for speculation. Instead of presenting a clear plan the government's proposals are embedded in grand objectives for a better system without necessarily explaining how each will contribute to the desired outcome. The lack of clarity risks further alienating professionals who already feel disengaged from the debate and are suspicious of unspecified intentions. If the government wants professionalism to drive quality health care it needs to attend to its relationship with those professionals.

The consultation proposes a more active and powerful council than first envisaged in the NHS plana council with greater potential for reshaping the landscape in line with the Kennedy report's wish to establish a new public service professionalism for all health workers. This is good. A commitment to its more radical possibilities could lead regulation out of what one commentator has called the current limbo land of semi-modernised historical structures.⁶ It might also meet the rationale behind Rudolf Klein's call, of over 28 years ago, for such an overarching council to develop a policy for all the professions.⁷

Britain's prime minister, Tony Blair, recently warned, "It's not reform that is the enemy of public services. It's the status quo."⁸ As the current proposals turn into more detailed formulation of policy an opportunity arises for the government to opt for a more radical regulatory model. But reform requires more than contempt for the current: its lifeblood is informed debate and clarity of purpose. The overarching council is welcome but the much needed overarching vision is still missing.

Steve Dewar, fellow. 

sdewar@kehf.org.uk

Belinda Finlayson, research officer. 

Health Care Policy Programme, King's Fund, London WIG OAN

1.	Department of Health. Modernising regulation in the health professions: consultation document. London: Department of Health, 2001.
2.	The National Health Service reform and health care professions bill. London: Stationery Office, 2001.
3.	Department of Health. The NHS Plan. London: Stationary Office, 2000.
4.	Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984-1995. In: Learning from Bristol. London: Stationery Office, 2001. (Cmnd 5207.)
5.	General Medical Council. The National Health Service reform and health care professions bill 2001: Note from the presidents of eight statutory regulatory bodies of health professions. 20 Nov 2001. www.gmc-uk.org
6.	Davies C. The demise of professional self-regulation: a moment to mourn? In: Lewis G, Gewirtz S, Clarke J, eds. Rethinking social policy. London: Sage, 2000.
7.	Klein R. Complaints against doctors: a study in professional accountability. London: Charles Knight, 1973.
8.	Blair T. Leader's speech at the Labour Party conference: Brighton 2001. 3 October 2001. (www.labour.org.uk)

© BMJ 2002

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