Published: 06/02/2003, Volume II3, No. 5841 Page 22 23
For Professor Sir Ian Kennedy, shadow chair of the Commission for Healthcare Audit and Inspection, patients come first, even if it means that chief executives have 'the odd sleepless night'
'It was our duty to give something back, if we made it.
That is what has driven my approach to what I've done for the whole of my life.'
Professor Sir Ian Kennedy - recently appointed shadow chair of the Commission for Healthcare Audit and Inspection and former chair of the Bristol inquiry - describes himself as 'a child of the welfare state', who is still paying off his social debts.
His background was 'overtly poor working-class': he was one of three sons growing up in the Black Country, post-war. His parents, a teacher and an electrician, 'were, to a degree, victims of the Depression'.
Sir Ian's success - and that of his brothers - was made possible by his parents' ambitions and the changing political landscape of the times.
'They were both very absorbed with the idea of educating their three sons.My father in particular was anxious to inculcate in us the notion that we were getting what opportunities we were enjoying by virtue of the taxes and the welfare state, on the back of those who had gone to war - some of whom never came back. It was our duty to give something back, if we made it.'
All three brothers followed their father's advice: Sir Ian's eldest brother Stuart became a surgeon.
He died - during the Bristol inquiry's hearings - after contracting hepatitis while operating on a patient. His other brother, Alan, is a professor of psychology.
The duty to 'give something back' was the reason Sir Ian, an academic lawyer and expert in legal ethics, agreed to chair the public inquiry into children's heart surgery at the Bristol Royal Infirmary, which began in 1998.
'The answer to why I took it on is simple. I was asked: and duty kicks in. I remember phoning my father and saying 'You have done it again, ' and he said 'What have I done?' And I said 'Well, It is this bloody word duty.' And he said: 'What's the matter with duty?'.'
Sir Ian, aged 61, laughs at the memory. But it is clear that he takes his responsibilities as a citizen seriously. And it appears to be the point where a cerebral and rationally questioning professional demeanour collides with emotional and passionately held views on social justice.
When the Bristol report was launched, he said he had written the chapter on children's health services - and the neglect of them - 'in anger'.
Sir Ian sees failings in the NHS's treatment of children as symptomatic of a wider malaise; a failure of society 'to recognise the importance of children because they are the only purpose that we are here for' - not just in health, but also in social care and education.
He describes as 'deplorable' social trends in the 1980s and 1990s that saw playing fields sold off and local authority cutbacks on road safety at a time when Britain had the worst rate in Europe for child pedestrian casualties.
'We introduced lollypop people - and then they got cut if there was a local council problem with raising funds. We got rid of playing fields and facilities for kids to play safely: so they played in the street...so they got run over. These sorts of social trends were, I thought, deplorable in the 80s and 90s.'
'Now the present government is trying to wrestle with these things, but for a very long time there was neglect, and I regret that as I think any thinking citizen would.'
Sir Ian says he was 'very impressed' with the government's response to the Bristol inquiry.
'The fact that 186 out of 198 recommendations were more or less accepted is an indication that the government appreciated the work we were doing and recognised that the report tended to work with the warp of a modernising tendency within government.'
Central to these recommendations, of course, was the proposal to create a new independent and expanded inspection body which would also take responsibility for performance data.When the government responded by announcing CHAI, Sir Ian was a natural candidate to become its chair.
Indeed, back in 1980, a series of Reith lectures he gave were examining the need to reshape medical systems by introducing professional audit. At the time, he says, the idea was seen as 'mad'. The British Medical Association's annual meeting of the same year rejected the notion as 'unnecessary, undesirable and, in some ways, offensive'.
Now he has what looks like his perfect job - and 15 months to get things right before CHAI goes live.
Based - temporarily - in a cramped and stuffy office in Wellington House, the DoH's Waterloo outpost, Sir Ian is spending the bulk of his time meeting and greeting the various inspection bodies and royal colleges and working on transfer arrangements for staff who join CHAI from other inspection bodies. Last week, he interviewed candidates shortlisted for the crucial job of chief executive.
