Standard bearer

'We need to learn from the past and not live in it.'

For Professor Ian Kennedy, chair of the Bristol inquiry, the past three years will have been wasted if the Bristol story does not mean change for the whole NHS.

He is determined that part two of the report, The Future, should be given due care and attention.

Little wonder. It includes some radical proposals, and some of the implied criticisms of current government systems may make for uncomfortable reading in the corridors of Whitehall.

Most of its 198 recommendations pick up where the NHS plan left off, pressing on with the concept of a patient-centred service, suggesting ways to improve consent and communication, and to put patients and clinicians on an equal footing.

But others call for fundamental change. Of these, ideas on scrutiny of the NHS are likely to cause the most headaches for the government.

Professor Kennedy wants a massively expanded role for the Commission for Health Improvement and the National Institute for Clinical Excellence. He wants them to report to a new body, a council for the quality of healthcare, which would report to Parliament. Furthermore, he believes the independence of these bodies is crucial.

'CHI and NICE must be at arm's length from government, because if the government is the monopoly provider to the NHS of healthcare, it can't be right to allow the government to also hold responsibility for checking standards.

'There is always a risk, although the government would deny it, that the standards which are set reflect the political exigencies of the day.'

Under his proposals, CHI would take on additional powers, and a vast workload, through a new role to validate and revalidate hospitals. It would have the power to withdraw, withhold or suspend validation. Trusts that failed to meet such standards would not 'be permitted to offer' such services.

Professor Kennedy insists such a role is achievable: 'It shouldn't frighten the horses. There is already a system like this that works in Scotland' (see right).

But perhaps, speaking on the day his report came out, he was aware that politicians might see things differently. 'It was noticeable that the secretary of state didn't say anything about something which we call a very significant recommendation, ' he noted.

The thought seems to anger him: 'It is a fact that there must be a number of hospitals that, if we were to check, wouldn't cut the mustard.' What's more, 'the excuses are tired and they are lame'.

And Professor Kennedy believes that while his ideas are radical, in the end they could strip away some of the layers of scrutiny and audit within an NHS that he describes as 'replete with duplication and confusion over accountability'.

His report also recommends that CHI take charge over a new body, the Office for Information on Healthcare Performance, that has already been given the goahead by Mr Milburn. Such a move would co-ordinate all monitoring of clinical performance.

The report says NICE should be given all responsibility for coordinating action on setting, and keeping under review, national clinical standards. The Department of Health should not be able to rescind or detract from standards issued by NICE. A timetable should be published for national clinical standards.

Professor Kennedy has 'deliberately' not costed his recommendations. But he believes at least half could be implemented at little or no extra cost. And he believes many of the changes rely on action from individuals, not the state.

'It doesn't need any say-so from Whitehall for a nurse or doctor to treat a patient with courtesy and dignity. It doesn't take Alan Milburn to do anything about that.'

Model approach: the Scottish system of validation According to the inquiry team, a validation and revalidation programme to check generic standards in hospitals would follow a model already set up by the Clinical Standards Board for Scotland.The CSBS was created in April 1999 to develop a coherent set of standards against which hospitals'clinical standards will be judged.

It has already drawn up some 20 guidelines in key areas, mirroring to an extent the government's priorities of mental health, coronary heart disease and cancer.Standards have been set and published in the areas of adult schizophrenia, cancers of the bowel, breast, lung and ovary, and secondary prevention following acute myocardial infarction.Others include acute elderly care, nutrition, and infection control.

Multidisciplinary visits to all trusts providing these specialist services to see how they measure up have been under way for some months.But to say the system is already working in Scotland is something of an exaggeration.

The CSBS has yet to publish findings from these visits.The first report, on coronary heart disease, is due in September.So it is unclear so far how the actual system will pan out.

As well as the topic-specific inspections, the board is also inspecting trusts on generic standards, concentrating on patient focus and safe and effective care.

Trusts will be visited by a team of inspectors, drawn mainly from the service and lay members, and assessed on key standards.They will be accredited accordingly and reinspected at intervals to be decided.So far, the CSBS has inspected seven of Scotland's 28 trusts and aims to publish its first national report in January.

What will happen to trusts that do not make the grade is uncertain.As a quango, the CSBS does not have the power to take action against 'failing'trusts.It can only tell the Scottish Executive what it has found, then leave the rest to it.

The body will measure hospitals'standards against Scotland's new performance assessment framework, and unified health boards will hold trusts to account if they fail to deliver.It would be down to those boards to recommend a service be suspended.

Other key recommendations in Learning from Bristol:

Partnership with patients: increased involvement in decision-making, quality of information and communications around consent.

Improved support and counselling services.

A duty of candour to be placed on healthcare professionals to tell patients when things have gone wrong.

The creation of a council for the regulation of healthcare professionals to oversee the regulatory bodies for separate healthcare groups.

A review of consultants'contracts and distinction awards.

Improved education in non-clinical aspects of care, investment in multi-professional training, and pilot schemes on joint undergraduate education for those wishing to become healthcare professionals.

Periodic appraisal for all healthcare professionals.

Improved supervision for clinicians trying out new procedures.

48-hour immunity from disciplinary action for 'whistleblowers', except where they themselves have committed a criminal offence.

The current system of clinical negligence should be abolished and replaced.