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The NHS reforms will demand a more managed form of clinical practice - which many will not like, says Kieran Walshe

It is the conventional wisdom that governments talk a lot, but actually do rather less. Yet health ministers seem to be turning that convention on its head with the NHS quality reforms.1

Slowly, the implications for clinicians, managers, professional bodies and other interest groups are emerging, and not everyone likes what they see.

It is becoming clear that these arrangements represent a quantum leap in the importance of quality and performance to NHS organisations, and involve real changes to the way clinicians and senior managers deal with clinical performance.

March guidance focused on establishing leadership, accountability and reporting arrangements for clinical governance.2 Trust chief executives and boards will be directly accountable for quality failures in future, and clinical professionals will find their performance under greater scrutiny.

Where there are serious quality problems, doing nothing will be a risky and increasingly unsustainable option. We are already seeing the first signs of this in a dramatic rise this year in consultant medical staff suspended because of concerns about their clinical performance.

Arrangements for clinical governance in trusts will be checked by the Commission for Health Improvement. It is increasingly apparent that CHI will be a powerful health services inspectorate in all but name. The Health Bill gives it statutory powers to enter NHS premises, gather information, copy records or databases, publish reports - for which it cannot be sued for defamation - and even breach normal patient confidentiality requirements if necessary to deal with quality failures. And the health secretary can change its remit at will.

While much depends on who is appointed to chair and direct the new commission, it already seems likely to become the most important force in external review and monitoring of quality and performance in the NHS.

Another example of cautious talk and radical action can be found in the early work of the National Institute for Clinical Excellence. A consultation paper has been produced on how NICE will appraise new and existing healthcare interventions and offer guidance on whether they should be used in the NHS.3 This goes well beyond early expectations that NICE would bring together useful work by a range of bodies on guidelines and evaluation.

Crucially, the promoters of new interventions will have to demonstrate their comparative clinical and cost-effectiveness. This will apply not only to drugs, but also to new surgical techniques and medical devices, which are traditionally subject to much less evaluation than pharmaceuticals.

The Health Bill contains two other radical provisions: to replace the current voluntary pharmaceutical pricing regulation scheme agreement with a statutory scheme for drug pricing, and to impose heavy fines on companies that don't co-operate. While ministers have been quick to say that there are no plans to use these powers at present, and that they are directed only at companies that abuse the voluntary scheme, there is no denying that it strengthens the Department of Health's position in negotiating with the industry.

The bill also gives the government wide-ranging powers to change arrangements for professional regulation of doctors, nurses and other clinical professions without further legislation. The government says this will simply be more flexible and responsive. But future governments will be able to create new professional registers, and change or abolish existing ones more easily than in the past, so exerting more control over the health professions.

So far, the government has proved itself adept at presenting the quality reforms in terms that make opposition difficult. It was probably no coincidence that the guidance on clinical governance was launched just as the Bristol inquiry began to take evidence from the parents of children affected.

But it is already evident from debates in the House of Lords that the bill will face serious critical scrutiny there, even if its passage in the Commons is guaranteed by the government's majority.

These reforms represent a huge step towards an NHS in which quality and effectiveness really matter. But they also demand a move to a more managed form of clinical practice, which many will not welcome once they realise what is involved.

Dr Kieran Walshe is senior research fellow, health services management centre, Birmingham University.


1 A First-Class Service: quality in the new NHS. DoH, 1998.

2 Clinical Governance in the New NHS. HSC 99 (65). DoH, 1999.

3 Faster Access to Modern Treatments. DoH, 1999.