Accountable… but to whom?

In proposing accountability as the missing attribute of NHS management, you stop short of exploring its inherent conflict. ¹ For 65 years doctors and nurses have wrestled with having two masters, the patient (as ever) and the Service. The NHS has relied upon them juggling this tension within an overarching doctrine of patient priority. The General Medical Council (GMC) and the Nursing and Midwifery Council (NMC) have been the ultimate arbiters of this, explicitly describing professional and unprofessional conduct. Paradoxically, doctors derive comfort from GMC disciplinary activity when it reinforces patient primacy, sometimes iconoclastically, as a few senior doctors have found to their cost.

NHS managers have a Code of Conduct, of course, signed by the NHS Chief Executive. ² But therein lies the problem. The code that protects the patient-centred manager from his political bosses is policed by those very same political bosses. The first paragraph may advise them to ‘make the care and safety of patients my first concern […]’ but later the document requires them to ‘support […] the local NHS in putting national policy into practice and delivering targets’.

No wonder NHS managers often lack courage to take patient-centred decisions. Better they should steer clear of the wards and the patients and avoid controversy. How can they rely for their defence upon a document emanating from the maker of ‘national policy’?

It is fashionable for the GMC and NMC to be painted as villains in the drive for patient accountability, but they do have the advantage of being separate from both executive and management. Doctors and nurses who act unequivocally in their patients’ interest have little to fear from them. A similar body for NHS managers would give their profession strength in the face of the executive. And that strength would ultimately be in the interests of patients and the NHS.