At the same time, the Department of Health published a joint statement of purpose with the Commission for Social Care and Inspection setting out how the non-deparmental public bodies will operate.
Sir Ian says he is anxious to learn from the various scrutiny bodies at work now, in order to inform the role that CHAI will play. But he is also keen to take an approach which not only judges the service, but helps it to improve.
'I've made it fairly clear that I think we should be concerned with monitoring and inspecting against standards, but with a view to seeking to help and to share best practice.'
He believes the climate of the NHS now - informed by the Bristol inquiry and its attempt to find answers 'without assassinating individuals' - means the service is more inclined to open itself up to scrutiny than was the case, for example, in education, when Ofsted (the Office for Standards in Education) was created in 1992.
He also insists that there is no conflict between the role CHAI will play in independently measuring the service against strict standards, and its part in supporting the service's continuous improvement.
Perhaps Sir Ian's stewardship of the Bristol inquiry offers some clues about how this dual approach might work. What London School of Economics professor Rudolf Klein disparaged as 'the longest and most expensive course of psychotherapy in the NHS' offered - to Sir Ian's mind - 'a process of healing' and 'some kind of catharsis' to a community in trauma.
But his sensitive handling of grieving parents and sometimes defensive professionals did not undermine the needs of an inquiry which shone a light on the dark corners of systemic failure and made far-reaching recommendations about how services should be delivered and measured.
The most radical of all of those proposals, perhaps, was that the body in charge of inspecting the NHS should be independent from its political masters.
Which, in theory, CHAI will be.
But there is a tension between its independence and its remit to hold the NHS to account - against a tightly prescribed government agenda.
Sir Ian describes independence as 'a kind of journey': 'You can't expect the government to just hope and close its eyes. It has some little ties it can pull back on, some little tethering ropes. This body has to earn that trust from the public it serves and from the government that creates it.'
Last month, Audit Commission chair James Strachan told the Commons public administration committee that the NHS was constrained by too many government targets.
And Sir Ian says: 'I happen to agree with James Strachan that certain, rather more general, targets are both necessary and useful.
But a plethora of targets seems to me to get in the way of allowing professionals to get on with what we pay them to use - namely their profession and their judgement.'
Safe to say, then, that targets will be a testing ground for the strength of the relationship between CHAI and the government.
Sir Ian says that while the government has an entitlement to say what, globally, should be delivered by the NHS, the bodies it sets up, such as CHAI, must be able to negotiate if they think - as Sir Ian appears to - that targets are distorting the delivery of services.
'In a resource-constrained environment, they merely mean that this part of the toothpaste tube gets squeezed rather than that.'
So will Sir Ian be lobbying the health secretary to scrap some of the existing targets dogging the health service?
He answers cautiously.
'Lobbying would be too strong a word. I think those conversations about the detailed meeting of targets pursuant to certain dates...those conversations will have to go on all the time and I am sure they are going on within government as we speak.'
But if the overall number of targets were to be reduced, managers might sleep more soundly.
There, Sir Ian offers little comfort: 'I am not against the idea of chief executives having the odd sleepless night - if That is going to be in the interests of serving patients. I have the odd sleepless night myself.
Though not very many.'
Perhaps what might cheer some managers, fed up with being at the sharp end of the performance management regime, is Sir Ian's intention that CHAI will hold government agencies, such as the Modernisation Agency, to account.
'I feel it would be incumbent on me to comment, in the public interest, on whoever is involved in the delivery of services or advising on the delivery of those services. Is the advice good?
Because in that case we'll share it.
If it is not, we'll say so.'
Strong words. So is he, as one former member of the government noted approvingly, 'just the sort of awkward bastard' the NHS needs to take charge of inspection and audit?
Sir Ian hesitates: 'The moment you say what you see, some regard that as awkward. No-one likes to have a mirror held in front of them because it tends to show the lines.
'Well, I guess I've been in the business of holding up mirrors for a very long time.'