Royal College of Surgeons president Bernie Ribeiro is on a mission to stand up for education and to set up a national audit of clinical outcomes to convince commissioners of ISTCS' shortcomings

Royal College of Surgeons president Bernie Ribeiro is on a mission to stand up for education and to set up a national audit of clinical outcomes to convince commissioners of ISTCS' shortcomings

Doctors have been excluded from policy over the last 10 years and need royal colleges that are explicitly political to defend their interests - such is the promise of Bernie Ribeiro. Halfway through his three-year term as president of the Royal College of Surgeons, Mr Ribeiro has established a more combative stance than his predecessors - and believes it is beginning to show the first fruits.

'In the 10 years since Labour has been in power, the profession has been marginalised to a large extent. Joint planning on workforce, the medical advisory committee to the chief medical officer - all those areas have been removed.'

There are not many professions in existence that would not claim to be unfairly treated by the state, but Mr Ribeiro believes his members have more cause than most to complain.

'There has been a disconnection between the formulation of policy and implementation. Reform won't happen unless you get buy-in from people who feel they have had a part in creating it.'

He believes he has had some success as there is now 'a recognition from the health secretary that there needs to be more clinical engagement, though I do hate the term'. It is no coincidence that he was in HSJ's list of the 50 most influential people in healthcare last year. However, it is clearly not a case entirely won. Sunday's announcement from prime minister Tony Blair that trusts needed to run theatres through the night to meet the 18-week target came as yet another surprise for the royal college.

Certainly there is a need to find common ground - the college opposes most of the Blairite reforms, from independent sector treatment centres and choice to reforms of doctor training. Deeper than that is a hostility to what Mr Ribeiro describes as the managerialism introduced by the Thatcher reforms of the late 1980s.

He cites the introduction of three ISTCs in Essex run by Mercury Health and which he says will cost his employer, Basildon and Thurrock foundation trust,£11m a year unless they radically restructure. 'I still have the scars on my back from defending in a public consultation a local hospital' which the ISTC will make unviable, he says.

Divided loyalties
In his view, the ISTC programme is light on evidence of quality and needed capacity, and long on political expedience. He has little optimism of reversing the programme - 'it is a policy, emanating from Number 10 rather than the DoH, to reduce waiting lists as quickly as possible'. This is not an aim about which he sounds particularly positive.

He asserts there is a strong chance that consultants will begin to react to ISTCs by leaving trust employment to set up chambers - although he also accepts there are a number of financial incentives for them to stay put, despite frustration.

The college's well-honed hostility to ISTCs (which unlike traditional private providers do not provide work to NHS doctors) is reflected in its bid to run an audit of clinical outcomes, comparing English and Welsh NHS trusts, ISTCs and other private sector providers for the first time (news, page 7, 22 February).

Its clinical effectiveness unit is 'pretty close' to getting funding from the Department of Health to begin the work this year. The initial audit work, he says, would be a three-year programme looking at orthopaedics, with initial results published as early as next spring.

He says this work would be far more useful than existing audits via patient-reported outcome measures. 'This will look at the hard surgical-technical side, comparing teams rather than individuals, and if we get it right we will be able to deliver the very thing that the public has asked for and which commissioners can use.'

The subtext is, clearly, that armed with good data, commissioners would not favour ISTCs.

He holds up his Basildon trust as an excellent example of clinical and managerial relationships - and arguably foundation status means that national engagement is becoming less important than local ones. Ironically it is one of the few pieces of government policy that Mr Ribeiro favours: 'The concept of the foundation, which I was totally against when it first came up, has freed hospitals from the dead hand of government.'

One of the problems identified by many researchers in this area is the fact that consultants are loyal to their specialty and peers rather than organisation (not surprising when most of today's consultants were appointed not by a hospital but by a region). Mr Ribeiro positively celebrates this.

'We are creating a culture where doctors are asked to see their responsibility as being to the trust, the organisation, and if it is failing then they need to change their practice to make it financially viable - that is taking away the role as a public servant providing a service.'

He does not see any tension between disconnect from the organisation and his desire for clinicians to be involved in management. His vision of clinical management, what he argues was the original spirit of the Griffiths report of the 1980s, resolves it by making the professions (or at least one set of professionals) synonymous with the organisation.

He has little time for the kind of managers isolated from clinical practice that he feels were exemplified by the now famous Sir Gerry Robinson documentary on Rotherham foundation trust. His vision is for a consultant-led NHS with a cohort of clinical leaders being developed who have the power to 'hold budgets, hire and fire and incentivise staff. Once you loosen the sole grip of the chief executive on budgets you will create leaders. We are accused of blocking change but in fact we are creators of change through advances in medical practice'.

This is not that divorced from many trusts' ideas about developing a larger group of clinical directors. But Mr Ribeiro sees these clinical champions - based on disease type rather than specialty and with a wider portfolio of skills - not as a companion to management but as an alternative, right up to the chief executive.

A lack of engagement, independent treatment centres and the financial imperative come together in Mr Ribeiro's mind in damaging changes to the way doctors are trained. Most immediately he says that the 'raiding' of medical education budgets in the drive to break even will permanently lower the bar on what level of spending is acceptable.

The education battle
'We have made repeated protests to the secretary of state over the raiding of the funding - if there is one single thing that has damaged training it is that. What is taken away this year will be reflected in next year's budget.'

Added to this is his lack of confidence that second-wave ISTCs' commitments to train will be realised. It is already, he says, having 'a huge impact on surgery training for easy operations' and without the payment by results tariff being changed to take account of training, this won't change.

'Traditionally the private sector is prepared to do it but an overseas company might not be - it is really goodwill on the part of providers to say whether they will have training or not.'

The third objection is Modernising Medical Careers, the education revamp that comes into effect in August. 'The battle may be lost but not the war. The principle was right in stopping senior house officers swimming round the system for years not getting anywhere - what was wrong was having no policy for managing the transition.

'We wanted three years transition and an extra thousand places and I still don't have that written down. When MMC is implemented in August we need someone to manage the transition - we need the department to realise they can't just disband the team and leave MMC to its good offices.'

Mr Ribeiro says he became the president with 'the primary aim of politicising' the royal college. He now has another 18 months to prove he can deliver change as well as firm opposition.